Post-Traumatic Stress in Children and Adolescents during the COVID-19 Pandemic: A Meta-Analysis and Intervention Approaches to Ensure Mental Health and Well-Being

Abstract

Background: Since the World Health Organization (WHO) declared the COVID-19 pandemic in March 2020, many measures have been taken to prevent the spread of the virus. Consequently, many minors have been confined to their homes and have had to subsequently adapt to countless protocol changes. These factors appear to have contributed to post-traumatic stress disorder (PTSD) in many children. Materials and Methods: The authors searched Medline through PubMed and other databases for studies published from 1 December 2019 to 31 December 2021 on the prevalence of PTSD in schoolchildren. The authors used a random-effects model to calculate the pooled prevalence of PTSD. Results: A total of six studies were included in this review. Our results show a pooled prevalence of PTSD of 14% in children and adolescents. Subgroup analyses identify a significantly higher prevalence of PTSD for studies conducted in China and a higher prevalence in boys. The prevalence of PTSD appeared independent of child age or the methodological rigor of the study. Conclusions: Our results suggest that a large number of children may be suffering from PTSD (post-traumatic stress disorder). Public health measures are thus needed to improve children’s mental health during and after the pandemic, so that the suffering is mitigated to prevent long-lasting effects.

1. Introduction

The COVID-19 pandemic brought a major halt to all educational systems in all countries around the world. Most schools closed in order to avoid contagion, and many switched to a non-face-to-face mode of study [1]. In the months following the pandemic, those schools gradually returned to regular education because, among other reasons, it was verified that their closure was directly affecting the welfare of children [2].

The WHO [3] states that this pandemic has had a disproportionate impact on children’s physical and emotional state, and that for some children and young people, in all countries, these effects could be lifelong. In the first months of 2020 when lockdowns were declared all over the world, research has confirmed that being confined to their homes affected children’s physical, psychological, social and academic well-being [4,5,6,7,8].

One of the Sustainable Development Goals (SDGs) of the 2030 Agenda [9] highlights the importance of ensuring the well-being and healthy lives of all citizens [10]. Furthermore, within this SDG, it has been highlighted that health emergencies, such as the one resulting from COVID-19, pose a global risk and that preparedness and specific intervention is vital [11].

This is why much research has been conducted on child and adolescent well-being during the pandemic. Among the most relevant variables analyzed from a psychoeducational approach are psychosocial variables: feelings of loneliness, a lack of social support, etc. [12,13,14,15]; physical variables that disrupt children’s well-being: weight gain, a sedentary lifestyle, etc. [16]; academic variables: a lack of contact with teachers and students, difficulty following classes, etc. [17]; and greater economic fragility, concern for subsistence and poorer health habits [18].

However, within this framework of well-being [19], the impact on the mental state of childhood is especially relevant, as scientific evidence has found that emotional variables are among the most affected [13,20,21].

With regard to mental health, many authors have also asserted that the consequences of the pandemic have created a great uneasiness among children and adolescents, particularly with lockdowns and adjustments at school engendering emotions of loneliness, isolation, anxiety, and depression [12,22,23,24]. In addition, emergency e-learning [25,26] also required a readjustment to new forms of education, with an understandable decline in support from teachers, and disadvantages for children in more precarious situations [27,28]. Another problem for children is that their own parents may have been less mentally healthy, and may also have received more violence and abuse at home because they were confined with parents who are violent toward their children [29,30,31]. Children living in the most vulnerable contexts have school as a safe place for physical, psychological and social support [32].

Even so, it is known that these impacts on the health and well-being of children have continued to exist after the lockdowns because the restrictive measures have continued for months and years [33,34]. Even when they returned to school, children had to do so under strict hygiene measures and experienced continuously changing protocols according to the epidemiological situation of the pandemic [35,36].

This overall situation has brought suffering to children and adolescents, and has caused symptomatology such as fear, anxiety, depression, stress, general mental health problems, self-injury and suicidal thoughts [37]. Therefore, several studies point to the fact that this direct and indirect exposure to COVID-19 may also have contributed to post-traumatic stress among them [38].

Post-traumatic stress disorder (PTSD) often arises after having lived through a severely distressing event [39]. Symptoms often include the reactivation of reminders of the traumatic experience, over-awareness, negative feelings, and avoidance of events and locations that are reminders of the stressful event. There are several factors that make a child more vulnerable and psychologically distressed. These include poverty, loneliness, a lack of social or parental support, or previous mental health problems they may have had. On the other side, protective factors would be school attendance, family support, social and emotional skills, and peer support. Conversely, protective factors, such as school connectedness, parental support, problem solving, self-regulation skills, peer social support, perceived self-efficacy, and positive mother–child relationships can ameliorate the psychological impact of sudden and large-scale disruptions [40]. Therefore, the prevalence of this symptomatology will affect children and adolescents clinically, socially and academically, and sometimes may lead to post-traumatic stress disorder (PTSD). For the purpose of this meta-analysis, post-traumatic stress is used interchangeably with PTSD, as various validated measures and thresholds have been used without unbiased rates, making the line between the experience of post-traumatic stress and the occurrence of the complex disorder unclear.

Regarding the pandemic, a meta-analysis conducted with 23 studies, involving 57,927 children and adolescents, examined various mental health problems. However, only two studies explored post-traumatic stress [41]. The meta-analysis found that approximately 48.0% of youth aged 0–18 years had experienced post-traumatic stress, but there was a 95% confidence interval range between −25.4% and 121.4%, suggesting that there is very little utility to finding the 48%. Neither study gave adequate information on age or gender to make any claim in those regards. Additionally, this meta-analysis only looked at the period between December 2019 and September 2020 and therefore only had two papers from China and from the first Chinese lockdown period, which makes it still more difficult to generalize its findings. It is probably only now that we will begin to see the aftermath of the situation, as post-traumatic moments present unique challenges for rigorous research. Therefore, it is essential to have an up-to-date and more accurate picture of the problem. In the present work, a meta-analysis that assesses post-traumatic stress in childhood and adolescence has been carried out. More specifically, we will study whether there are differences between genders, ages and different countries. A systematic review will also be carried out on the interventions proposed in order to address the suffering and discomfort that children may have experienced.

2. Materials and Methods

The present meta-analysis follows the same methodology used in recent reviews that focus on the influence of the COVID-19 pandemic on mental health across different population strata published by our research team [42,43].

This study was conducted in accordance with the PRISMA guidelines for reporting systematic reviews and meta-analyses [44] (Supplementary Table S1).

2.1. Search Strategy

Following the standards set by The Methods Group of the Campbell Collaboration [45], two researchers (JS and BV) searched for all cross-sectional studies reporting the prevalence of post-traumatic stress disorder published from 1 December 2019 through to 31 December 2021, using MEDLINE via PubMed. The search proceeded as follows:

We searched for (covid[tiab] OR COVID-19[tiab] OR coronavirus[tiab] OR SARSCoV-2[tiab] OR “Coronavirus” [Mesh] OR “severe acute respiratory syndrome coronavirus 2” [Supplementary Concept] OR “COVID-19” [Supplementary Concept] OR “Coronavirus Infections/epidemiology” [Mesh] OR “Coronavirus Infections/prevention and control” [Mesh] OR “Coronavirus Infections/psychology” [Mesh]) AND (“Post-traumatic stress” [Mesh] OR “Posttraumatic stress” [Mesh] OR PTSD [Mesh]).

No language restriction was made. References from selected articles were inspected to detect additional potential studies. Any disagreement was resolved by consensus among the third and fourth researchers (NO-E and NI), according to [46].

2.1.1. Selection Criteria

Studies were included if they met the following criteria: (1) reported cross-sectional data on the prevalence of post-traumatic stress disorder, or information sufficient to compute this, during the COVID-19 outbreak; (2) focused on children and adolescents; (3) included a validated instrument to assess PTSD; (4) the full text was available.

We excluded studies focusing only on community-based samples of the general population or specific samples that were not children and adolescents (e.g., teachers, medical professionals, patients), as well as review articles.

2.1.2. Data Extraction

A pre-designed data extraction form was used to extract the following information: country, sample size, proportion of girls, average age, response rate and sampling methods, the instruments used to assess PTSD, and their prevalent rates. Two researchers (JS and BV) coded the studies independently and then reached consensus.

3. Methodological Quality Assessment

Two independent reviewers (IL and JS) assessed the articles selected for retrieval for methodological validity prior to inclusion using the standardized Joanna Briggs Institute (JBI) Critical Appraisal Checklist for prevalence studies [47]. The researchers evaluated their quality according to nine criteria, providing a total score between 0 and 9 (1 or 0 for each criterion). The questions were as follows: (1) Was the sample appropriate to address the target population? (2) Was study recruitment of participants appropriate? (3) Was the sample of adequate size? (4) Were the participants and setting adequately described? (5) Was the data analysis conducted sufficiently for the identified sample? (6) Was the condition identified by valid methods? (7) Was the condition reliably measured for all participants? (8) Was the statistical analysis appropriate? (9) Was the response rate adequate or was a low response rate appropriately managed? Disagreements that arose between the reviewers were resolved by further discussion with additional researchers (NO-E and NI).

Statistical Analysis

The researchers used a standard inverse variance method, employing a random effects model [48], including the double arcsine transformation of proportion. This method accounted for the variability in and heterogeneity of the prevalence rates in the studies that were included [49]. The researchers used Knapp–Hartung adjustments [50] to calculate the confidence intervals around the pooled prevalence. Research [51] has shown that this adjustment reduces false positives, especially with a small number of studies. The researchers presented the main outcomes in a proportion format with a 95% confidence interval (95% CI) and a 95% prediction interval (95% PrI), together with heterogeneity results. The researchers reported the Hedges Q statistic to assess heterogeneity across the studies, with significance set at p < 0.10. The researchers also used the I² statistic and 95% confidence interval to quantify heterogeneity [52]. With this, values between 25–50% are considered as low, figures between 50–75% are considered moderate, and figures of 75% or more are considered high [53]. The heterogeneity of effects between studies may occur when differences in results for the same exposure–disease association cannot be fully explained by the sampling variation. Sources of heterogeneity include differences in study design or demographic characteristics. The researchers performed meta-regression and subgroup analyses [54] to explore the sources of heterogeneity expected in the meta-analyses of observational studies [55]. We also conducted a sensitivity analysis to determine the influence of each individual study on the overall result by omitting studies one by one. The researchers used the visual inspection of a funnel plot and also Egger’s test [56] (p < 0.05) to determine publication bias, as funnel plots were found to be inaccurate for assessing publication bias in meta-analyses of proportion studies [57].

In our meta-analysis of proportion studies, the DOI plot and the Luis Furuya-Kanamori (LFK) index represent better approaches for graphically representing publication bias. A symmetrical triangle implies the absence of publication bias. In contrast, an asymmetrical triangle indicates possible publication bias [58]. The DOI plot and LFK index have higher sensitivity and thus detect publication bias more accurately than the funnel plot [59]. Basically, the LFK index provides a quantitative measure to assess the degree of asymmetry; here, a score within 1 suggests ‘no asymmetry’, ±2 suggests ‘minor asymmetry’, and a score exceeding ±2 suggests ‘major asymmetry’. Additionally, the fail-safe N value is an indicator of publication bias [60]. This statistic is recommended with <10 studies in the MA [53,61] and suggests the number of non-significant, unpublished, or missing studies that would need to be added in the MA to reduce the finding of non-significance. JS ran the statistical analyses with R statistical software [62].

4. Results

4.1. Search and Selection

Figure 1 shows the flowchart of the search strategy and study selection process. A total of 469 records were initially identified from Medline via PubMed, of which 450 records were excluded after a first screening of the titles and abstracts. After reading the remaining 19 articles in full, we finally included 6 in our meta-analysis [63,64,65,66,67,68]. The reasons for the exclusion of articles are detailed in Figure 1.

4.2. Characteristics and Methodological Quality of the Included Studies

Table 1 and Table 2 show the characteristics of the six studies included in the meta-analysis. Table 1 provides a description of the study characteristics. Four came from China, one came from Saudi Arabia, and one came from Japan. The sample sizes ranged from 537 [65] to 57,948 [63] participants, while the mean age ranged from 12.2 [65] to 16.7 years [67]. In one study [67], the participants were only girls, and in the other studies, on average, 51.3% of the participants were girls. The response rate was between 76.3% [67] and 98.23% [64]. All of the included studies used standardized and validated scales with online questionnaires. Of those studies reporting a sampling methodology, two used probabilistic methods [66,67], and the rest employed non-probabilistic methods [64,65,68].

Table 2 breaks down the methods of measurement, the cut-off PTSD scores and the reported number of cases and prevalence found in each study.

Regarding the quality of the studies, the scores ranged from 4 to 6 on the 9-point JBI Critical Appraisal scale. In all of the studies, the confidence intervals and described prevalence were provided, and the participants and settings were described. All studies were limited because they did not use unbiased reviewers to measure PTSD, due to using online surveys. Additionally, most studies did not have unbiased sampling methods or adequately high response rates. Table 3 presents the precise methodological attributes that were present and absent.

4.3. PTSD Prevalence

Prevalence rates ranged from 6% [67] to 21% [64] (Table 1). We estimated the overall prevalence of PTSD to be 14% (95% CI: 11–18%), with significant heterogeneity in the sample of studies (Q test: p < 0.01; I² = 98.7%) (Figure 2). The prediction interval showed that the proportion of PTSD in future similar studies would range between 4% to 29% (Figure 2).

Our subgroup analyses, performed in order to identify sources of heterogeneity, found a significantly higher prevalence of PTSD in studies in China (17% [95% CI: 13–21%]) compared to those in Japan or the Kingdom of Saudi (9% [95% CI: 5–14%]). We also observed a higher prevalence of PTSD in the studies using convenience samples (17% [95% CI: 9–27%]) compared with other sampling methods (11% [95% CI: 6–18%]); nevertheless, this difference did not reach statistical significance. Similarly, no differences were observed depending on which PTSD scale was used (p = 0.891). Our meta-regression showed that the prevalence of PTSD was lower with a lower percentage of girls (b = −0.36, p = 0.005), and was independent of the mean age at baseline (p = 0.514) or methodological quality (p = 0.284). No meta-regression analysis according to the response rate was performed due to insufficient data available.

Excluding studies one by one from the analysis did not substantially change the pooled prevalence of PTSD, which varied between 13% (95% CI: 9–18%), with Xu et al. [68] excluded, and 15% (95% CI: 12–19%), with Shek et al. [66] excluded (Figure 3). This indicates that no single study had a disproportional impact on the overall PTSD prevalence.

Figure 4 shows the DOI plot and an LFK index of −2.84, indicating ‘major asymmetry’ and a high likelihood of publication bias. In contrast, a fail-safe N of 3887 indicated an absence of publication bias, meaning that 3887 studies with null results would be needed to reduce the observed overall prevalence to non-significance.

5. Recommendations for Intervention

Finally, a review was carried out to analyze which interventions to improve the mental health and well-being of children and adolescents were recommended by each article, and the results can be seen in the Table 4.

6. Discussion

This is the first study to conduct a meta-analysis of PTSD in adolescents and children during the COVID-19 pandemic. It is important to have carried out this meta-analysis as the WHO has made it its objective to take special care of the mental health of this group after the pandemic we have experienced [3]. This is why this meta-analysis of PTSD in children and adolescents during the pandemic has been conducted. After the analysis of the collected works, it was found that the estimated prevalence of post-traumatic stress in this population group is 14%, with it being predicted that a PTSD prevalence range between 4% to 29% in children and adolescents will be found in future similar studies.

This prevalence is clearly lower than that found by Ma et al. [64] in the first months of the pandemic in China. This was to be expected, as the confinement of those first months and the severity of the pandemic was extreme in China. However, other mental health markers analyzed in children during that time found a prevalence of 22.6% for depression and a prevalence of 18.9% for anxiety in Hubei province itself, where the crisis originated [69]. Even Ma et al. (2021) found a prevalence of 29% and a prevalence of 26% for depression and anxiety, respectively, in the same review. Thus, one might suspect that the 48% incidence they found for PTSD could be challenged by further research. In fact, the prevalence of PTSD in China is significantly higher in our study. If we compare the 14% prevalence with that found in the adult population, it is observable that in the general population, the prevalence of PTSD during the COVID-19 pandemic ranged from 15% to 28.34% [68,70,71,72,73]. Variability is also found in specific populations, such as health care workers, with a prevalence of PTSD between 18% and 29.22% [72]. Finally, Qui et al. [73] also found a PTSD prevalence of 29.39% in the teachers/students cohort. However, in this analysis, there was only one group of students and teachers, and it did not take into account other variables such as age, grade, or sector of education. With greater precision, ref. [74] found a PTSD prevalence of 10% in teachers and one of 23% in university students. Therefore, looking at these average values, it seems that the prevalence of PTSD among children and adolescents may be somewhat lower than adults in general, or than older students such as university students. However, it is striking that it is higher than that found among teachers.

Several research studies have shown that girls may experience more PTSD because of their possible tendency to ruminate more [75]. Age range may also influence the development of PTSD [75] because they have less language skills, and they may have difficulty understanding what is happening during the pandemic [76]. However, the study by Ma et al., 2021, showed no significant age and gender results for PTSD during the COVID-19 pandemic among children and adolescents. In the present study, differences by gender were found, with a lower incidence among girls. Contrary to the adult population, there have also been previous studies in which the well-being of girls has been found to be higher than that of boys during the pandemic [4].

Age range may also influence the development of PTSD [75], as younger children have less knowledge and less language; this affects their understanding of the events and the number of events, and they are less able to regulate their emotions, which affects how they process the event [76]. However, the study by Ma et al., 2021 [64] showed that coping psychologically with the pandemic had been more difficult for adolescents than for younger children [64]. In the present study, in terms of age, the mean age range of the articles analyzed was between 12.2 and 16.7 years, i.e., there were no studies with young children, something that could generate variability.

6.1. The Importance of Intervening in Order to Respond to the Impact of the Pandemic on Children’s Mental Health and Well-Being

In our review, the different authors of [66] made proposals to reduce the impact of the pandemic on the mental health and well-being of children and adolescents. The proposals included improving the family and rebuilding social support systems, to create [63], to improve online educational systems and to implement psychoeducational interventions and programs in it that are effective [64,66], to increase awareness among parents and teachers [65], to conduct assessments using rapid teacher assessment tools [66] and to provide training for frontline teachers and allied professionals.

However, these proposals do not propose a specific strategy to help children and adolescents. However, science has shown that emotional education can be key to helping these minors [77,78,79,80].

Specifically, emotional intelligence could improve PTSD and the impact of the pandemic on children’s mental health. According to Goleman, the key elements related to emotional intelligence are emotional self-awareness, emotional self-control, self-motivation, empathy and interpersonal relationships [81]. Therefore, thanks to the skills acquired by emotional intelligence, we acquire a better knowledge of our own emotions. We learn to identify our emotions and control them in an adequate way, and develop the ability to regulate them. Emotional intelligence will not eliminate problematic situations from our lives, but it does allow us to control them better and thus prevent reactions that could harm us in the long term.

Post-traumatic stress often goes hand in hand with anxiety and depression, and it is important to work on all the emotions that appear when starting to experiencing the symptomatology of PTSD in order to cope with it. If children and adolescents, thanks to their emotional skills, are able to name the intense emotions that they are feeling at that moment, they will be able to better manage that feeling. It has been demonstrated that the expression of emotions produces a change in the amygdala, which then induces calm and tranquility [82]. In addition, an emotionally intelligent person will be able to anticipate adversity and its impact, as well as anticipate the possible reaction of others to adversity. This will enable him/her to develop appropriate responses to adversity and to recover quickly.

Emotional intelligence helps individuals to deal with environmental stressors by understanding their own and others’ emotions [83]. Therefore, educating children and adolescents in emotional intelligence can help them to cope with the traumatic situation they have experienced during the pandemic, and also to prevent possible future traumatic situations.

Thanks to emotional education, the child/adolescent will be able to adapt to the social world, not only in pre-school, but also from infancy to adulthood, providing them with emotional, communicative, motivational and problem-solving skills [84].

Likewise, an intervention based on emotional intelligence in educational environments should take into account that one should be educated to know, understand and adequately regulate one’s own feelings and emotions, and those of others, in order to adapt to the environment more easily and efficiently [85]. To this end, a good emotional literacy program in educational environments should take into account the following points:

• -. Work on emotional self-knowledge. In this way, children would learn more about emotions and their causes.

• -. Learn the difference between action and emotion.

• -. Learn to manage the following emotions: frustration, anger management, stress management or feelings of inferiority.

• -. Work empathy: to learn how to understand others, their feelings and how to listen. In this way, they would be more able to understand and analyze others, help deal with conflicts, improve communication and create more cooperation.

Therefore, we support the idea that learning about emotional intelligence should become an explicit part of the curriculum.

6.2. Strengths and Limitations

A strength of the current study is that it is a Feasible, Interesting, Novel, Ethical, and Relevant piece of research that follows the FINER framework [86]. This meta-analysis gives us an update on a problem that could affect nearly 14% of children, and is something that should be considered if we want to raise mentally healthy children. As such, this study may provide a basis for further studies along this line of research.

However, some limitations should be considered when interpreting our results. First, it cannot be guaranteed that the results were measured by unbiased raters, as only online surveys were employed. In addition, most of the included studies had sampling shortcomings. Most did not have a random sample, an unbiased sampling frame, or adequate response rates (>70%). While they were not statistically significant, we found a lower prevalence of PTSD in studies only reporting convenience samples. In addition, the studies were generally of moderate-to-low methodological quality, as suggested by the JBI Critical Appraisal results. Moreover, there was little variety in the countries analyzed among the studies, so it is difficult to generalize these results to the world population. Finally, there were only a few studies included. However, it is clear that meta-analyses based on a few studies can be successful and provide substantially better estimates than isolated moderate or low-quality studies, or narrative reviews [87]. However, this study is also a basis from which to push for further studies on the topic.

7. Conclusions

The results of the present study led us to conclude that it is important to attend to the mental health of children, and that the psychological suffering they have experienced during the pandemic may have long-term consequences given the emerging development of their identities and personalities. As the WHO [3] itself states, the well-being of children was in a vulnerable position during the pandemic, because they have less experience and fewer tools to cope with the events they experience. Therefore, it is important to care for children who may be suffering the most from the psycho-social-economic consequences of the pandemic, such as those experiencing post-traumatic stress. Moreover, it is also important to continue research on children’s mental health in the face of and recovery from the pandemic.

Taking into account the recommendations we have extracted from the selected articles, and bearing in mind that we are bio-psycho-social humans [88], we will draw on Bronfenbrenner’s theory [89] to give some recommendations for dealing with the post-traumatic stress that children may have suffered in the pandemic.

It is important that they have family support [90] in order to not suffer psychologically. That is why parents should be taught via an emotional education strategy [91] so that they can pass emotional intelligence on to their children in order to improve their micro-system. Moreover, since the ecosystem influences the emotional state of children as well, parents should have better working conditions so that they can take better care of their children and dedicate more time to them, thus also devoting more time to emotional care.

Taking into account Bronfenbrenner’s mesosystem, parents should have a close relationship with their children’s schools, so that there is good communication regarding emotional health education [92].

It is also obvious that an adequate macrosystem is necessary in order for children to have a good emotional education. For this, governments must give value to the health care of children and adolescents, and create policies to take into account their mental health [93].

Finally, we must take into account the chronosystem in which children all over the world are living. A pandemic and post-pandemic moment must not be left aside, and the mental health of children and adolescents must be taken into account. Therefore, this study has made us aware of the studies on post-traumatic stress in children and adolescents so far. It is also important to understand the policies and recommendations that should be applied to improve children’s mental health. Finally, it is a basis for further research on children and adolescents’ mental health.

Author Contributions

Conceptualization, J.S., N.I.-M., J.H.D.C.-W. and N.O.-E.; methodology, J.S., B.O., N.I.-M., I.L.F. and N.O.-E.; writing—original draft preparation, J.S., B.O., N.I.-M. and N.O.-E. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Not applicable.

Conflicts of Interest

The authors declare no conflict of interest.

Footnotes

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Figures and Tables

Figure 1. Flowchart of the Study Search and Selection Process.

Figure 2. Forest Plot for the prevalence of PTSD among children and adolescents [63,64,65,66,67,68].

Figure 3. Sensitivity Forest Plot for the prevalence of PTSD among children and adolescents [63,64,65,66,67,68].

Figure 4. DOI Plot for the prevalence of PTSD among children and adolescents.

Table 1

Characteristics of the Studies Included in the Meta-Analysis.

Study	Country	Sample Size	Age Mean (SD)	Proportion Females	Response Rate	Sampling Method(Sampling Technique Category)	JBI Critical Appraisal
Cao et al. (2021) [63]	China	57,948	14.8 (1.6)	51.6%	NR	NR	4
Ma et al. (2021) [64]	China	668	NR	49.7%	98.2%	Purposive(Non-probability sampling)	5
Sayed et al. (2021) [65]	Kingdom of Saudi Arabia	537	12.2 (3.7)	51.2%	NR	Convenience(Non-probability sampling)	4
Shek et al. (2021) [66]	China	4981	13.1 (1.3)	51.5%	NR	Cluster(Probability sampling)	5
Takeda et al. (2021) [67]	Japan	871	16.7 (0.9)	100%	76.3%	Stratified(Probability sampling)	6
Xu et al. (2021) [68]	China	7769	15 (NR)	52.5%	NR	Convenience(Non-probability sampling)	5

Abbreviations: SD, standard deviation; NR, not reported.

Table 2

PTSD Assessments in the Included Studies.

Study	PTSD Assessment
	Scale	Criteria	No. Cases (Prevalence)
Cao et al. (2021) [63]	GPS-T	≥3	9810 (16.9%)
Ma et al. (2021) [64]	IES-R	>20	138 (20.7%)
Sayed et al. (2021) [65]	UCLA-BCSCA	≥21	70 (13%)
Shek et al. (2021) [66]	CRIES-13	>30	517 (10.4%)
Takeda et al. (2021) [67]	IES-R	≥24	49 (5.6%)
Xu et al. (2021) [68]	CRIES-13	>30	1639 (21.1%)

Abbreviations: GPS-T, Global Psychotrauma Screen for Teenagers; IES-R, Impact of Event Scale Revised; IES-6, The Impact of Event Scale-6; UCLA-BCSCA, Brief COVID-19 Screen for Child/Adolescent; CRIES-13, Children’s Revised Impact of Event Scale.

Table 3

Quality Assessment.

Study	1	2	3	4	5	6	7	8	Total
Cao et al. (2021) [63]	0	0	1	1	0	0	1	1	4
Ma et al. (2021) [64]	0	0	1	1	0	1	1	1	5
Sayed et al. (2021) [65]	1	0	1	1	0	0	1	1	5
Shek et al. (2021) [66]	0	0	1	1	0	0	1	1	4
Takeda et al. (2021) [67]	1	0	1	1	0	1	1	1	6
Xu et al. (2021) [68]	0	1	1	1	0	0	1	1	5

Abbreviations: (1) Random sample or entire population; (2) Unbiased sampling frame (census data); (3) Adequate sample size (>300 subjects); (4) Standard measures were used (5) Outcome measured by unbiased reviewers; (6) Adequate response rate (>70%) and description of losses; (7) Confidence intervals and subgroup analysis; and (8) Study subjects described.

Table 4

General recommendations for intervention.

ID	Study	General Recommendations for Intervention
1	Cao et al., 2021 [63]	Improving the family context and increasing social support are strategies to improve long-term mental health in adolescence.
2	Ma et al., 2021 [64]	As the mental health of the population continues to be deteriorated by COVID-19, authorities must take action and implement online interventions to improve mental health.
3	Sayed et al., 2021 [65]	Parents and professionals should detect the following alarming symptoms in order to prevent PTSD: intrusion, avoidance, negative mood and arousal/reactivity. If parents and teachers are aware of the severity of the symptoms they can help children to cope with these situations.
4	Shek et al., 2021 [66]	Psycho-educational programmes, early intervention assessments by teachers and professionals and mental health training for teachers would be very useful to help children and adolescents.
5	Takeda et al., 2021 [67]	---
6	Xu et al., 2021 [68]	---

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/su15065272/s1, Table S1: PRISMA guidelines for reporting systematic reviews and meta-analysis.

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