Wellbeing recovery: what should summer support programmes look like for schoolchildren this year?

• Children

• education

• roundtable report

• Wellbeing

This is a rapid, evidence-based response to the policy need that was identified at IPPO’s roundtable discussion on the mental health and wellbeing of young people. It has been written by a team of 13 academic specialists led by Dr Maria Loades from the University of Bath

Report summary

This paper offers a rapid, evidence-based answer to the question: how should this summer’s holiday support programmes for school-age children in the UK be designed and structured?

A particularly strong theme emerging from the International Public Policy Observatory roundtable on 11 February 2021 was the need to use the 2021 summer holiday not simply for children to catch up academically, but to give them a chance to recover in other ways: emotionally, physically and socially.

The evidence presented in this paper underscores that message: its authors conclude that this summer should not be filled with extra lessons. Rather, children, parents and teachers need time and space to recover, reconnect, and re-build confidence following the complex challenges of the past year.

While there is understandable concern about catching up academically, children will not learn effectively if their mental health and wellbeing is poor. Adequate nutrition, social interaction, play, physical activity, and good mental and physical health need to come first to enable academic catch-up and learning going forwards.

This paper presents five key considerations to underpin the design of any recovery plan for children during the summer holidays:

• Nutrition/diet: including provision of high-quality and varied food, plus opportunities to eat in social contexts and for hands-on involvement with preparing food.
• Sleep: sleeping well benefits children’s mental and physical health, and having a good sleep routine will help their transition back to school after the summer.
• Physical activity: the evidence suggests a clear association between physical exercise and good physical and mental health outcomes for children.
• Valued activity: social (re)connection, play, spending time outdoors and in nature, and creative arts can all help to overcome loneliness, promote wellbeing and inspire hope.
• Family support: parents can be empowered to help themselves and their children to recover, and to manage emergent emotional and behavioural difficulties.

This paper also offers suggestions for what this could mean in practice, in terms of designing:

• Structured summer programmes based on existing evidence-based approaches and community needs (a key recommendation is that these programmes should avoid looking or feeling like term-time school, with time allotted for free play every day).
• Community-based initiatives.
• Parental support programmes.
• Tailored support for children who need more individualised help, for example with their mental health (a summary of the groups of children who have been disproportionately affected by COVID-19 is included at the end of this paper).

Author’s note: throughout this paper, the term ‘children’ is used to refer to those of school-going age (i.e., 5-18 years old). ‘Parents’ is used to refer to parents or primary caregivers.

Part 1: Key negative impacts of COVID-19 for children

The past year of lockdowns and other virus containment measures have had a substantial impact on children. There have been marked individual differences in responses¹: while a minority of children have experienced benefits^2-6, there is growing evidence that the overall and longer-term impact has been detrimental:

1. Physical health. Food security has been profoundly affected, which has had a negative impact on diet quality and quantity, and reduced food variety. Increased levels of food insecurity have affected vulnerable groups such as families with children who normally receive free school meals, and families where parents’ income has suddenly reduced due to being unable to continue with their jobs in lockdown conditions.^7,8 Furthermore, lockdown/restrictions have changed the experience of food and eating as a social activity. Sleep patterns and quality have altered in children⁹ who are, on average, having more difficulties initiating and maintaining sleep, as well as delayed bedtimes and wake times.¹⁰ Many children are less physically active and more sedentary than they were prior to the pandemic.^9,11,12
2. Mental health and wellbeing. During the pandemic, there has been an increase in mental health issues among children. For example, in England, one in six (16%) 5–16-year-olds was identified as having a probable mental disorder in July 2020, an increase from one in nine (10.8%) in 2017.⁴ Difficulties have been heightened as restrictions have persisted.¹³ The pandemic and associated lockdown restrictions have brought a range of concerns and challenges for children and families including: worries about catching coronavirus¹⁴, the health/health of their family and friends¹⁵, food shortages/money worries¹⁶, worries about education and longer-term opportunities, school closures^5,17, school work and learning from home^18,19, exams and academic pressures²⁰, educational opportunities, the economy, and jobs^15,20, stresses around not seeing friends and restricted social interaction^21,22, feeling isolated and disconnected²³, managing boredom and not able to do enjoyable things ^5,14,15,24, managing ongoing uncertainty^25,26, a lack of opportunities to play²⁷, increased family stress and conflict²⁸, and increased child sexual abuse.²⁹ This has been compounded by decreased access to support, reflected in, for example, a decrease in referrals to mental health services^30,31 and for child protection³² although the use of helplines has increased.³³ Many children have not felt confident about knowing how to access support.⁵
3. Developmental progression. Childhood is a life stage of dramatic growth and development. Primary school leaders in the UK reported relative weaknesses in several developmental domains on the return to school in autumn 2020, including communication and language development, and fine and gross motor skills.³⁴ Some also reported decrements in social skills.³⁴ For teens, ongoing home confinement and lack of opportunities to explore, develop skills and gain confidence in their abilities separately from their family has had a likely impact on their sense of independence and on their development of key life skills, such as using public transport independently to get to school. Those who are at key transition points have missed out on activities that are symbolic rites of passage, such as proms and graduations.³⁵

Part 2: Why is this summer so important for children?

There is substantial evidence that good mental health and wellbeing are critical precursors to satisfactory learning and academic progress.^36-39 Furthermore, children who experience psychological distress are more likely to be excluded from school.⁴⁰ Therefore, if children are to achieve rapid, long-lasting and effective learning, we must first make sure that they are in a psychologically fit state to be taught.

The summer holidays are the mental health ‘reset button’ on the school year; there is evidence pre-pandemic that during this period of the year, adolescents’ symptoms of anxiety and depression and their reports of daily hassles are lower than during term-time.⁴¹ Suicide propensity is also known to decrease.⁴²

This summer, the ‘reset’ is even more important than usual as an opportunity to promote children’s social and emotional wellbeing, crucial to thriving at school and in post-lockdown life. Many children will already have gone back to school before the summer break, but this is unlikely to have been enough to remediate for the impacts of the pandemic. Therefore, the holiday period represents a key time to recover, develop, (re)build confidence, (re)establish friendships, and foster emotional health. Even though this may happen to some extent with summer holidays ‘as usual’, the evidence is that, alongside the benefits of weekends and summer holidays, children are usually less physically active during these times, and spend more time on screens, have more irregular sleep patterns, and eat less healthily – all of which might compound the negative impacts we have seen in children during lockdown.

Maximising the opportunity for physical and mental health recovery will require investment in a dedicated programme of support. To help children be physically and emotionally ready for academic learning in the next academic year, the key goals for the summer recovery programme are to remediate both the losses in physical health that have arisen, and the developmental, psychological, and social losses that children have experienced during the pandemic.

Part 3: Five key considerations to underpin this summer’s recovery strategy

Based on the evidence, the following key principles should be considered in planning for recovery in children during the summer holidays:

1. Nutrition/diet

Children are particularly vulnerable to poor nutrition and this can have a detrimental effect on their learning capabilities, mood, and physical health^3,43,44, with long-term consequences for their life chances. Children’s confidence in social interactions may have been reduced through lack of shared eating opportunities. The aim during recovery should be to ensure that children have access to high-quality nutrition with improved food security and food-related social interaction. Specifically, recovery will require:

(i) The provision of high quality and varied food, in appropriate quantities throughout the summer. On days when activities are provided, meals should be integrated into the plan and could include breakfast, hot meals, packed meals and/or healthy snacks. The importance of eating together for re-socialising children after lockdown should not be underestimated.

(ii) Opportunities for hands-on involvement with food. This could include engaging children in meal-planning, preparation, and cooking. Cookery classes have been shown to be effective in familiarising children with new foods.⁴⁵ They are often enjoyed by children and are likely to increase skills and confidence in teamwork, verbal communication, following instructions and making meals from fresh unprocessed ingredients.⁴⁶

(iii) Learning about healthy nutrition as a foundation for play activities. For example, gardening and growing edible items provide opportunities for children to make the connection between ‘farm’ and ‘fork’, as well as fostering other skills including social skills. The fruits and vegetables harvested can be prepared and consumed, adding to dietary variety.

2. Sleep

Good sleep is critical to physical and mental health, enabling physical recovery and repair as well as normal cognitive and emotional functioning.⁴⁷ Difficulties initiating and maintaining sleep are typically caused by stress, or poor bedtime routines. Persistent problems with sleep quality can lead to both immediate and longer-term difficulties across daily functioning such as concentration, attention, anxiety and low mood.⁴⁸ Since the beginning of the pandemic, children have shown greater difficulties initiating and maintaining sleep compared to pre-COVID, as well as delayed bedtimes and wake times.^9,10

This may also be a challenge when children return to school, and their sleep patterns do not suit their daily schedule. Although teenagers may be getting more sleep on school nights, compared to pre-pandemic, likely due to being able to wake up later as they do not have to travel to school, this increase in sleep time does not appear to reflect improvements in sleep quality.¹⁰

Various aspects of ‘lockdown life’ are likely to be unhelpful for sleep, such as home-schooling, particularly where schoolwork is done in the bedroom as this can break the body’s association between bedroom and sleep and recreate an association between bedroom and stimulation. As other aspects of life begin to return to normal, and children are encouraged to engage in a wider range of activities, it is important that sleep routines are prioritised including through the summer holidays. This will enable their physical and mental health recovery and their ability to engage in a range of different summer activities.

3. Physical activity

There is evidence that physical inactivity in children has increased since the start of the pandemic^9,11,49, and this may be particularly true of those living in urban areas.⁵⁰ Physical activity is linked to good physical health. Additionally, the evidence suggests a clear positive association between physical exercise and mental health, good cognitive (thinking) functioning, lower levels of psychological difficulties (e.g., depression, stress, negative affect, distress), and greater psychological wellbeing (i.e., self-image, satisfaction with life and happiness).^51-53 Activity selection and matching individual preferences are important so children need access to a range of options; inappropriate provision (e.g. of a sport that a child does not enjoy) may have negative impacts on their wellbeing.⁵⁴

4. Valued activity

Doing more of what matters (i.e., things that we value) is an important way to increase feelings of achievement, closeness, and enjoyment^55-57, all of which, ultimately, underpin good mental health. During the pandemic it has been difficult for children to engage in many of their normal valued activities, and this is likely to have contributed to feelings of disengagement, hopelessness, lack of motivation, boredom, and loneliness.^5,6,58 The summer holidays, therefore, provide a crucial opportunity for children and families to re-engage in these activities.  Many valued activities will involve spending time with other people outside of the home. Depending on age and individual preferences, valued activities may include playing, being outdoors and in nature, and engaging in any form of creativity (see below). After a long time away from valued activities, children might find it hard to re-engage and therefore support and encouragement is likely to be helpful. Children need to have opportunities provided for them, to be inspired and to regain a sense of hopefulness about their futures.

(i) Social (re)connection. Children need time to (re-)connect with one another socially: a lack of social interaction with peers has substantial impacts on the development of social skills and self-identity, and on mood.^59-62 Loneliness is associated with poor mental health, both depression and anxiety, both concurrently, and prospectively, up to nine years later.⁶³ There is evidence that loneliness has increased in schoolchildren during the pandemic.^5,6,64,65 Children need the time and opportunity to play and spend time with peers to socially (re)connect. Children need to (re)build their social networks, both in quality and quantity, to experience social rewards, to feel part of a group, and to know that there are others they can look to for support. They may need specific support to overcome loneliness.⁶⁶

(ii) Play. Although some children will have spent more time playing than usual during lockdown, either alone or with parents and siblings, many will have played less than usual. For example, there is evidence that Welsh children were playing less during the third lockdown compared to the first lockdown.⁵ Moreover, most children have missed out on seeing and playing with their peers.^5,21 This is worrying for two key reasons:

(a) Children’s social interaction with their peers happens primarily via play. Play with peers is unique because peer relationships are voluntary and egalitarian; they require negotiation and compromise in a way that sibling relationships do not.⁶⁷ Because of this, play with peers provides vital learning experiences that support healthy social, cognitive and literacy development.^37,68 Play is so essential to children’s wellbeing that The United Nations Convention on the Rights of the Child, Article 3169, defines play as a fundamental right. It has substantial benefits for children’s holistic development and emotional wellbeing.⁷⁰

(b) Play can help children to recover from difficult experiences and support their physical and mental health. Peer Play is beneficial during times of anxiety, stress and adversity⁷¹: it provides a sense of control and independence, it helps children make sense of things they find hard to understand⁷², and it supports their coping and resilience.⁷³ Importantly, in highly stressful situations (e.g. war zones, hospitals, orphanages), research has shown that playing with other children is therapeutic.^74,75

(iii) Being outdoors and in nature benefits wellbeing. Regular access to green space is beneficial to mental health and wellbeing in children.⁷⁶ Outdoor play has been linked to increased physical health as well as social and emotional health^77,78, and there is robust evidence that time spent outdoors and in nature is associated with stress recovery and decreases in anxiety.^79-81

(iv) Creative arts. Engagement with projects and initiatives in creative arts can have a positive impact on children’s wellbeing, confidence, social skills, academic achievement, and attitude towards learning.^82-84 Research also suggests that participation in creative arts can be especially important in re-engaging disengaged pupils with education and narrowing the gaps associated with disadvantage. Students who are highly engaged with creative arts, in comparison with those who are not, are more likely to graduate, enrol at university, participate in extra-curricular activities, and display civic engagement (e.g., community volunteering).^85,86 There is a gap in our understanding of the differences between curricular and extra-curricular creative arts programmes. However, ongoing work during the pandemic suggests that voluntary engagement with creative arts projects, as well as supportive and inclusive environments, appear to be beneficial for the development of positive psychological outcomes identified above.⁸⁷

5. Supporting families

Children are part of family systems in which adult caregivers play a pivotal role in promoting and maintaining their health and wellbeing. Parents of children in the UK have faced enormous demands and appear to have experienced an increase in mental ill-health during the pandemic^28,88-90, and parents in Europe have reported the negative effects of home-schooling, with increased stress, worry, social isolation and domestic conflict.⁹¹ There is extensive research that highlights the potential reciprocal relationship between child and parent distress, with recent evidence of this within the pandemic context⁹²; furthermore, there is clear evidence that parents can be supported and empowered to help their children manage emotional and behavioural difficulties, and that this brings benefits to both children and parents.^93,94

Part 4: What this means in practice – summer support programme design

This year, the summer holidays present an opportunity to promote children’s social, emotional, and physical recovery from the impacts of the pandemic and to deliver them to school in the new academic year in optimal readiness for learning. To maximise returns on this opportunity, we recommend the following:

1. Structured summer programmes

For the reasons outlined above, we recommend that summer programmes should not focus on direct academic instruction with formal classroom-based teaching, but on supporting psychosocial wellbeing. In other words, programmes should avoid looking or feeling like term-time school.

To be clear, this does not mean that very real academic concerns should be left unaddressed: on the contrary, there is much evidence that well-planned summer programmes can have significant impacts on children’s academic outcomes even if not directly focused on these.⁹⁵ For example, it has been shown that programmes focused on engagement with nature have concomitant effects on children’s academic performance, as well as the self-esteem, resilience, social skills, and physical development that they were primarily aiming for.⁹⁶ Programmes focused primarily on sports and physical activity have also been shown to have positive secondary impacts on children’s executive functioning (thinking, planning, and organising skills)⁹⁷ and other academic outcomes.⁹⁸

As well as the incidental learning that arises as part of such activities, skilled educationalists should be employed to devise activities that will not be perceived as formal learning, but which will bolster academic development. For example, a well-planned treasure hunt could integrate stealth literacy and numeracy activities while children have fun developing their softer skills of teamwork, negotiation, planning, and so on.

Summer programmes should be carefully planned, based on the existing evidence, and considering the needs of the specific population and community the programme is intended to serve. Involving families, children and community groups in the planning will be important for ensuring that what is provided is a good match to the needs of the community it serves. Furthermore, there are substantial developmental differences over the course of childhood, and it is important that planning takes account of the specific needs of both younger and older children. For example, as lockdown restrictions ease, adolescents may (in general) be more able to meet their own needs for social contact than younger children. Therefore, programmes will need to be tailored to meet the developmental needs of different age groups.

For further advice on developing high quality, evidence-based programmes, please see the RAND Corporation review. A good example of a well-evaluated, successful summer programme based on therapeutic principles is Over the Wall for children with chronic illnesses and their families. This programme pivoted their approach successfully and ran virtual summer camps in the summer of 2020, with evidence of wide-ranging benefits including increased self-confidence, increased positive feelings about the future, decreased worries and loneliness, feeling happier and improved ability to make friends⁹⁹. Another longstanding example is the Tower Hamlets Summer University (a.k.a. Futureversity), which provides independent learning programmes for young people aged 11 to 25.

However, it should also be noted that whilst structured activities are of enormous value, the opportunity for children to engage in free play should not be overlooked. The importance of free play to children’s development cannot be overstated, and we should not assume that high-quality free play opportunities with peers are available to all children equally; many children from disadvantaged backgrounds will have limited access to safe outdoor spaces and to high-quality green spaces where they can play with friends.¹⁰⁰

Even where structured programmes are available, it is important to ensure that children are not ‘over-scheduled’ with too many highly structured, adult-directed activities. There should be time for free play every day. For adolescents, ‘play’ may be less applicable than other self-directed and self-selected valued activities, which become an increasingly important source of identity and self-esteem with age.¹⁰¹ Adults can help independent free-play by giving children time, space, and resources to be creative. Children need to be offered choices to empower them to engage in valued activities of their choosing.

Given the evidence that mental health and safeguarding concerns may have increased during the pandemic, and the fact that there have been fewer opportunities for these to be identified, we suggest that any structured summer programmes are particularly alert to these issues. We recommend that all frontline summer programme staff receive high-quality training in identifying and responding to mental health and safeguarding concerns. Managers of summer programmes must establish strong links with local safeguarding and mental health services at an early stage, and ensure that a clear plan for responding to concerns is in place from the outset.

No child will thrive if they are hungry. It is essential that we set up systems to ensure that children receive healthy, filling meals during the summer. Some families will have adequate resources for this, but it is important that those with financial difficulties are supported in feeding their children. Food provision must be planned and tested to make sure it is fit for purpose. It is not enough to rely on charities such as food banks to supply food without support and funding. Different areas may have different solutions, but they should be in place before children finish school at the end of the summer term. Some meal provision should occur as an integral part of any structured summer activity provision. This could usefully include hands-on involvement from children.

Maintaining a consistent routine, being physically active and getting out of their bedrooms through the summer will be likely to promote children’s sleep and to help them to re-establish a sleep pattern that is more conducive to that required by attending school in the next academic year.

2. Community-based initiatives

Structured summer programmes are unlikely to be appropriate, available, or wanted in all contexts. To meet the needs of children in these environments, community-based initiatives become increasingly important. Examples of community based initiatives include the playstreets initiative^102,103, playwork practice in outdoor adventure playgrounds (e.g. thebigswing.org), large-scale loose parts play provision in school playgrounds¹⁰⁴, and organised trips to local nature reserves/country parks that include time for independent play such as following a nature trail in a small group. Summer projects in creative arts, particularly where they employ creative practitioners from diverse demographic and professional backgrounds trained in community arts project delivery, have strong potential to nourish the supportive and inclusive benefits described above.

3. Supporting parents

Parents need to be enabled, empowered, and supported to help their children to recover and thrive. In order to do this the basics needed to be covered, for example, food and access to activities (particularly for disadvantaged families), along with access to: (a) information to promote understanding of their child’s difficulties, (b) clear guidance on how best to support their child, (c) support to develop confidence and be empowered to support their child, (d) opportunities to gain understanding and support from others who have had similar experiences, along with (e) direct practical, social and psychological support for parents themselves.

Welcoming and parent-friendly Summer Activities could help re-establish a supportive community amongst parents, for example by inviting parents to interact at drop-off, or by holding formal or informal parent support sessions before pick-up. Summer programmes that establish links with local parent-support agencies could offer parents workshops on issues of known difficulty. Where parents are facing particular difficulties with child emotional or behavioural difficulties, support needs to be available that can be accessed rapidly and in ways that work for parents (who may be juggling work and childcare demands), including flexible digital options (see for example^105,106). Given the mental health impacts of the pandemic on parents, rapid access to mental health support for parents of under-18s is needed.

4. Tailored support

Based on evidence from previous epidemics, some children will need more individualised help and support with their physical health (e.g. addressing sleep, diet), mental health (including social and emotional wellbeing) and developmental gaps, following exposure to virus containment measures.¹⁰⁷ Structured summer activities will provide an opportunity to identify those in need and to signpost them to help and refer to support services. This will include those children with difficulties that have increased in frequency during the pandemic; e.g. eating disorders and tics.^108,109

For some children, an individualised approach will be needed to ensure that emergent mental health problems do not continue to interfere with their functioning over the long-term. Therefore, we need to ensure that both safeguarding and mental health services are prepared to deal with an increase in demand and can provide assessments and evidence-based treatments in a timely and accessible manner, including remotely.

Part 5: Which groups of children have been disproportionately affected by COVID-19?

There is evidence that those living under more severe lockdown restrictions have been disproportionately impacted¹¹⁰; therefore, efforts should be directed to areas of the UK that have experienced the longest and most severe restrictions. Those children who are due to move schools (e.g., from primary to secondary school) have specific needs which may, in the pandemic context, also require particular consideration.^111-113

Additionally, there is growing evidence that some groups of children are likely to have suffered disproportionately during the pandemic (see Table 1). Responses need to be co-developed with children and families from the communities that they will be supporting to ensure they are engaging, accessible, and meet their needs. Where resources are limited, efforts should be made to target those who have suffered most, or who are likely to experience the most disadvantage going forwards.

Table 1: Summary of evidence pertaining to specific groups which have been disproportionately affected during the pandemic

Specific group	Evidence of how this group has been disproportionately affected
Age	Although the increase in the prevalence of mental health problems during the pandemic, compared to pre-pandemic levels, has been similar among primary and secondary schoolchildren114, the types of difficulties experienced and timing of particular difficulties has varied with age.13,114 Parent-reported increases in emotional and behavioural difficulties have been higher in primary compared to secondary school aged children in the UK.13 High levels of emotional problems were reported in secondary school-aged girls in the most recent UK lockdown.13
Ethnicity	Studies in the USA that followed-up participants who provided data before the pandemic and compared this to their experience during the pandemic found that multiracial adolescents reported a more negative impact on their mental health than Hispanic/Latino adolescents, and Black/African American adolescents showed smaller increases in depressive symptoms than white adolescents.110 In the UK, young people (aged 16-24) who identified as Black/Black British ethnicity were almost four times more likely to experience poor mental health.115 In Wales, children from ethnic minority backgrounds were more likely to have had more negative experiences of lockdown and were more likely to feel unsafe and lonely.5 In a multi-ethnic cohort in Bradford, those children from families who identified as ‘Pakistani’ or ‘Other’ ethnicity were less likely to meet the guidelines for minimum physical activity per day than ‘White British’ children.12
Poverty	Children living in low income households have had consistently and substantially elevated mental health symptoms throughout the pandemic.13 Moreover, this group of children may be most vulnerable to loss of academic skills during lockdown116 as has been shown during summer holidays prior to the pandemic.117
Children without siblings	During the first UK lockdown, children without a sibling showed an overall increase in mental health symptoms1, potentially because of a heightened risk of loneliness because of not being in school and around peers63 and from the lack the support and companionship that having a sibling can provide. Previous research has demonstrated that the presence of a sibling is a protective factor for children experiencing stressful life events.118
Children who identify as LGBQT+	There is some evidence that LGBTQ+ adolescents are experiencing greater mental health difficulties during the pandemic than other adolescents.29,119,120
Pre-existing mental health problems or heightened risk for mental health problems	Some studies conducted early in the pandemic (during lockdown 1) found that some children who had struggled with mental health prior to the pandemic reported a reduction in mental health symptoms.121 Subsequent studies have shown that children with probable mental disorders were more likely to report being worried about the virus and associated risks and to say that lockdown had made their life worse than those unlikely to have a mental disorder.29 Worsening of symptoms has been reported among children with eating disorders and, obsessive compulsive disorder compared to pre-pandemic (OCD).122,123
Children with SEN and/or developmental disorders (such as ASD and/or ADHD)	Children with special educational needs and/or neurodevelopmental disorders have had consistently and substantially elevated mental health symptoms throughout the pandemic.13,124 They have also reported difficulties in accessing specialist services.5,125 Adolescents with ADHD were more likely to experience an increase in inattention, hyperactivity/impulsivity and oppositional/defiant symptoms from shortly before the pandemic to the spring-summer of 2020 as compared to those without ADHD.126 There may have also been disproportionate challenges faced by children with learning disabilities.127
Children with chronic illnesses	Children with chronic illnesses such as allergies, asthma, heart problems, obesity and gastrointestinal problems are generally at heightened risk of developing mental health problems.128 Canadian adolescents and young adults with chronic illnesses have reported greater declines in mental health compared to those without chronic illnesses.129
Children of parents with mental health problems	In England, in July 2020, 30.2% of children whose parent experienced psychological distress were found to have a probable mental disorder, compared with 9.3% of children whose parent was not experiencing psychological distress.89 Parents have been found to have experienced greater increases in mental distress during the pandemic than other working age adults88, particularly parents with pre-existing mental health problems.122 In the pandemic context, families with higher levels of conflict and lower levels of warmth have tended to report elevated mental health problems.1 Whilst these children can be difficult to identify, schools will often be aware, and could nominate children for extra support, as could organisations that support young carers.

Concluding comments

• There is understandable concern about catching up academically, but children will not learn effectively if their mental health and wellbeing is poor.
• Adequate nutrition, social interaction, play, physical activity, and good mental and physical health need to come first to enable academic catch-up and learning going forwards.
• Therefore, this summer should not be filled with extra lessons; children, parents and teachers need time and space to recover, reconnect, and (re)build confidence following the challenges of the past year.

 

Appendix

Contributors to this IPPO paper:

Name	Professional role	Organisational affiliation
Maria Loades	Senior Lecturer in Clinical Psychology	University of Bath
Ruth Sellers	Senior Lecturer in Child Development & Community Mental Health	University of Sussex
Jenny Gibson	Senior Lecturer in Psychology & Education	University of Cambridge
Helen Dodd	Professor of Child Psychology	University of Reading
Sam Cartwright-Hatton	Professor of Clinical Child Psychology	University of Sussex
Pauline Emmett	Senior Research Fellow, Centre for Academic Child Health	University of Bristol
Caroline Taylor	Senior Research Fellow, Centre for Academic Child Health	University of Bristol
Cathy Creswell	Professor of Developmental Clinical Psychology	University of Oxford
Maruša Levstek	PhD Student, School of Psychology	University of Sussex
Robin Banerjee	Professor of Developmental Psychology	University of Sussex
Faith Orchard	Lecturer in Psychology	University of Sussex
Shirley Reynolds	Visiting Professor	University of Reading
Polly Waite	Associate Professor of Clinical Psychology	Universities of Oxford and Reading
Roz Shafran	Professor of Translational Psychology	UCL Great Ormond Street Institute of Child Health

Acknowledgements

With thanks to Rosie Hutson, placement student at the University of Sussex who supported the literature searches.

References

1. Raw J, Waite P, Pearcey S, Creswell C, Shum A, Patalay P. Examining changes in parent-reported child and adolescent mental health throughout the UK’s first COVID-19 national lockdown. 2021.
2. Stallard P, Pereira AI, Barros L. Post-traumatic growth during the COVID-19 pandemic in carers of children in Portugal and the UK: cross-sectional online survey. BJPsych Open. 2021;7(1).
3. Khalid H, Gill S, Fox AM. Global aid for nutrition-specific and nutrition-sensitive interventions and proportion of stunted children across low-and middle-income countries: does aid matter? Health policy and planning. 2019;34(Supplement_2):ii18-ii27.
4. Digital N. Mental Health of Children and Young People in England, 2020: Wave 1 follow up to the 2017 survey. https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2020-wave-1-follow-up Published 2020. Accessed.
5. CCfW. Coronavirus and Me: A second nationwide survey of the views and experiences of children and young people in Wales. 2021.
6. Lockyer B, Sheard H, Smith H, et al. Her whole little life has changed dramatically. Findings of a qualitative study into children’s mental wellbeing in Bradford during Covid-19. 2020.
7. Loopstra R. Vulnerability to food insecurity since the COVID-19 lockdown. London: The Food Foundation. 2020.
8. Barker M, Russell J. Feeding the food insecure in Britain: learning from the 2020 COVID-19 crisis. Food Security. 2020;12(4):865-870.
9. Bates LC, Zieff G, Stanford K, et al. COVID-19 Impact on behaviors across the 24-hour day in children and adolescents: physical activity, sedentary behavior, and sleep. Children. 2020;7(9):138.
10. Becker SP, Dvorsky MR, Breaux R, Cusick CN, Taylor KP, Langberg JM. Prospective Examination of Adolescent Sleep Patterns and Behaviors Before and During COVID-19. Sleep. 2021.
11. Dunton GF, Do B, Wang SD. Early effects of the COVID-19 pandemic on physical activity and sedentary behavior in children living in the U.S. BMC Public Health. 2020;20(1):1351.
12. C-SAG B. Children’s physical activity during Covid-19 from the Born in Bradford Cohort. 2021.
13. Skripkauskaite S, Shum A, Pearcey S, Raw J, Waite P, Creswell C. Changes in children’s and young people’s mental health symptoms: March 2020 to January 2021. 2021.
14. MIND. The mental health emergency. How has the coronavirus pandemic impacted our mental health? . 2020.
15. Girlguiding. Impact of COVID-19 on girls and young women. 2020.
16. Pearcey S, Shum A, Waite P, Creswell C. Supplementary Report 04: Pandemic related worries over time, between keyworker and non-keyworker parent/carers, and households with and without a COVID case; Changes in household arguments over time; Changes in avoidance of COVID-19 discussions with primary and secondary children; Parent-reported stressors. 2020.
17. Parliament SY. LockdownLowdown – what young people in Scotland are thinking about COVID-19. 2020.
18. Scotland CsP. How are you doing? A report on the findings from the How are you doing? Survey using data from April, May and June 2020.
19. TeenCovidLife S. TeenCovidLife Survey 1 General Report Health and wellbeing of young people in lockdown. 2020.
20. Shum A, Pearcey S, Waite P, Creswell C. Supplementary Report 06: Young people’s concerns about the return to school (Parent and Self-report). 2020.
21. Pearcey S, Raw J, Shum A, Waite P, Creswell C. Communication with friends (Sept 2020). 2020.
22. Wigg CMD, de Almeida Coutinho IMF, da Silva IC, Lopes LB. The mental health of children and adolescents during the COVID-19 pandemic: a narrative review. Research, Society and Development. 2020;9(9):e704997687-e704997687.
23. England CsCf. Stress among children in England during the coronavirus lockdown. . 2020.
24. Council VSE. Youth voices project in Essex ‘Youth in Lockdown’ April-June 2020. 2020.
25. Pearcey S, Raw J, Shum A, Waite P, Creswell C. Supplementary Report 08: Parent and child concerns about attending school. 2020.
26. OxWell SS. Preliminary Summary Report from the OxWell School Survey 2020. 2020.
27. Graber KM, Byrne EM, Goodacre EJ, et al. A rapid review of the impact of quarantine and restricted environments on children’s play and the role of play in children’s health. Child: care, health and development. 2021;47(2):143-153.
28. Shum A, Skripkauskaite S, Pearcey S, Raw J, Waite P, Creswell C. Changes in parents’ mental health symptoms and stressors (Jan 2021). 2021.
29. Jeffery M, Gilleard A, Lereya T, Edbrooke-Childs J, Deighton J, Cortina MA. Emerging Evidence: Coronavirus and children and young people’s mental health. 2020.
30. Chen S, Jones PB, Underwood BR, et al. The early impact of COVID-19 on mental health and community physical health services and their patients’ mortality in Cambridgeshire and Peterborough, UK. J Psychiatr Res. 2020;131:244-254.
31. Greater Manchester News.
32. Viner RM, Russell S, Saulle R, et al. Impacts of school closures on physical and mental health of children and young people: a systematic review. MedRxiv. 2021.
33. Hennessy M. Isolated at home with their tormentor”: Childline experiences increase in calls since closure of schools. The Journal. 2020.
34. OFSTED. COVID-19 series: briefing on schools, November 2020: Evidence from interim visits to 297 schools between 2 and 24 November 2020. 2020.
35. Demkowicz O, Ashworth E, O’Neill A, Hanley T, Pert K. Teenagers’ Experiences of Life in Lockdown: The TELL study briefing. 2020.
36. Wickersham A, Sugg HVR, Epstein S, Stewart R, Ford T, Downs J. Systematic Review and Meta-analysis: The Association Between Child and Adolescent Depression and Later Educational Attainment. Journal of the American Academy of Child & Adolescent Psychiatry. 2021;60(1):105-118.
37. Gibson JL, Newbury DF, Durkin K, Pickles A, Conti-Ramsden G, Toseeb U. Pathways from the early language and communication environment to literacy outcomes at the end of primary school; the roles of language development and social development. Oxford Review of Education. 2020:1-24.
38. Agnafors S, Barmark M, Sydsjö G. Mental health and academic performance: a study on selection and causation effects from childhood to early adulthood. Social Psychiatry and Psychiatric Epidemiology. 2020:1-10.
39. Wentzel KR, Jablansky S, Scalise NR. Peer social acceptance and academic achievement: A meta-analytic study. Journal of Educational Psychology. 2021;113(1):157.
40. Ford T, Parker C, Salim J, Goodman R, Logan S, Henley W. The relationship between exclusion from school and mental health: a secondary analysis of the British Child and Adolescent Mental Health Surveys 2004 and 2007. Psychological medicine. 2018;48(4):629-641.
41. Verma S, Allen NB, Trinder J, Bei B. Highs and lows: Naturalistic changes in mood and everyday hassles over school and vacation periods in adolescents. Journal of adolescence. 2017;61:17-21.
42. Laido Z, Voracek M, Till B, et al. Epidemiology of suicide among children and adolescents in Austria, 2001–2014. Wiener klinische Wochenschrift. 2017;129(3-4):121-128.
43. Sinha IP, Lee AR, Bennett D, et al. Child poverty, food insecurity, and respiratory health during the COVID-19 pandemic. The Lancet Respiratory Medicine. 2020;8(8):762-763.
44. Sorhaindo A, Feinstein L. What is the relationship between child nutrition and school outcomes?[Wider Benefits of Learning Research Report No. 18]. Centre for Research on the Wider Benefits of Learning, Institute of …; 2006.
45. Hasan B, Thompson WG, Almasri J, et al. The effect of culinary interventions (cooking classes) on dietary intake and behavioral change: a systematic review and evidence map. BMC nutrition. 2019;5(1):29.
46. Drummond C. Using nutrition education and cooking classes in primary schools to encourage healthy eating. The Journal of Student Wellbeing. 2010;4(2):43-54.
47. Gregory AM, Sadeh A. Annual Research Review: Sleep problems in childhood psychiatric disorders–a review of the latest science. Journal of child psychology and psychiatry. 2016;57(3):296-317.
48. Orchard F, Gregory AM, Gradisar M, Reynolds S. Self-reported sleep patterns and quality amongst adolescents: cross-sectional and prospective associations with anxiety and depression. Journal of child psychology and psychiatry, and allied disciplines. 2020.
49. López-Bueno R, López-Sánchez GF, Casajús JA, Calatayud J, Tully MA, Smith L. Potential health-related behaviors for pre-school and school-aged children during COVID-19 lockdown: A narrative review. Preventive Medicine. 2021;143:106349.
50. Chambonniere C, Lambert C, Fearnbach N, et al. Effect of the COVID-19 lockdown on physical activity and sedentary behaviors in French children and adolescents: New results from the ONAPS national survey. European Journal of Integrative Medicine. 2021;43:101308.
51. Biddle SJ, Ciaccioni S, Thomas G, Vergeer I. Physical activity and mental health in children and adolescents: An updated review of reviews and an analysis of causality. Psychology of Sport and Exercise. 2019;42:146-155.
52. Rodriguez-Ayllon M, Cadenas-Sánchez C, Estévez-López F, et al. Role of physical activity and sedentary behavior in the mental health of preschoolers, children and adolescents: a systematic review and meta-analysis. Sports medicine. 2019;49(9):1383-1410.
53. Dale LP, Vanderloo L, Moore S, Faulkner G. Physical activity and depression, anxiety, and self-esteem in children and youth: an umbrella systematic review. Mental health and physical activity. 2019;16:66-79.
54. Bailey R, Howells K, Glibo I. Physical activity and mental health of school-aged children andadolescents: A rapid review. International Journal of Physical Education. 2018;55(1):1-14.
55. Aafjes-van Doorn K, Sweeney K. The effectiveness of initial therapy contact: A systematic review. Clinical psychology review. 2019;74:101786.
56. Lewis-Smith I, Pass L, Reynolds S. How adolescents understand their values: A qualitative study. Clinical child psychology and psychiatry. 2021;26(1):231-242.
57. Reynolds S, Pass L. Brief Behavioural Activation for Adolescent Depression: A Clinician’s Manual and Session-by-Session Guide. Jessica Kingsley Publishers; 2020.
58. YoungMinds. Mental health ‘much worse’ for many young people with mental health needs – new report. 2020.
59. Blakemore S-J. Adolescence and mental health. The Lancet. 2019;393(10185):2030-2031.
60. Blakemore S-J. Development of the social brain in adolescence. Journal of the Royal Society of Medicine. 2012;105(3):111-116.
61. Blakemore SJ, Choudhury S. Development of the adolescent brain: implications for executive function and social cognition. Journal of child psychology and psychiatry. 2006;47(3‐4):296-312.
62. Orben A, Tomova L, Blakemore S-J. The effects of social deprivation on adolescent development and mental health. The Lancet Child & Adolescent Health. 2020;4(8):634-640.
63. Loades ME, Chatburn E, Higson-Sweeney N, et al. Rapid Systematic Review: The Impact of Social Isolation and Loneliness on the Mental Health of Children and Adolescents in the Context of COVID-19. Journal of the American Academy of Child & Adolescent Psychiatry.
64. How Adolescents Use Social Media to Cope with Feelings of Loneliness and Anxiety During COVID-19 Lockdown. Cyberpsychology, Behavior, and Social Networking.0(0):null.
65. Ellis WE, Dumas TM, Forbes LM. Physically isolated but socially connected: Psychological adjustment and stress among adolescents during the initial COVID-19 crisis. Canadian Journal of Behavioural Science/Revue canadienne des sciences du comportement. 2020;52(3):177.
66. Loades ME, Demkowicz O, Qualter P, Shafran R. Loneliness and Reconnection Guide. https://www.bath.ac.uk/publications/loneliness-and-reconnection-guide/. Published 2021. Accessed.
67. Rubin KH, Coplan R, Chen X, Buskirk AA, Wojslawowicz JC. Peer relationships in childhood. 2005.
68. Goldstein J. Play in children’s development, health and wellbeing. Toy Industries of Europe Brussels; 2012.
69. McGoldrick D. The United Nations convention on the rights of the child. International Journal of Law, Policy and the Family. 1991;5(2):132-169.
70. Hobbs C, Atkinson C, Barclay M, Bristow S, Finney R, Mannello M. Children’s right to play.
71. Fearn M, Howard J. Play as a resource for children facing adversity: An exploration of indicative case studies. Children & Society. 2012;26(6):456-468.
72. Levin DE. Beyond banning war and superhero play. Young Children. 2003:61.
73. Lester S, Russell W. Play for a Change. National Children’s Bureau; 2008.
74. Feldman D. Children’s Play in the Shadow of War. American journal of play. 2019;11(3):288-307.
75. Brown F, Webb S. Children without play. Journal of Education. 2005;35(1):139-158.
76. McCormick R. Does Access to Green Space Impact the Mental Wellbeing of Children: A Systematic Review. Journal of pediatric nursing. 2017;37:3-7.
77. Dodd HF, Lester KJ. Adventurous play as a mechanism for reducing risk for childhood anxiety: a conceptual model. Clinical child and family psychology review. 2021:1-18.
78. Tremblay MS, Gray C, Babcock S, et al. Position statement on active outdoor play. International journal of environmental research and public health. 2015;12(6):6475-6505.
79. Gill T. The benefits of children’s engagement with nature: A systematic literature review. Children Youth and Environments. 2014;24(2):10-34.
80. Roe J, Aspinall P. The restorative outcomes of forest school and conventional school in young people with good and poor behaviour. Urban forestry & urban greening. 2011;10(3):205-212.
81. Ulrich RS, Simons RF, Losito BD, Fiorito E, Miles MA, Zelson M. Stress recovery during exposure to natural and urban environments. Journal of environmental psychology. 1991;11(3):201-230.
82. Bungay H, Vella-Burrows T. The effects of participating in creative activities on the health and wellbeing of children and young people: a rapid review of the literature. Perspectives in Public Health. 2013;133(1):44-52.
83. See BH, Kokotsaki D. Impact of arts education on children’s learning and wider outcomes. Review of Education. 2016;4(3):234-262.
84. Jindal-Snape D, Davies D, Scott R, Robb A, Murray C, Harkins C. Impact of arts participation on children’s achievement: A systematic literature review. Thinking Skills and Creativity. 2018;29:59-70.
85. Catterall JS. The Arts and Achievement in At-Risk Youth: Findings from Four Longitudinal Studies. Research Report# 55. National Endowment for the Arts. 2012.
86. Hallam S, Council ME. The power of music: A research synthesis of the impact of actively making music on the intellectual, social and personal development of children and young people. International Music Education Research Centre (iMerc); 2015.
87. Levstek M, Banerjee RA. A Model of Psychological Mechanisms of Inclusive Music-Making: Empowerment of Marginalised Young People [Manuscript submitted for publication], School of Psychology, University of Sussex. 2021.
88. Shevlin M, McBride O, Murphy J, et al. Anxiety, depression, traumatic stress and COVID-19-related anxiety in the UK general population during the COVID-19 pandemic. BJPsych Open. 2020;6(6).
89. Pierce M, Hope H, Ford T, et al. Mental health before and during the COVID-19 pandemic: a longitudinal probability sample survey of the UK population. The Lancet Psychiatry. 2020.
90. Chandola T, Kumari M, Booker CL, Benzeval M. The mental health impact of COVID-19 and lockdown-related stressors among adults in the UK. Psychological medicine. 2020:1-10.
91. Thorell LB, Skoglund C, de la Peña AG, et al. Parental experiences of homeschooling during the COVID-19 pandemic: differences between seven European countries and between children with and without mental health conditions. European child & adolescent psychiatry. 2021:1-13.
92. Russell BS, Hutchison M, Tambling R, Tomkunas AJ, Horton AL. Initial Challenges of Caregiving During COVID-19: Caregiver Burden, Mental Health, and the Parent–Child Relationship. Child Psychiatry & Human Development. 2020;51(5):671-682.
93. Bennett C, Barlow J, Huband N, Smailagic N, Roloff V. Group-based parenting programs for improving parenting and psychosocial functioning: A systematic review. In: Society for Social Work and Research; 2013:300-332.
94. Barrhök J, Huss L. Why does parents’ mental health improves by participation in parent training programs?-Testing two mediating pathways. In:2016.
95. McCombs JS, Augustine CH, Unlu F, et al. Investing in Successful Summer Programs: A Review of Evidence under the Every Student Succeeds Act. RR-2836-WF. ERIC; 2019.
96. Mygind L, Kjeldsted E, Hartmeyer R, Mygind E, Bølling M, Bentsen P. Mental, physical and social health benefits of immersive nature-experience for children and adolescents: a systematic review and quality assessment of the evidence. Health & place. 2019;58:102136.
97. Alvarez-Bueno C, Pesce C, Cavero-Redondo I, Sanchez-Lopez M, Martínez-Hortelano JA, Martinez-Vizcaino V. The effect of physical activity interventions on children’s cognition and metacognition: A systematic review and meta-analysis. Journal of the American Academy of Child & Adolescent Psychiatry. 2017;56(9):729-738.
98. Vazou S, Pesce C, Lakes K, Smiley-Oyen A. More than one road leads to Rome: a narrative review and meta-analysis of physical activity intervention effects on cognition in youth. International Journal of Sport and Exercise Psychology. 2019;17(2):153-178.
99. Jolly A. Over The Wall: Camp in the Clouds report. In:2021.
100. Crawford D, Timperio A, Giles-Corti B, et al. Do features of public open spaces vary according to neighbourhood socio-economic status? Health & place. 2008;14(4):889-893.
101. Crenna-Jennings W. Young People’s Mental and Emotional Health: Trajectories and Drivers in childhood and adolescence. 2021.
102. Pike EC, Page A, Vinas V. Playing Out: A Movement for Movement? Frontiers in Sociology. 2018;3:32.
103. Ferguson A. Playing out: a grassroots street play revolution. Cities & health. 2019;3(1-2):20-28.
104. Bundy A, Engelen L, Wyver S, et al. Sydney playground project: a cluster‐randomized trial to increase physical activity, play, and social skills. Journal of school health. 2017;87(10):751-759.
105. Co-CAT. https://osiresearch.org.uk/co-cat/.  Accessed 09/03/2021.
106. KCL. https://www.kcl.ac.uk/news/new-project-to-develop-an-app-that-addresses-the-negative-effect-of-covid-19-on-childrens-behaviour.
107. Sprang G, Silman M. Posttraumatic stress disorder in parents and youth after health-related disasters. Disaster medicine and public health preparedness. 2013;7(1):105-110.
108. Heyman I, Liang H, Hedderly T. COVID-19 related increase in childhood tics and tic-like attacks. Archives of disease in childhood. 2021:archdischild-2021-321748.
109. Cooper M, Reilly EE, Siegel JA, et al. Eating disorders during the COVID-19 pandemic and quarantine: an overview of risks and recommendations for treatment and early intervention. Eating disorders. 2020:1-23.
110. Barendse M, Flannery J, Cavanagh C, et al. Longitudinal change in adolescent depression and anxiety symptoms from before to during the COVID-19 pandemic: An international collaborative of 12 samples. 2021.
111. West P, Sweeting H, Young R. Transition matters: pupils’ experiences of the primary–secondary school transition in the West of Scotland and consequences for well‐being and attainment. Research papers in education. 2010;25(1):21-50.
112. Rice F, Frederickson N, Seymour J. Assessing pupil concerns about transition to secondary school. British Journal of Educational Psychology. 2011;81(2):244-263.
113. Evans D, Borriello GA, Field AP. A review of the academic and psychological impact of the transition to secondary education. Frontiers in psychology. 2018;9:1482.
114. Newlove-Delgado T, McManus S, Sadler K, et al. Child mental health in England before and during the COVID-19 lockdown. The Lancet Psychiatry.
115. Dewa LH, Crandell C, Choong E, et al. CCopeY: A Mixed-Methods Coproduced Study on the Mental Health Status and Coping Strategies of Young People During COVID-19 UK Lockdown. Journal of Adolescent Health. 2021.
116. Chor E. Unequal Impact: COVID-19 and Early Childhood Education. COVID-19 Research. 2020.
117. Morgan K, Melendez-Torres GJ, Bond A, et al. Socio-Economic Inequalities in Adolescent Summer Holiday Experiences, and Mental Wellbeing on Return to School: Analysis of the School Health Research Network/Health Behaviour in School-Aged Children Survey in Wales. International Journal of Environmental Research and Public Health. 2019;16(7):1107.
118. Gass K, Jenkins J, Dunn J. Are sibling relationships protective? A longitudinal study. Journal of child psychology and psychiatry. 2007;48(2):167-175.
119. Fish JN, McInroy LB, Paceley MS, et al. “I’m Kinda Stuck at Home With Unsupportive Parents Right Now”: LGBTQ Youths’ Experiences With COVID-19 and the Importance of Online Support. Journal of Adolescent Health. 2020;67(3):450-452.
120. Gato J, Leal D, Seabra D. When home is not a safe haven: Effects of the COVID-19 pandemic on LGBTQ adolescents and young adults in Portugal. Revista PSICOLOGIA. 2020;34(2):89-100.
121. NIHR SfPHR. Young People’s Mental Health during the COVID-19 Pandemic. Initial findings from a secondary school survey study in South West England. . 2020.
122. Westrupp E, Bennett C, Berkowitz TS, et al. Child, parent, and family mental health and functioning in Australia during COVID-19: Comparison to pre-pandemic data. 2020.
123. Whittle S, Bray K, Lin S, Schwartz O. Parenting and child and adolescent mental health during the COVID-19 pandemic. 2020.
124. Colizzi M, Sironi E, Antonini F, Ciceri ML, Bovo C, Zoccante L. Psychosocial and Behavioral Impact of COVID-19 in Autism Spectrum Disorder: An Online Parent Survey. Brain Sciences. 2020;10(6):341.
125. CEAR. The impact of Covid-19 on learning and wellbeing. 2020.
126. Breaux R, Dvorsky MR, Marsh NP, et al. Prospective impact of COVID-19 on mental health functioning in adolescents with and without ADHD: protective role of emotion regulation abilities. Journal of Child Psychology and Psychiatry.n/a(n/a).
127. Fegert JM, Vitiello B, Plener PL, Clemens V. Challenges and burden of the Coronavirus 2019 (COVID-19) pandemic for child and adolescent mental health: a narrative review to highlight clinical and research needs in the acute phase and the long return to normality. Child and adolescent psychiatry and mental health. 2020;14:1-11.
128. Brady AM, Deighton J, Stansfeld S. Psychiatric outcomes associated with chronic illness in adolescence: A systematic review. Journal of adolescence. 2017;59:112-123.
129. Hawke LD, Monga S, Korczak D, et al. Impacts of the COVID-19 pandemic on youth mental health among youth with physical health challenges. Early intervention in psychiatry. 2020.