Associations of School Closures with and without Social Lockdown on Physical and Mental Health of Children and Young People during the First COVID-19 Wave: A Systematic Review

Importance: School closures during COVID-19 are likely to be associated with significant health harms to children and young people. A systematic review of the evidence is needed to inform policy decisions around school closures and reopenings. Objective: To assess the associations of school closures on health and well-being outcomes in children and young people aged 0 to 19 years, excluding associations with transmission of infection. Evidence Review: Eleven databases were searched from inception to September 2020, and machine learning was applied for screening articles. A total of 16817 records were screened, 151 were reviewed in full text, and 43 studies were included. Quality assessment was tailored to study type. A narrative synthesis of results was undertaken because data did not allow meta-analysis. Findings: A total of 43 studies from 12 countries with 104630 study individuals were included in analysis. Of those, 9 (21%) were longitudinal pre-post studies, 5 (12%) were cohort, 28 (65%) were cross-sectional, and 1 (1%) was a modeling study;all assessed change by comparison with population reference data. Eighteen studies (42%) were high quality, 19 (45%) were medium quality, and 6 (14%) were low quality. Cause of closure in all studies was the first COVID-19 wave with the exception of 5 influenza studies (11.6%). Twenty-seven studies (62.8%) concerning mental health identified considerable associations across emotional, behavioral, and restlessness/inattention problems;18% to 60% of children and young people scored above risk thresholds for distress, particularly anxiety and depressive symptoms. Two studies reported nonsignificant rises in suicide. Child protection referrals fell 27% to 39% to half the expected number of referrals originating in schools. Data suggested marked rises in screen time and social media use and reductions in physical activity;however, data on sleep and diet were inconclusive. Available data suggested likely higher harms in children and young people from more low-resource populations. Conclusions and Relevance: School closures as part of social distancing measures are associated with considerable harms to children and young people's health and well-being. Associations of school closure were not able to be separated from broader lockdown. Available data are short term;longer-term harms are likely to be magnified. Data on longer-term associations using strong research designs are needed, particularly among vulnerable groups. These findings are important for policy makers seeking to balance the risks of transmission through school-aged children with the harms of closing schools..