This study conducted in Portugal on children ages 7 to 17 years old found that 15.4% of these children exhibited signs of depression using the CDI scale. Schools were closed for almost nine months due to the isolation protocols for the COVID-19 pandemic from March 16, 2020, to September 14, 2020, and again from January 15, 2021, to April 5, 2021. This survey was conducted as the children returned to school once the infection control restrictions eased allowing the school to reopen. Our results suggest an increase in psychological distress during the pandemic, as a Portuguese study described a rate of pre-pandemic depressive symptoms of 11.2% in this age group , suffering an increase to 15.4% with the COVID-19 pandemic. To our knowledge, this is one of the first studies that show an association between depressive symptoms and the COVID-19 pandemic in a sample of children and adolescents in Portugal .
The present study aimed to measure the psychological impact of COVID-19 restrictive measures and school closure on children and adolescents during one of the most unique periods in recent history, in which children and adolescents did not go to school for weeks and had limited contact with friends and family. The results showed that a significant percentage of children and adolescents had more depressive symptoms than before the COVID-19 pandemic. This finding is consistent with previous studies of childhood and adolescent mental illness before the COVID-19 pandemic, which showed lower rates of clinically depressive symptoms [5,6,14,15].
Current findings suggest that closure measures have worsened rates of depressive symptoms in children and adolescents [16,17]. In addition, schools are often the primary site for mental health services. Eighty percent (80%) of children rely on school-based services to improve their mental health. For many children, these services had been unavailable due to school closures, and the schools included in this study also did not have these services available .
In a meta-analysis, the prevalence rates of depressive symptoms were higher as child age increased, and we reported the same in our study .
Furthermore, our study showed no difference between children and adolescents living in a village or a city regarding depressive symptoms, however, there is a difference in the rate of concern because children and adolescents living in a village reported a higher degree of concern (72.7%) as compared with children and adolescents living in a city (57.7%).
Nevertheless, other studies found that a harmonious social environment, like a rural environment, is more positively associated with better mental health . In our study, children and adolescents living in a village reported a greater rate of concern, but this is difficult to clarify in other studies.
As the results showed, children and adolescents with a personal or familial history of a past COVID-19 infection had more depressive symptoms, as well as if there was any family member working on pandemic-related work. However, to our knowledge, there are no other studies in the literature that support this; therefore, it would be important to extend this study to other schools in Portugal, in order to justify the measures to be adopted.
Hence, it would be important to establish some protective measures to improve this situation. Additional resources and training would likely be needed to prepare teachers to support children with low moods and increase their awareness of referral pathways for professional support, as previous studies also suggested .
It would be important to increase the number of psychologists available in schools, in order to follow children and adolescents with warning signs. Children and adolescents with a personal or familial history of a past COVID-19 infection should be flagged at school and early psychological work should be initiated, in order to prevent the increase of depressive symptoms. Additionally, it would be important to talk with parents of children and adolescents who have family members working on pandemic-related work, in order to recognize possible signs of depression.
An important conclusion from the current findings is that the potential link between disease containment measures and children’s mental health may be included in the decision-making process of policymakers.
It would have been interesting if we had assessed the familial functionality and the presence of depressive symptoms in the parents of children and adolescents, as other studies showed that 28.3% of children with mental health problems lived in a family that reported problems with family functioning, compared with 11.7% of children without mental health problems . The same study, curiously, found that children and adolescents whose parents had a mental illness were less likely to receive regular support at school.
There are some limitations in our study. First, is not possible to obtain a causal explanation of the results due to the nature of this study. Second, the small sample size reduces the statistical power and precision of estimates. The current study does not have the statistical power to detect small but clinically significant changes. Third, because it is a random sample, the proportion of responders is relatively small compared with the size of the overall cohort. Finally, caution should be exercised in generalizing the results to other populations, because we surveyed only some schools of a city in the Lisbon region.