key: cord-0838603-4amgrry5
authors: Li, S.; Beames, J.; Newby, J.; Maston, K.; Christensen, H.; Werner-Seidler, A.
title: The impact of COVID-19 on the lives and mental health of Australian adolescents
date: 2020-09-09
journal: nan
DOI: 10.1101/2020.09.07.20190124
sha: 6c092ffe9840fb60caace6f9663ff48ff1527d54
doc_id: 838603
cord_uid: 4amgrry5

Objective: There has been significant disruption to the lives and mental health of adolescents during the COVID-19 pandemic, but the exact nature of the effects is not known. The purpose of this study was to assess the psychological and lifestyle impact of the pandemic on Australian adolescents, using an online survey, administered during and after the peak of the outbreak (June-July 2020). Method: Self-report surveys were administered online to a sample of 760 Australian adolescents aged 12-18 years old. Surveys assessed worry about contracting COVID-19, behavioral change in response to the pandemic, impact on education, peer and family relationships, lifestyle factors including exercise, technology use and sleep, as well as mental health outcomes including psychological distress, loneliness, health anxiety and wellbeing. Results: Overall, young people expressed significant concern and worry about contracting the virus, and most (>85%) engaged in behaviors to reduce the risk of transmission. Three quarters of the sample reported a worsening of their mental health since the pandemic began, with negative impacts reported by most respondents on learning, friendships and family relationships. More than 40% of young people reported a decrease in exercise and 70% reported an increase in technology use since the outbreak. There were high levels of uncertainty about the future reported by respondents, and their scores on validated measures indicated higher levels of sleep disturbance, psychological distress and health anxiety, and lower levels of wellbeing, relative to normative samples. Reponses on the Kessler Psychological Distress Scale indicated that 48.3% of the sample were experiencing distress consistent with a probable mental illness, which is much higher than pre-pandemic prevalence rates. Effects on mental health were worse among those who reported a previous diagnosis of depression and/or anxiety relative to those without a history of depression and/or anxiety. Conclusion: These results indicate high levels of disruption and psychological distress experienced by adolescents during the current COVID-19 pandemic. Adolescents are already vulnerable to the onset of mental illness at this developmental stage, and the current research underscores the need to find rapid and accessible ways to support adolescent mental health during times of crisis. There is a need for longitudinal research to evaluate the enduring effects of the pandemic on adolescents.

As of the 31 st of August 2020, there have been more than 24 million COVID-19 cases and 838,924 deaths worldwide 1 , with 25,547 cases and 600 deaths in Australia. As the pandemic and associated restrictions continue, there has been growing concern about the impact on mental health. Studies from around the world have shown that most individuals report increased psychological distress and worsened mental health [2] [3] [4] , an effect which seems to be amplified among those with a history of mental illness 5, 6 . Although worsened mental health has been documented across the lifespan, several studies have found young adults (aged 18-24 years) are experiencing the greatest deterioration in mental health 3, 7 . Very few studies have assessed the impact of the pandemic-related disruption on adolescents 8 , which is concerning because adolescence represents a time of social transformation, marked by an increased need for peer interaction and heightened sensitivity to social stimuli 9 . Adolescents demonstrate increased independence from their families, begin to establish relationships with peers based on shared values and ideas 10 , and become more sensitive to peer acceptance, approval and rejection than either children or adults 11 . Because of this sensitivity, it is likely that social distancing measures, together with school closures, may have a greater negative effect on adolescents. Support for this comes from a recent review of the literature involving more than 50,000 young people that found that social isolation and loneliness significantly increases the risk of mental illness in young people 12 .

Despite the significant potential impact of pandemic-related restrictions on adolescents, little empirical work has addressed this possibility. Four published studies have assessed adolescent mental health (<18 years) in response to the pandemic, three conducted in China and one in the US [13] [14] [15] [16] , which collectively show that the prevalence of mental illness (most commonly depression and anxiety) is elevated relative to pre-pandemic prevalence estimates. Evidence of a similar pattern of worsening youth mental health in Australia is emerging. For example, the Kids Helpline (a 24-hour free counselling service for 5-25 year All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted September 9, 2020. . https://doi.org/10.1101/2020.09.07.20190124 doi: medRxiv preprint olds), has reported a 40% increase in calls to the service, and the number of young people attending the hospital Emergency Department for self-harm has increased by 33%, both relative to the same period in 2019 17, 18 . In addition, young people's behavior and lifestyles have also been impacted by . For example, one study 16 found that most teenagers reported engaging in at least some social distancing, and another found that 94% of adolescents reported engaging in protective behaviours, such as wearing a mask, hand washing and social distancing 14 . Moreover, worsening sleep and feelings of isolation and loneliness have been reported 19 , as has disruption to learning and education 14 . Together, the available data indicates significant impact on young people's daily lives.

Beyond these studies, it is unknown how the disruption to daily life has impacted adolescents' behavior and worries as they relate to COVID-19. The impact on their peer relationships, family relationships, feelings of loneliness, learning and education, lifestyle factors (e.g., exercise, sleep, technology use), and how these relate to mental health, requires investigation to understand the support adolescents require. The overall objective of the current study is to address this gap and answer calls from the scientific community to assess how young people's lives and mental health has been impacted by the pandemic 20,21 . The first aim of this study was to investigate the psychological impact of the pandemic on adolescents. We included measures of psychological distress, loneliness, health anxiety and wellbeing, which we expected to have worsened, as informed by the emerging literature 13, 14, 16 . Based on previous studies from the adult literature 5,6 , we expected that those who had a pre-existing history of depression and/or anxiety would show a worse psychological response to the pandemic.

The second aim was to understand how the pandemic and associated containment measures impacted the lives of Australian adolescents. To this end, we collected data on young people's demographic characteristics, worry about contracting COVID-19, changes to All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted September 9, 2020. Data was collected from an online survey distributed via social media advertisements.

While this method may not produce a representative sample of the entire population 22 , it nonetheless allowed timely access to a significant number of young people while containment measures remained in place. The recruitment period (end of June-beginning of August 2020) included the relaxing of lockdown restrictions across Australia (end of June-beginning of July), with the exception of Melbourne and the state of Victoria, which went into a second lockdown on the 8 th of July (Melbourne) and 2 nd of August (Victoria).

Participants were recruited via social media and were aged 12-18 years, living in Australia. Data was collected via the Qualtrics platform from 22 June 2020-5 August 2020.

The study was approved by the UNSW Human Research Ethics Committee (HC200334). All respondents were required to pass a Gillick Competency Task to ensure the understood the study, and had the capacity to provide informed consent, before providing consent 23 .

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Information was collected on participants' age, school grade, gender, country of birth, language spoken at home, Aboriginal and Torres Strait Islander status, state of residence and who they lived with. Participants indicated if they had a parent or carer whose job had been impacted by the pandemic. Participants rated their self-rated health 24 , and were asked whether they had a chronic illness, had ever been diagnosed with depression or anxiety by a professional, and current mental health treatments.

The items below were generated from a previous survey 25 .

Participants were asked five yes/no questions about COVID-19 -whether they had been tested/diagnosed, whether a family member or close contact had been diagnosed, and whether they had been required to quarantine for 14 days. They then rated perceived likelihood would catch the virus on a visual analogue scale (VAS) from 0 (not at all likely) to 100 (extremely likely), and perceived behavioural control (i.e., how much they thought they could do to protect themselves from catching the virus), on a 0 (I can't do anything) to 100 (I can do a lot) VAS. The final questions assessed perceived illness severity if they did catch COVID-19 (response options were: no symptoms, mild symptoms, moderate symptoms, severe symptoms, severe symptoms requiring hospitalisation, and severe symptoms leading to death). All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted September 9, 2020. . https://doi.org/10.1101/2020.09.07.20190124 doi: medRxiv preprint Behaviour Change. Participants indicated whether they had engaged in eight social distancing and hygiene behaviours over the past week (hand washing, hand sanitising, facemask wearing, avoidance of: going to the shops/touching surfaces/spending time with people from outside the household/going to school and whether they stayed home as much as possible). Response options were on a 5-point scale (1=not at all to 5=to all of the time).

Physical and mental health. Young people were asked, in two separate questions, whether their physical and mental health had been impacted by the pandemic (a lot better, a little better, stayed the same, a little worse, a lot worse).

Respondents indicated whether their school shut down during the pandemic and whether they participated in online learning (both yes/no). Those engaged in online learning reported up to three challenging aspects of completing school work at home, from a forced choice list (not enough family support, parents working and didn't have time to help, access to technology, speed of internet, harder to learn online, too many distractions, not enough support from teachers, not motivated, other). Participants indicated how much they felt the pandemic had impacted their learning overall (positively, not at all, negatively).

Peer relationships. Two questions assessed how the pandemic had impacted participants' friendships; first, how socially connected they felt to their friends (more connected, no change, less connected); and second, impact on friendships overall (positively, negatively, not at all).

All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted September 9, 2020. . https://doi.org/10.1101/2020.09.07.20190124 doi: medRxiv preprint Family functioning. Two items assessed young people's family relationships, in terms of overall impact on relationships with family members (improved, no change, worsened), and impact on family stress levels (less stress, no stress, more stress).

Exercise. Participants indicated the number of days they exercised for at least 30 minutes over the previous week (0, 1-2 days, 2-4 days, 5-6 days, every day, don't know), and to report whether, they exercised more, less, or the same amount as they usually would.

Technology use. For the previous week, participants estimated total time spent in front of screens each day, not including time spent on school work (<1 hour, 1-2 hours, 2-4 hours, 6-8 hours, and >8 hours). They also reported how much time was used to connect with friends or family (same response options) and whether their use of technology had changed since the pandemic (less than before, the same, more than before).

Sleep. Sleep was measured using the Insomnia Severity Index (ISI), which is a sevenitem self-report measure of insomnia symptoms over the previous two weeks 26 . Responses are reported on a Likert scale from 0-4 with the following cut-off scores: 0-7 no clinically significant insomnia, 8-14 subthreshold insomnia, 15-21 moderate severity insomnia, 22-28 severe insomnia 26 . The ISI has been widely administered to, and validated in, general adolescent samples 27 .

A single item was selected to assess loneliness and was taken from the UCLA Loneliness Scale 28 . Participants were asked to indicate how often they felt alone over the past two weeks (hardly ever, some of the time, often). All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted September 9, 2020. . https://doi.org/10.1101/2020.09.07.20190124 doi: medRxiv preprint Uncertainty about the future. A single item was selected to ask participants about their feelings of uncertainty about the future, ranging from 'not at all' to 'extremely' on a five-point scale where a higher score represents greater levels of uncertainty.

The Kessler-6 (K6) assessed general psychological distress over the past 30 days 29, 30 , and the 7-item Warwick Edinburgh Mental Wellbeing Scale -short form SWEMWS; 31 assessed mental wellbeing over the past two weeks. Both scales have been validated for use in young people 32, 33 . The three item Body Preoccupation Scale of the Illness Attitude Scales 34 was administered to assess health anxiety.

Participants responded to study advertisements by clicking on a link which took them to the survey landing page. They read the electronic information sheet and consent form, completed the Gillick Competency Task, before accessing the survey. Upon completion, participants were placed in a draw to win one of five $50 vouchers.

Demographic and clinical characteristics were reported using descriptive analyses.

Where possible, outcomes from standardised measures were compared to normative, general population data. Independent samples t-tests compared participants with and without a prior diagnosis of anxiety and/or depression on outcome variables (e.g., K6). Zero order All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted September 9, 2020. . https://doi.org/10.1101/2020.09.07.20190124 doi: medRxiv preprint correlations were conducted between worry about COVID, behaviour change, lifestyle and mental health variables.

In total, 1743 young people viewed the study page, and 945 participants provided consent and started the survey. Of those, 185 did not provide enough data (<90% complete) to be included. The final sample comprised 760 participants. Table 1 summarizes participant characteristics. Participants were 14.8 years on average, and ranged in school year from Years 7-12. Most were female (72%), spoke English at home (87.7%) and were born in Australia (88.1%). Participants lived across all states and territories. Almost two-thirds of the sample (63.2%) reported living with two parents, and 50% indicated that their parent or carer's job had been impacted by the pandemic.

The mean rating for overall health was 3.44/5 (SD=1.01), with most rating their health as either 'good' (29.8%) or 'very good' (38.5%). Twenty one percent reported a current chronic illness, 34% reported a previous diagnosis of either depression or anxiety, and 27.8%

were receiving current mental health treatment (See Table 1 ).

Exposure. Only 0.3% had a diagnosis of COVID-19. Few participants had a family member who had contracted the virus (1.9%), while just under 10% had a close contact who had the virus. All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted September 9, 2020. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted September 9, 2020. . https://doi.org/10.1101/2020.09.07.20190124 doi: medRxiv preprint perpetuity.

preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in

The copyright holder for this this version posted September 9, 2020. 

Physical and mental health. See internet was also noted. Overall, two in three young people (62.6%) felt that the pandemic All rights reserved. No reuse allowed without permission.

perpetuity.

preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in

The copyright holder for this this version posted September 9, 2020. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted September 9, 2020. perpetuity.

preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in

The copyright holder for this this version posted September 9, 2020. . https://doi.org/10.1101/2020.09.07.20190124 doi: medRxiv preprint

See Table 2 . perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted September 9, 2020. . https://doi.org/10.1101/2020.09.07.20190124 doi: medRxiv preprint preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in

The copyright holder for this this version posted September 9, 2020. 

Young people with and without a self-reported diagnosis of depression and/or anxiety were compared on outcomes (See Table 3 ). After removing those who did not know if they had a diagnosis or chose not to say, 60% percent of the remaining sample reported no history of mental illness, and 40% reported a previous diagnosis of depression or anxiety (3.9% depression only, 12.6% anxiety only, and 23.3% both depression and anxiety). These categories were collapsed for the subsequent analyses into presence or absence of a diagnosed depression and/or anxiety. Participants with a history of depression or anxiety reported worse mental and physical health on all measures (see Table 3 ), and reported lower levels of exercise, great use of technology, poorer sleep, higher levels of loneliness, uncertainty about the future, psychological distress, health anxiety and lower levels of wellbeing (all ps <0.05; see Table 3 for full statistics).

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See Supplementary materials for results. There was a significant positive correlation between fears about contracting COVID-19, and behaviour change, feelings of uncertainty about the future, poor sleep, psychological distress, and health anxiety (all ps<.01). Greater exercise was associated with lower levels of screen time, better sleep, lower levels of psychological distress and a greater sense of wellbeing (ps<.01). Overall screen time was associated with more psychological distress; however, when screen time was used to connect with friends and family, the relationship with distress was no longer evident, and increased screen time for connection was associated with lower levels of loneliness and higher levels of wellbeing (ps<.01). Finally, as expected, all the mental health variables were significantly associated, with positive correlations between loneliness, health anxiety and psychological distress, and an inverse association between these variables and wellbeing being detected.

This survey of 760 Australian adolescents aged 12-18 years provides the first insight into the disruption experienced following the outbreak of the COVID-19 pandemic. Although respondents had little direct or indirect experience with COVID-19, more than three quarters were worried about contracting the virus, replicating findings with adults 6 and adolescents 14 .

Most young people believed they could reduce their risk of contracting COVID-19 and engaged in behaviors to lower their (e.g., handwashing and social distancing), in contrast to common portrayals by the media suggesting young people are not compliant with restrictions e.g., 35 . Our results showed that worry about contracting COVID-19 was associated with greater levels of overall behaviour change, demonstrating a practical benefit of some degree of worry.

This study also sheds light on the disruption and impact of the pandemic on young people's lives. Almost the whole sample (>95%) had engaged in online learning, and most reported a negative impact. At the time our survey was undertaken, schools and families had to adapt to online learning from home with little-to-no preparation time. While meta-analyses have shown that with optimal delivery and support, online formats can be as effective as faceto-face in terms of learning outcomes for adults 36 , there is no evidence to suggest this is the case for young people. Indeed, because school education is primarily face-to-face, data about the effectiveness of online schooling is lacking. Online learning requires a greater level of independence, motivation, and discipline than classroom learning and these are skills which young people may not have fully developed 37 .

Participants reported a negative effect of the pandemic on friendships, and feelings of loneliness, which were associated with higher psychological distress and lower wellbeing. perpetuity.

preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in

The copyright holder for this this version posted September 9, 2020. . https://doi.org/10.1101/2020.09.07.20190124 doi: medRxiv preprint 15 . Most young people in our study reported spending about 4 hours a day connecting with others online. Whether this will mitigate potential long-term consequences of social deprivation associated with lockdowns will need to be addressed by future longitudinal studies.

Most respondents indicated that the pandemic had increased stress levels within their family and half reported an impact on the job of a parent or carer. Viewed in this context, together with adjusting to online learning and the requirement for parents to manage their own professional responsibilities with caring and supporting their child's learning, it is not surprising this has been a stressful time for families. This aligns with findings from around the world that are beginning to highlight higher levels of stress and mental ill-health experienced by certain sub-groups of the population, including women, who are more likely to be in caring roles, as well as parents and young people 3, 7 . Despite this increased family stress, >50% indicated that their relationships with family members had remained unchanged, and an additional 18.7% reported an improvement. It could be the case that in some families, more time at home with family members has some advantages, and feeling more connected to loved ones is a benefit of COVID-19 that has been documented in the adult literature 41 .

Encouragingly, >50% of the young people continued with or increased their regular levels of exercise. There are well-documented links between exercise and reduced risk of depression and anxiety across the lifespan 42 and the relationship between exercise and lower levels of psychological distress and great wellbeing in our sample is consistent with this broader literature 15 . Given that even the strictest lockdowns in Australia have allowed for up to 1 hour of exercise per day, exercise could be promoted in public health campaigns as a means to prevent deteriorating mental health should the lockdown and period of restrictions continue. Relatedly, a significant proportion of young people also reported increased All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted September 9, 2020. . https://doi.org/10.1101/2020.09.07.20190124 doi: medRxiv preprint difficulty sleeping, and exercise is one way in which sleep quality and duration can be improved 43 , which was supported by our correlational analyses.

Of concern was that about half of the sample reported a worsening in their physical health since the pandemic began, while 75% reported a negative effect on their mental health.

The worsening of mental health in our sample was markedly consistent to that of a recent adult Australian survey 6 , which found that 78% of their respondents had reported worsened mental health. Overall, young people reported greater psychological distress and lower levels of wellbeing relative to normative data available from population surveys conducted prior to the pandemic 44, 45 , with rates of psychological distress indicative of probable mental illness increasing almost two fold from 24.3% before the pandemic 45 , to 48.3% in this survey. This finding accords from the studies from China showing elevated mental illness 8 . It is important to note that the K6 is not a diagnostic interview and so without information about the exact duration of the symptoms, degree of interference in daily life and distress to the individual, drawing diagnostic conclusions is not possible. We also cannot rule out the heightened levels of psychological distress as being at least in part attributable to sampling bias, inherent with online surveys. With these limitations in mind, our data nonetheless suggest that there are significantly elevated rates of psychological distress 45 , providing insight into the acute effects of the COVID-19 pandemic on adolescent mental health.

Over one third (34%) of participants had a self-reported history of depression or anxiety, which is comparable to lifetime prevalence estimates for adolescents 46 . Consistent with the adult literature 5,6 , our results showed that relative to those without a history of depression or anxiety, those with a history experienced heightened levels of loneliness, greater trouble sleeping, more uncertainty about the future, higher levels of health anxiety, greater psychological distress and lower levels of wellbeing among those who had a previously diagnosed mental illness. These finding advance knowledge of youth mental All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted September 9, 2020. . https://doi.org/10.1101/2020.09.07.20190124 doi: medRxiv preprint health by showing an exacerbation of mental illness among those with a history of anxiety and/or depression.

The findings reported in this study underscore the need for a proactive mental health response to support young people through this tumultuous and disruptive time in their lives.

High levels of psychological distress reported in this study are consistent with increased demands on youth mental health services e.g., 18 . Readily accessible interventions are needed for young people that are engaging and effective, with a focus on treatment, and prevention.

Digital mental health interventions, and blended modalities with combine digital with clinician support hold this promise 47 .

There are several study limitations. First, as a convenience sample recruited online due to the ease of rapid administration, 72% were female, limiting the generalizability of findings to the broader Australian adolescent population. The importance of sampling approach has been noted as a key concern during COVID-19 22 . Follow-up studies should use diagnostic assessments, to provide an independent assessment of mental health. The study was cross sectional and so causal conclusions cannot be drawn. We will be continuing to follow this sample longitudinally to learn about how their lives and mental health change over time in response to the pandemic. All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted September 9, 2020. . https://doi.org/10.1101/2020.09.07.20190124 doi: medRxiv preprint Acknowledgements:

Sincere thanks to all the study participants for taking part in this survey. Thanks also to Iana Wong for assisting with Qualtrics programming, to Dr Samantha Spanos for survey testing and to Dr Lyndsay Brown for providing feedback on the manuscript.

This study was supported by the Black Dog Institute, a NSW Health Fellowship awarded to AW-S, a MRFF Career Development Fellowship awarded to JN. The funders had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.

None to declare. All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted September 9, 2020. . https://doi.org/10.1101/2020.09.07.20190124 doi: medRxiv preprint All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted September 9, 2020. . https://doi.org/10.1101/2020.09.07.20190124 doi: medRxiv preprint

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