As the current coronavirus disease 2019 (COVID-19) continues to challenge public health, most recently by the emergence of new variants of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), schools in many regions of the world continue to be largely closed. It has been estimated that from March to May 2020, this affected up to 1.5 billion children and young people (CYP).
A new study by researchers in the US and the UK explores the damage caused by school closures to educational progress, health, and well-being in CYP globally. Surprisingly, the damage appears to be far less than was originally thought. The team has released their findings on the medRxiv* preprint server.
Perceived importance of schools
The aim of such closures was to reduce social interactions and possible transmission of the virus between CYP, and in turn, to others in their families. Despite a number of high-class studies, the effects of such closures remain controversial, with only partial evidence of protective outcomes.
In the sphere of education, most research hitherto has focused on the loss of work opportunities caused by school closures. However, says the current paper, “Education is one of the strongest determinants of health and disruption to it can influence health and wellbeing in various ways.” For one, they say, health and lifespan are negatively influenced by the loss of education.
Again, social support networks are breached, school healthcare and social protective mechanisms operating through schools are removed, physical activity is reduced, and among deprived sections of society, the loss of the school meals may cause a serious deficit in overall nutrition for CYP.
This is supported by international papers showing a broad range of ill effects on CYP due to physical isolation and school closures during the pandemic, exacerbated among those already among the lower socioeconomic strata.
Effects on healthcare seeking
The researchers found that Emergency Department (ED) attendances by CYP were lowered across all countries, by a range of 64% to 89%. The percentage of reduction was comparable across the major causes of attendance, such as respiratory infections, injuries and burns.
Total hospital admissions fell by 31% to 86% depending on the study and the country, across most of the developed world. Proportionally, ED admissions rose during lockdown by 13-15% for ward admissions, and by 6% for intensive care admissions among children in the UK. In Italy, the corresponding increase in ED admissions was by 164%.
Low-risk conditions such as fever and respiratory infections fell considerably as a cause for admission, while the rates for admission for pediatric asthma fell by 76%.
Admissions for domestic accidents rose five-fold in one Italian study but remained unchanged in another. One UK study showed an increase by almost 1500% for suspected head trauma due to abuse, but this was not confirmed by another. Hand trauma admissions fell by over 80% in one UK study.
Diabetes admissions in India fell by 80%, including a 75% drop in diabetes incidence, during the lockdown. Of the new cases during this period, all had severe diabetic ketoacidosis. This change was not found in a German study.
Presentation to healthcare
Did school closures during the lockdown impinge on the timely presentation of pediatric illnesses to healthcare? It would appear that despite the fall in hospital attendances, the actual number of deaths due to the delay was relatively low.
A UK study found that a third of pediatricians in urgent care, and about a fifth of other pediatricians, reported having had delayed presentations, with nine of the cases resulting in death as a result. In another study, there were over 50 cases of delayed presentation to the ED among CYP, with six admissions, including one intensive care admission.
In a five-center Italian study, there were 12 delayed presentations in a week, resulting in serious illness, with six intensive care admissions and four deaths. Most of these cases related to diabetic ketoacidosis, infection or cancer.
In Pakistan, daily immunization visits among infants fell by over 53%, but improved by half towards the end of the lockdown. Early vaccination of infants in the UK remained unchanged in the early phase of lockdown, but the first dose of the measles-mumps-rubella vaccine was delayed in a quarter of cases compared to pre-lockdown figures.
However, immunization coverage surpassed 2019 figures by the middle of this period.
Studies across the world showed no significant increases in suicide in the UK among CYP, while psychiatric admissions fell by over 40% during the lockdown. Similar marked reductions occurred for self-harm and other presentations at the ED related to mental health, with one US study pegging this decrease at 50% overall, and 63% for self-harm-related attendances.
Symptoms like anxiety and depression were found to be present in more than half the girls and over 44% of boys in the UK, between 13-18 years old, during the lockdown, compared to the general population. These were seen most commonly in CYP who had little family or peer support before the pandemic.
In China, some cross-sectional studies reported anxiety and depression in up to a fifth and two-fifths of CYP, though one paper put it at only 6%. This was echoed in the reporting of depressive symptoms among 25% to 30% of Canadian CYP and Bangladesh, and anxiety symptoms in about 20% in Brazil.
Suicidal ideas were reported in about a fifth of CYP between 16 and 18 over the week before the survey, up from 6% before the pandemic. Some studies report high levels of poor behavior, hyperactivity, poor concentration, but these are most frequent among children if they or their parents have pre-existing mental ill-health.
Another study showed that about 85% reported no difficulties with being at home during the lockdown, though 37% said they missed seeing friends and family. Among CYP, a study in the UK (among children 2-5 years old), and in Ireland (4-11 years), showed no evidence of decreased emotional well-being.
In the UK study, though parents reported reduced emotional turmoil and increases in poor behavior among 11-16-year-olds, the children themselves reported no change. Parents also reported better emotional health after the lockdown for children with pre-existing emotional problems in both studies.
Substance abuse figures were not available.
Notifications of child abuse in Florida and the UK fell, by a quarter and two-fifths, respectively. However, this is likely due to reduced school referrals.
In India, 13-25-year-olds said they were sleeping better during the lockdown. In Italy and Spain, CYP reported no changes in sleep.
About a quarter of CYP between 16 and 24 in one UK sample said they had developed sleep problems due to worries. This was mirrored in a small Italian study, with over 60% saying they found it difficult to fall asleep or stay asleep, and in China, with comparable numbers saying they slept eight or fewer hours a night.
Physical activity fell among CYP in the UK and in India, in up to half the sample, while a quarter reported higher levels. Spanish and Italian studies also showed that physical activity fell by a half. Screen time rose by about three hours a day, or by 245%, in Spain, but in India, by five hours, a rise of 70%, during lockdown. Similar results were found in Italy.
Social media use among older teenagers increased by over three hours a day, from 32% to 77%, in a Canadian study. This was reflected in England, showing a rise by three or more hours a day among girls but not boys on weekdays but not weekends.
Dietary consumption increased in some Indian, Italian, and Spanish studies, mostly of junk food, but eating disorders showed no change.
Conditions like enlarged tonsils, inflammatory bowel disease (IBD), and celiac disease showed fewer admissions and symptomatic improvement, but not glucose control in juvenile diabetes.
ED attendances were lower among those from African-American backgrounds or on public insurance. Poorer people in Pakistan were more likely to miss child vaccinations.
Behavioral problems were less reported among parents with higher income, while employees said their children had less behavioral and attention problems during the lockdown, compared to low-income and unemployed parents, respectively.
What are the implications?
While most of the studies indicated that CYP had suffered some adverse impacts because of the lockdown and school closures, most were of low quality. Few of the cross-sectional studies were representative of the study population due to the use of convenience sampling. Confounding factors were not adjusted for.
Secondly, direct comparisons are difficult due to the lack of pre-pandemic data and the confounding effect of the lockdown during the same period. However, available studies fail to identify school closures as the main reason for ED attendance changes during COVID-19.
In fact, there is evidence of benefit to CYP during this period. “For some CYP, time at home with care-givers may have strengthened social support and the sense of cohesion in some families or communities.”
The changes in psychological symptoms during this period are exaggerated by the use of convenience sampling, but there is evidence of some increase in anxiety and depressive symptoms. This is especially with prolonged or severe lockdown restrictions as in the Chinese study, or when either the parents or the children already have mental health complications.
Objective measures such as self-harm, or ED admissions for psychiatric illness show a clear reduction during the lockdown period. The number of suicides showed no significant change. This may be interpreted in the light of the observed beneficial effects of the school closure on emotional health in some studies, or as evidence of unmet psychological needs.
Overall, the study calls for more data on the long-term impacts of school closures with robust study designs. Such data is essential for framing policies on school reopenings in the context of this pandemic.
medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.