Profiles

Mental health conditions affect about 1 in 7 adolescents globally. In the context of COVID-19, the importance of mental health and psychosocial support for all has been undoubtedly confirmed. Despite the increased attention to mental health issues, there is a dearth of evidence on what determines child and adolescent mental health, who is most at risk, and what works to foster mental health across contexts, cultures and distinct population groups. This conceptual framework aims to inform research on child and adolescent mental health. It incorporates children’s developmental stages and the dynamic environment in which they live and grow. Informed by a review of existing theoretical frameworks on mental health and child development, this framework integrates elements of the socio-ecological model; the life course approach; the social determinants of health approach; and Innocenti Report Card’s Worlds of Influence Framework. Combining diverse aspects of these frameworks and approaches, we propose an integrated model to guide UNICEF’s research in this area.

COVID-19 is a crisis like no other in modern times. It has reached every population and community. While the evidence base is still nascent, this report looks at the impacts of disasters and past epidemics – such as Ebola, HIV, SARS/MERS and Zika – on child and adolescent mental health and psychosocial wellbeing, and examines how these insights can guide policies and progammes to support children, their families and communities during the current pandemic.

The initial impression that paediatric SARS-CoV-2 infection is uncommon and generally mild has been replaced by a more nuanced understanding of infectious manifestations in children and adolescents across low-, middle-, and high-income countries, with recognition of a widening disease spectrum. Critical knowledge gaps, especially in low- and middle-income countries, remain that have significant public policy and programme implications. Insufficient data disaggregated by age, geography and race/ethnicity continue to hinder efforts to fully assess prevalence of infection and disease manifestations in children and adolescents and their role in transmission. Potential biologic differences in susceptibility to infection and transmissibility between children, adolescents and adults need to be assessed. Determination of mother-to-child SARS-CoV-2 transmission during pregnancy, the peripartum period, or through breastfeeding requires appropriate samples obtained with proper timing, lacking in most studies. Finally, predictors of disease progression, morbidity and mortality in children need to be determined and whether these predictors vary by geographic location and in settings where poor nutritional and health conditions and other vulnerabilities are more frequent. Countries, UN agencies, public health communities, donors and academia need to coordinate the efforts and work collectively to close the data and knowledge gaps in all countries (high-, middle- and low-income) for better evidence to guide policy and programme decision-making for children and COVID-19 disease.

(19 November 2020) From health to education, every child in the world has been affected by the COVID-19 pandemic, with many impacted in multiple ways. As the crisis rages on, further entrenching pre-existing inequalities, there is an urgent need for scalable and cost-effective solutions for children. Such solutions require more evidence on COVID-19, which is not yet available. A new report by the UNICEF Office of Research—Innocenti, Beyond Masks: Societal impacts of COVID-19 and accelerated solutions for children and adolescents, examines past health crises (such as HIV/AIDS, SARS, and Ebola) to provide insights into COVID-19, and proposes proven and promising solutions.

It is commonly accepted, at least for now, that children and adolescents (0-19 years) have been largely spared the direct epidemiological effects of the COVID-19 crisis on their own health and survival. This narrative is based predominantly on early data from the first affected countries of the virus, notably from China (Wuhan Province) and Italy in early 2020, and also other high-income countries including the United States and some European nations. This narrative has conditioned subsequent screening and testing of COVID-19 cases in children and adolescents, which have been notably lower than for other age cohorts. But demographic dynamics differs widely among countries, and assumptions and narrative made on evidence taken from ageing societies and mainly from high income countries may not hold for more youthful and growing populations (Figure 1). For this reason, we began to investigate the burden of COVID-19 cases for children and adolescents globally. And what we have found so far, despite major data limitations, suggest that children worldwide may be more affected by COVID-19 than the dominant narrative so far suggests. The narrative [that children have been spared] is based predominantly on early data from the first affected countries of the virus, notably China and Italy and other high-income countries including the United States and some European nations.Italy source: https://www.statista.com/statistics/1103023/coronavirus-cases-distribution-by-age-group-italy/ Kenya source: https://www.health.go.ke/wp-content/uploads/2020/06/Kenya-SITREP-090-15-Jun-2020.pdfThe dataset we have compiled from websites of 42 countries with available disaggregated data shows that the average of COVID-19 reported cases among children and adolescents under 20 years as a percentage of total cases is 8.1 per cent. There is an incredibly broad spread among the proportions, ranging from Paraguay, where under-20s account for about 23 per cent of the national COVID case load on 14 June 2020, to Spain, where they represented just 0.82 per cent by 4 June 2020. (Figure 2). A pattern of the child and adolescent burden of reported COVID-19 cases emerges when countries are aggregated along income levels and geographic locations. Using the World Bank income categorization, the share of COVID-19 cases among under-20s in the total reported burden is around 10 per cent for low- and middle-income countries (LMICS) including China compared to 7 per cent for high-income countries (Figure 1). When China is excluded, the share of COVID-19 cases among under-20s in the total national burden is around 11 percent. What is perhaps more disturbing, however, is that for some of the high-burden child and adolescent mortality countries – including Brazil, India and Nigeria – the proportion of cases among under 20s to the total national COVID-19 cases is in double digits. One reason that children may be neglected as sufferers from COVID-19 derives from the way the virus affects them. Children confirmed with COVID-19 generally have fewer symptoms than adults, including fever and cough, and much less dyspnoea (shortness of breath) than adults. Consistent with less severe disease, laboratory findings in children with COVID-19 are less abnormal than in adults, and they are less likely to require ICU or significant treatments. However, the emerging multi-system inflammatory syndrome (MISS or MIS-C) in children reported in Western countries is of great concern and calls for increased vigilance. Early detection is key to prevent unintended consequences for children. Much of the difficulty of drawing definitive conclusions from the available data is related to the fact that there is just too little of child specific data. From our search of diverse sources, we were only able to draw on data by age from 42 countries out of the 188 countries and territories that have confirmed cases of COVID-19, which represents about 20 per cent of these countries. It is even harder to obtain disaggregated data to evaluate proportional representation by age among children and adolescents with COVID-19. This omission requires rapid rectification if the full direct effects of the virus on children and adolescents – and indeed other stratifiers such as gender and race/ethnicity -- are to be better understood. While understanding the additional burden the accurate age reporting may place on already overstretched health systems, particularly in countries with weak health system capacity, experience from some low-and-middle-income countries proved that it is possible for much more age disaggregated data to be made available in a readily accessible format. This will not only benefit children and adolescents but the wider understanding of the impact of COVID-19 on all age cohorts. The same argument can and is being made for disaggregation by sex. A medical worker applies a flu vaccine to a girl in Asuncion, Paraguay amid the COVID-19 pandemic. Health authorities in Paraguay are encouraging people over 60 and children to be vaccinated against the flu.It is imperative to have standardized age data to enable a comprehensive and timely understanding of the patterns of vulnerability across ages, geography, co-morbidities and vulnerabilities, thus enabling better programme strategies and policy adoption that are context specific. At the end of the day, the pandemic is about people in different parts of the world, so invoking the SDG principle of leaving no one behind, and universal health coverage, we need to pay attention to everyone including children and adolescents, who are often the silent victims. Children are without a voice or platform and are among the most vulnerable. It is the responsibility of all governments and parties to make sure they are not left behind in this epidemic due to lack of data, research and testing. The pandemic has currently appeared to hit men and the elderly hardest, particularly in high income countries. But data emerging from the US and elsewhere points alarmingly to COVID-19 disease becoming an equity issue, with certain ethnicities and income groups much more likely to die from it than othersIn addition, a further call by the authors is for the continuous monitoring of age- and sex-disaggregated data for COVID-19 by governments and major international agencies. The pandemic has currently appeared to hit men and the elderly hardest, particularly in high income countries. But data emerging from the US and elsewhere points alarmingly to COVID-19 disease becoming an equity issue, with certain ethnicities and income groups much more likely to die from it than others, even when controlling for pre-existing health conditions, age, and other socio-demographic factors. Like polio before it, unless we continue to monitor its socio-demographic spread, COVID-19 may start out being a disease that first affects more affluent communities and countries but could end up lasting longest and deepest among the world’s poorest countries and communities. In the HIV crisis, age-disaggregated data appeared long after the aggregate numbers or even the sex-disaggregated, leaving child prevention, detection and treatment lagging well behind that of adults. Until it did, children were assumed to be affected largely by its secondary effects on their parents, caregivers and family members. The disaggregated figures showed that children were also primary victims of the crisis, as well as secondary ones, but by the time this happened, it was too late to stop this momentum. We must not make the same mistakes with the COVID-19 crisis. See a complete list of country level COVID-19 data sources.   Priscilla Idele is Deputy Director of UNICEF Innocenti. David Anthony is Chief of Strategic Planning  and Convening at UNICEF Innocenti. Kaku Attah Damoah, is a Research Consultant at UNICEF Innocenti working on poverty reduction. Danzhen You is Sr. Advisor, Statistics and Monitoring at UNICEF.             

In some way, mental ill health has touched everyone. The statistics are alarming, and by some accounts constitute a public health emergency. Today, around 10-20 per cent of all children and adolescents suffer from some type of mental health disorder and mental health conditions account for around 16 per cent of the global burden of disease and injury among adolescents. Worldwide depression is among the leading causes of disability among young people and suicides are the third leading cause of death among adolescents worldwide, and the second among 15-19-year-old adolescent girls. Fifty percent of mental health conditions arise before the age of 14, and 75 per cent by the mid-20s. Given the age-sensitive nature of predictors, early life investment makes good sense. However, globally relatively small sums have been allocated, with an estimate of less than 1 per cent of national health budgets in low-income countries being devoted to mental health. Yet the economic cost of mental health is enormous, amounting to around 4 per cent of GDP. Evidence supports early investment -- if left untreated, it is estimated that mental health disorders which emerge before adulthood can impose a health cost 10 times higher than those that emerge later in life. mental health disorders which emerge before adulthood can impose a health cost 10 times higher than those that emerge later in life.Emerging evidence indicates that the prevalence of mental ill-health is growing. Issues such as climate change, environmental degradation, unplanned and rapid urbanization, migration, demographic transition, youth unemployment, and technological leaps are implicated. These may have profound impacts on the minds of children and young people. Yet we know very little today about how to manage or harness these changes to improve the mental wellbeing of children. The 2018 Lancet Commission report compellingly illustrated the value of addressing mental health to advance a number of sustainable development goals. This suggests that effective mental health interventions may be potential development accelerators – with provisions that lead to progress across multiple SDGs. In the context of shrinking fiscal space, this makes it a highly desirable area of investment. Rafeya Akhter Moni, 14, plays a game with friends at a UNICEF-supported Adolescent Club near her home in Dhaka’s Duaripara slum. Twice each week Moni and 35-40 other young people have the opportunity to get together and be ordinary teenagers in a safe space.More work is needed to examine the state-of-the-art evidence, and the corresponding programmatic and policy responses on children’s mental health in the first decade of life, beginning in utero, through the first five years, and then into middle childhood (5-9 years). The evidence agenda is clear: we need to look at the latest findings from neuroscience; the overall prevalence and spread of mental ill health across ages and geographies; causes and contributing factors; and methods of preventing and treating mental ill health. These are all important parts of the puzzle, and critical to the response effort. Adolescence is a critically important stage of life when many of the mental health conditions prevalent in adulthood first manifest, and also the most challenging time for those entrusted with the care and protection of young people to reach them with solutions. Addressing the mental health of our children is imperative. Greater leadership and political commitment on policy, research and implementation is needed to turn the tide and advance healthy minds and healthy bodies of children and young people. A dedicated global plan or alliance through a shared value partnership for the mental health of children and young people is long overdue. On November 7 – 9 2019, UNICEF and WHO will convene a conference co-chaired by UNICEF’s Executive Director Henrietta H. Fore and WHO’s Director General Tedros Adhanom Ghebreyesus. The Inaugural Leading Minds for Children and Young People conference will focus on advancing the global agenda on mental health in children. This first year will bring together a broad array of the world’s thought leaders and decison makers – from academia, business, civil society, government, international development, philanthropy and of course, children and young people – to accelerate global progress to respond to this neglected issue. This will be the start of a critical conversation about what is needed to ensure children grow up with ‘healthy minds and healthy bodies.’ Throughout, the focus will be on the scale of the challenge and the proven and promising solutions to meet it. The conference’s final session will conclude with a deep dive into the pathways that global actors can take to tackle the issue of child and youth mental health. Crucially the voices of children living in challenging situations will be central. Sessions will be co-designed and run with and by the Youth Leaders of the conference. We need to understand and listen to them: their emotions, fears, coping strategies, and hopes. We need to engage with how they cope, what they do to support others, and what must be done for young people themselves to feel supported and thrive in a complex world.   Priscilla Idele is Director of the UNICEF Office of Research – Innocenti; Prerna Banati is former Deputy Director at UNICEF Innocenti and currently UNICEF Regional Advisor on Adolescent Development and Gender; David Anthony is Chief of Strategy and Policy at UNICEF Innocenti.

The 2022 edition of the Leading Minds for Children and Young People conference “On the Vital Importance of Child Identity”, will be held on 2-4 November in the Salone Brunelleschi of the Istituto degli Innocenti, in Florence, Italy. The Conference is co-hosted by the Italian Ministry of Foreign Affairs and the UNICEF Innocenti — Global Office of Research and Foresight. The conference will bring together some of the world’s leading thinkers — scholars, scientists, innovators, influencers, philanthropists, governments and of course young people — to understand the identity challenges that children and young people face. These range from the most traditional forms of identity — such as age, name, nationality, and family relations specified in the opening articles of the UN Convention on the Rights of the Child — to 21st century challenges related to mass migration, cyber identity, activist status, and transnationalism, among many other topics.  

UNICEF convened its inaugural Leading Minds conference this year, taking the pressing issue of mental health of children and young people as its theme. The purpose of the annual Leading Minds conference series is to bring attention to a theme pertinent to the present and future wellbeing of the world’s children and young people by convening some of the world’s leading minds to examine available evidence and solutions and contribute to accelerating progress on solutions and breakthroughs.