On March 11, 2020, the World Health Organization declared COVID-19 a global pandemic (World Health Organization, 2020). In response, countries around the world began to implement plans to protect public health and reduce virus transmission. These plans included the implementation of emergency measures which saw the closure of schools, home confinement, and insistence on social and physical distancing, and drastically escalated the percentage of the global population living in isolation, including an estimated 1.2 billion children and youth (Preston & Rew, 2022). At this time, to inform health decision-making, researchers began to evaluate the impact of emergency measures on mental health. In light of the unprecedented decision to close schools to in-person learning, and aware of the vulnerability of young persons to larger scale emergencies due to incomplete development and lack of previous exposure (Imran et al., 2020; Larsen et al., 2021), many studies have paid attention to the immediate impacts to mental health of children and youth. However, to date, few studies have been completed identifying longer-term impacts of pandemic emergency measures – specifically school closures – on child and youth mental health. This data which will be important when informing the current and future direction of mental health funding, prevention, intervention, and management, as well as the format and curriculum of elementary and secondary education.
The examination of this topic comes at a critical time, as globally, incidence of child and youth mental health diagnoses continue an upward trend; a troubling statistic independent of, but seemingly exacerbated by, the COVID-19 pandemic. In Canada alone, 1 in 5 children and youth is affected by or hospitalized with a mental illness or disorder with incidence expected to rise in the coming years (Canadian Association for Mental Health, 2021; Canadian Institute for Health Information, 2022). This rise is complicated by ongoing, pre-pandemic intervention and management challenges, including limited inpatient beds to support child and youth mental health admission, scattered, inconsistent, and waitlisted outpatient services, and ongoing health human resource challenges (Hoffman & Duffy, 2021; Power et al., 2020). Further study is necessary to best inform and advocate for the improvement or revision of upstream and downstream intervention both immediately and in future.
Literature review
A review of current literature was conducted using the PsycINFO database. Searches of key words were completed including combinations of the terms “youth,” “adolescent,” and/or “child,” with “COVID-19,” or “pandemic,” and “mental health,” as well as “isolation,” “social isolation,” “physical isolation” “school closure” “emergency measures,” “lockdown,” “disease containment,” or “quarantine.” Publication dates were limited to those within the last three years given pertinence. More than 30 results were returned, and abstracts of these reviewed and filtered based on relevance. The remaining 13 articles were then reviewed in full, and common themes of the importance of physical school attendance, increased screen time, and exposure to parental stress identified. Potential benefits of school closures to child and youth mental health was an additional, broader theme explored.
Importance of physical school attendance
When examining pandemic emergency measures, school closures were identified as the most detrimental change for child and youth mental health given the institution’s influence on academic, social, emotional, and physical development (Chadi et al., 202; Larsen et al., 2021; Power et al., 2020; Rosen et al., 2021). Following COVID-19 school closures, several studies noted reported deterioration across multiple domains of mental health, including focus/attention, motivation, depression/sadness, and anxiety (Cost et al., 2022; Hampshire et al., 2022; Larsen et al, 2021; Lehmann et al., 2022; Rosen et al., 2021). Many child, youth, and parent reports noted the presence of increased stress as well as presence and intensity of emotional reactions, associated with the transition to virtual learning and fears of learning loss (Samji et al., 2022), loss of structure and routine (Cost et al., 2022; Samji et al., 2022), and loss of peer support and interaction (Chadi et al., 2022; Cost et al., 2022; Larsen et al., 2021; Lehmann et al., 2022; Samji et al., 2022). Reactions were stronger with age (Larsen et al., 2021; Samji et al., 2022). Emerging longitudinal evidence has identified that increased symptomology was sustained over shorter study periods (Hampshire et al., 2022; Lehmann et al., 2022; Rosen et al., 2021).
Also of note is the marked symptom worsening reported by and on behalf of those with pre-existing mental health diagnoses and those with neurodiversity for whom disruption to routine can prove exceedingly detrimental, leading to increased irritability, aggression, regression, and social withdrawal (Doyle et al., 2022; Hampshire et al., 2022; Hoffman & Duffy, 2021; Imran et al., 2020). An uneven distribution of negative impact was also noted among racialized, low-income, and rural youth due to experiences of greater isolation and poor accessibility to online learning tools and infrastructure (Hoffman & Duffy, 2021; Power et al., 2020).
Increased screen time
The shift to virtual education was noted to drastically increase the amount of time per day that children and youth spend on screens as well as introduce additional stress associated with the navigation of technology challenges (Larsen et al., 2021). Increased screen time has been recognized as one of the greatest correlates to worsening mental health during initial pandemic waves, including distinct increases in anxiety, depression, and oppositionality (Doyle et al., 2022; Hoffman & Duffy, 2021) and a reported decrease in concentration (Larsen et al., 2021). Conversely, children and youth with the least reported technology consumption were also those with the least reported negative experience of pandemic stressors (Rosen et al., 2021).
Exposure to parental stress
A strong relationship was noted between parental stress and child mental health symptomology during periods of lockdown and school closure. Studies identified that children and youth, not previously exposed to high levels of parental stress, depression, and anxiety, began exhibiting greater incidence of these and similar symptoms themselves (Bai et al., 2022; Cost et al., 2022; Imran et al., 2020; Samji et al., 2022); This relationship grew stronger as isolation was prolonged (Samji et al., 2022), with deterioration at its worst during times of greatest restriction where exposure to parental stress was consistent and could not be alleviated through time apart or exposure to positive peer interactions (Cost et al., 2022). Less cited, but of equal importance is the recognition that school closures may confine children and youth to a home where abuse is or becomes present, causing both immediate detriment to safety, as well as the long-term impact of trauma (Imran et al., 2020; Larsen et al, 2021).
Potential benefits
The potential for positive consequences presented an additional area for consideration. Of note, the potential for improved parent-child relationships as result of more family time together, reconnection, and the development of new traditions (Larsen et al., 2021; Preston & Rew, 2021). Similarly, availability of parent support correlated to symptom stability or improvement across some domains of mental health during periods of school closure, including anxiety, depression, irritability, and attention (Cost et al., 2022; Doyle et al., 2022) as well as decreased parent-child conflict (Doyle et al., 2022). The potential for virtual education, specifically, to decrease mental health symptoms was also noted; associated with lessened social anxiety, usually in those with pre-existing diagnoses (Larsen et al., 2021; Lehman et al., 2022; Samji et al., 2022). Additionally, fewer negative responses to prolonged isolation were noted among children and youth who viewed online learning as positive (Larsen et al., 2021).
While longitudinal and/or more recent study data remains limited, available data suggest a relationship between COVID-19 school closures and consequences for child and youth mental health. In recognition of this, the purpose of this interpretive phenomenological study is to examine the perceived impacts to mental health of children and youth following the use of repeated school closures over the course of the COVID-19 pandemic. Further study will serve to identify if this relationship is strongly identified by children and youth participants in the absence of parent report, following more than two years of pandemic experience. The proposed use of a phenomenological methodology will serve to complement available research on the topic that includes largely quantitative data, through presenting a deeper analysis of participant attitudes and perceptions (Adler et al., 2019; Groenewald, 2004). The proposed research intends to explore the following questions as a starting point:
1. Is the relationship between school closures and mental health considered to be predominantly positive or negative?
2. Is the relationship between school closures and mental health considered to be short-term or long-term?
3. Is the impact of school closures on mental health considered to be immediate or delayed?
4. Do answers to the above questions change when examined on the basis of socio-demographic characteristics?
5. What implications does the relationship between school closures and mental health, whether positively or negatively regarded, have for the formulation and delivery of elementary and secondary education and mental health services?
Additional relevant questions may be identified as deeper insight and understanding is gained (Bhattacherjee, 2012, p. 105; Braun & Clarke, 2020).
Methods
Participants
Participants of the proposed research will include school-aged children and youth currently enrolled in primary or secondary education. Specifically, participants will need to have attended school during the period of repeated COVID-19 school closures (March 2020 - January 2022). Further, given the longitudinal nature of the proposed research, participants must also still be attending school for the study duration. As such, students meeting inclusion criteria are those in grade 1-10 at study outset, with those in junior and senior kindergarten, and those in grades 11 and 12 excluded. There is no requirement of experience with or diagnosis of mental health, nor is the presence of pre-existing mental health experience or diagnosis means for participant exclusion.
Procedures
Sampling
In keeping with principles of phenomenological research this study will utilize purposive sampling, employing researcher judgment to select participants who meet identified inclusion criteria (Adler et al., 2019; Campbell et al., 2020; Groenewald, 2014). The proposed sampling frame includes a selection of Grade 1-10 students in Waterloo Region, currently enrolled in a selected Waterloo Region District School Board (WRDSB) elementary or secondary school. In effort to obtain diversity of experience and perspectives, specific schools will be approached for participation, including those in urban and rural areas and representing a range of socio-economic status. Within the chosen schools multiple focus groups of approximately 6-10 participants per group will be conducted. Groups will be grade specific and grouped by gender where possible, to address potential discomfort with wider group sharing (Adler et al., 2019; Bergen & Labonté, 2019). Focus groups will not be conducted per grade at each school, but all grades will be sufficiently represented across total groups completed. The study will aim to have an even distribution of male and female participants, however there will be no specific quota, nor will the participation of alternate or non-gendered students be excluded. Sampling in this way serves to lessen barriers to research and researcher that would be presented by sampling the entire eligible child and youth population.
Total expected sample size is not known at this time but will be large enough to generate a thorough exploration of research questions and analysis of data (Braun & Clarke, 2020; Donalek, 2004). Practicality must also be considered, given the number of focus groups proposed, and data to be analyzed across the study period (Braun & Clarke, 2020).
Research Design
This study, guided by the principles of interpretive phenomenological research, intends to explore mental health in a way that is context-specific (Bhattacherjee, 2012, p.105) - related to use of repeated school closures during the COVID-19 pandemic - and from the subjective perspectives of child and youth participants (Bhattacherjee, 2012, p. 109). Study data will aim to create an improved and holistic understanding (Bhattacherjee, 2012, pp. 104-105; Donalek, 2004) of participants’ school closure experiences and perceived mental health impact rather than simply confirm pre-existing research and assumptions (Groenewald, 2004).
Recruitment. Participants will be recruited through written solicitation. An expression of interest, describing the purpose of research and other pertinent details (length of study, expected time commitment, data collection methods) will be distributed to parents/students from selected schools/classrooms. Those identifying interest will receive further documentation to complete that includes basic demographic information and consent. Should interest be high, only a specific number of participants will be chosen.
Consent. Informed consent in the form of written agreement will be required both from the WRDSB (prior to participant recruitment, as research will be ideally conducted both within the school setting and during school time), and from the parents of child and youth participants who are under the age of 16 at study outset. Those aged 16 will not require parent consent to participate (and will be able to consent on their own behalf) assuming the research to be conducted is deemed minimal risk by a Research Ethics Board (REB) (Government of Canada - Panel on Research Ethics, 2018, p. 22). Potential risks and benefits will be clearly communicated, as will the voluntary nature of participation and ability to withdraw consent at any time (Groenewald, 2004). Participants will be well briefed on the purpose of research prior to outset to ensure assent (Adler et al., 2019), comfort, and genuine participation (Groenewald, 2004).
Data Collection. This study will use multiple data collection methods including focus group interviews, written accounts in the form of open-ended questionnaires, and researcher field notes. Data will be collected over the study period of one year, with first focus groups occurring as immediately as possible post REB approval, and at two additional time points (month six and month 12). The longitudinal nature of data collection aims to fully illustrate the perceived mental health impact of school closure experiences of participants.
Focus group interviews will be conducted by the researcher using a semi-structured format, to allow for use of standardized questioning, while leaving room for further probing and clarification (Adler et al., 2019; Bhattacherjee, 2012, p. 78). Questions will explore participants’ experiences, feelings, and perceptions (Gillam, 2014; Groenewald, 2004) related to repeated school closures and how this has impacted personal mental health prior to and across the study period. Questions will be designed to be age appropriate, clear, and understandable, while careful not to introduce bias (Adler et al., 2019; Bhattacherjee, 2012, p. 75-77). Specifically, participants should not be directed towards negative responses (Bhattacherjee, 2012, p. 76). This is a concern given the predominant view of mental health as a negative phenomenon. Questions will be subject to pre-testing to ensure reliability and discussion will be reviewed prior to session endings to ensure all points addressed were well-understood by participants (Adler et al., 2019).
Focus groups are a preferred method of data collection in phenomenological research as they allow data to be gathered quickly, and for lesser cost than in one-to-one interviews (Adler et al., 2019; Bhattacherjee, 2012, p. 78; Gillam, 2014). However, working with children and youth, exploring the potentially triggering topic of mental health, and considering the inability to maintain participant anonymity, challenges with participation may arise. To address this participants will also be asked to complete a written account, comprised of questions related to the wider group discussion, which will yield complementary data without the pressure to mirror group responses (Bergen & Labonté, 2019). Identifying information will be required to match participant verbal and written responses, but participants will be assured of the confidentiality of these written responses prior to completion (Bergen & Labonté, 2019; Bhattacherjee, 2012, p. 78).
Participant observation in the form of researcher field notes will also be collected and analyzed in effort to triangulate data and validate the identification of common themes (Adler et al., 2019; Bergen & Labonté, 2019; Bhattacherjee, 2012, p. 106; Gillam, 2014; Groenewald, 2004).
Participants will be compensated for participation at the time of study completion. Compensation will take the form of a gift card to a local bookstore and will be mailed to participants/parents with a letter of thanks.
Analysis and Insight Generation
The exploration of study data will take the form of inductive thematic analysis. Focus groups will be audio recorded to facilitate researcher review (Bhattacherjee, 2012, p. 109; Groenewald, 2004). Collected data will be analyzed and aggregated based on the identification of broader themes (Donalek, 2004; Groenewald, 2004). These themes, subject to researcher interpretation of significance (Bhattacherjee, 2012, pp. 105-106; Donalek, 2004) will then be re-reviewed, and emergent ideas identified within and across each, allowing for the creation of the most holistic and meaningful account of participant data (Bergen & Labonté, 2019; Donalek, 2004). As numerous focus groups conducted at multiple time points will yield a large amount of data that risks not being effectively analyzed, analysis will occur simultaneously with data collection and be an iterative process (Bhattacherjee, 2012, p. 105). It is expected that themes will emerge and change as new data is collected and insights generated (Braun & Clarke, 2020). Additional analysis of participant’s written accounts and researcher field notes, as detailed previously, will occur in effort to validate researcher interpretation of significant themes (Adler et al., 2019).
Discussion
This study endeavours to capture the insights of children and youth whose direct participation is often ignored in traditional research due to ethical and logistical concerns. Participants will be able to offer relevant data through sharing of lived experience, beliefs and perceptions which may serve to influence service and curriculum improvements to the benefits of their peers now and in future. Purposive sampling as well as relatively few exclusion criteria will allow for the exploration of diverse, but representative data (Braun & Clarke, 2020; Campbell et al., 2020). Focus groups specifically should allow for the generation of deeper insight given the effects of group think and feelings of shared experience (Adler et al., 2019; Bhattacherjee, 2012, p. 78). This may be further enhanced given use of the familiar school setting which provides comfort to participants (Adler et al., 2019).
Limitations
The proposed research is not immune to limitations; specifically, the experience of bias. Of concern is recall bias given participants will be asked to reflect on past feelings and experience (Bhattacherjee, 2012, p. 82). Also of note is the potential for social desirability bias given the use of focus groups and choice of study population. Participants may be inclined to provide socially acceptable responses given lack of anonymity or allow a dominant member to speak for the group (Bergen & Labonté, 2019). While such behaviours could be mitigated through use of 1:1 interviewing, focus groups present a more efficient use of time and resources and so remain the preferred method of data collection for this study.
Additional concerns surrounding research validity are also recognized as, historically, qualitative research has been subject to greater criticism than other forms of research involving easily quantifiable and replicable data (Bhattacherjee, 2012, p. 104). However, this study aims not to quantify impact of repeated school closures on child and youth mental health, but rather to explore conscious experiences and associated perceptions of participants, using these to inform improvements to mental health service and primary and secondary education delivery and curriculum. The validity and rigor of the proposed research then, should be judged not on data replicability, but on representation and confirmability, relevance, and transferability (Bhattacherjee, 2012, pp, 110-111; Gillam, 2014). To facilitate this, results of analysis will be shared with participants to ensure accurate representation prior to wider dissemination (Adler et al., 2019; Donalek, 2004). It is recognized that the choice of purposive sampling may decrease transferability (Campbell et al., 2020) as experiences of those in alternate boards or educational arrangements are excluded but is hoped that the analysis presented will be representative enough to yield immediate as well as long-term change and service improvements.
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