Reflections
www.thelancet.com/child-adolescent Vol 4 June 2020 421
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Mental health effects of school closures during COVID-19
The coronavirus disease 2019
(COVID-19) pandemic—and the
social distancing measures that
many countries have implemented—
have caused disruptions to daily
routines. As of April 8, 2020, schools
have been suspended nationwide
in 188 countries, according to
UNESCO. Over 90% of enrolled
learners (1·5 billion young people)
worldwide are now out of education.
The UNESCO Director-General Audrey
Azoulay warned that “the global scale
and speed of the current educational
disruption is unparalleled”.
For children and adolescents with
mental health needs, such closures
mean a lack of access to the resources
they usually have through schools.
In a survey by the mental health
charity YoungMinds, which included
2111 participants up to age 25 years
with a mental illness history in the
UK, 83% said the pandemic had made
their conditions worse. 26% said they
were unable to access mental health
support; peer support groups and faceto-face services have been cancelled,
and support by phone or online can be
challenging for some young people.
School routines are important coping
mechanisms for young people with
mental health issues. When schools are
closed, they lose an anchor in life and
their symptoms could relapse. “Going
to school had been a struggle for [some
children with depression] prior to the
pandemic, but at least they had school
routines to stick with”, said Zanonia
Chiu, a registered clinical psychologist
working with children and adolescents
in Hong Kong, where schools have been
closed since Feb 3. “Now that schools
are closed, some lock themselves
up inside their rooms for weeks,
refusing to take showers, eat, or leave
their beds.” For some children with
depression, there will be considerable
difculties adjusting back to normal life
when school resumes.
Children with special education
needs, such as those with autism
spectrum disorder, are also at risk.
They can become frustrated and
short-tempered when their daily
routines are disrupted, said psychiatrist
Chi-Hung Au (University of Hong Kong,
Hong Kong, China). He advised parents
to create a schedule for their children to
reduce anxiety induced by uncertainty.
With speech therapy sessions and
social skills groups suspended, he
cautions that stopping therapy can
stall progress, and children with
special needs might miss their chance
to develop essential skills. He points
out that creative ways, such as online
speech and social skills training, are
needed to make up for the loss.
Many countries are postponing
or cancelling university entrance
exams. In Hong Kong, the authorities
made a last-minute decision on
March 21 to push back the Diploma
of Secondary Education (DSE) exams,
which were scheduled to start on
March 27, by a month to April 24.
According to a poll by the student
counselling group Hok Yau Club
in March, 2020, over 20% of the
757 candidates surveyed said their
stress levels were at a maximum 10 out
of 10, even before the postponement
was announced. 17-year-old DSE
candidate Yoyo Fung has been
experiencing loss of appetite and sleep
problems, and said she found the
uncertainties of whether the exams
could be delayed further stressful.
“I have a huge wave of fear that I might
contract the virus and thus cannot
make it to the exams. Staying healthy
has become another stressor”, she said.
Meanwhile, college and university
students are stressed about dormitory
evacuation and cancellation of
anticipated events such as exchange
studies and graduation ceremonies.
Some lost their part-time jobs as
local businesses closed. Students in
their fnal years are anxious about the
job market they are going to enter
soon. “College students […] are more
vulnerable than we think, especially
with the current academic and fnancial
burden”, said Chiu.
Social distancing measures can
result in social isolation in an abusive
home, with abuse likely exacerbated
during this time of economic
uncertainty and stress. Jianli County
in Hubei province, China, has seen
reports of domestic violence to the
police more than triple during the
lockdown in February, from 47 last
year to 162 this year. Increased rates of
child abuse, neglect, and exploitation
have also been reported during
previous public health emergencies,
such as the Ebola outbreak in west
Africa from 2014 to 2016.
However, not much is known about
the long-term mental health effects
of large-scale disease outbreaks on
children and adolescents. While there
is some research on the psychological
impact of severe acute respiratory
syndrome (SARS) on patients and
health-care workers, not much is
known about the effects on ordinary
citizens. Evidence is especially scarce
in children and adolescents. “This
is an important gap for research”,
Au said. COVID-19 is much more
widespread than SARS and other
epidemics on a global scale. As the
pandemic continues, it is important
to support children and adolescents
facing bereavement and issues related
to parental unemployment or loss
of household income. There is also
a need to monitor young people’s
mental health status over the long
term, and to study how prolonged
school closures, strict social distancing
measures, and the pandemic itself
affect the wellbeing of children and
adolescents.
Joyce Lee
Published Online
April 14, 2020
https://doi.org/10.1016/
S2352-4642(20)30109-7
This online publication has
been corrected.
The corrected version frst
appeared at thelancet.com/
child-adolescent on
April 17, 2020
For more on UNESCO’s data on
school closures worldwide see
https://en.unesco.org/covid19/
educationresponse
For the survey by YoungMinds
see https://youngminds.org.uk/
about-us/reports/coronavirusimpact-on-young-people-withmental-health-needs
For more on the psychological
impact of quarantine see
Rapid Review Lancet 2020;
395: 912–20
kiankhoon/iStock