Appendix 1: Literature review The Children Attending Paediatricians Survey, conducted in 2008, reviewed more than 8,000 attendances to paediatricians and found that around one in two children had developmental and behavioural issues—a known early sign of later mental health problems.71 1.2 What has happened to Australian children’s mental health during COVID-19? Research suggests that while mental health was already in decline prior to the pandemic, it has deteriorated even further as a consequence of it. This has regularly been described as an acceleration of the downward spiral that was already underway.72 UNICEF’s report, The State of the World’s Children 2021, suggests that ‘the pandemic may represent the tip of a mental health iceberg—an iceberg we have ignored for far too long’.73 The American Academy of Paediatrics has referred to the mental health decline of children and young people during the pandemic as a ‘national emergency’.74 Internationally, it is reported that the prevalence of depression and anxiety symptoms in children and adolescents has doubled during the pandemic, and cumulative harm is at play with these rates significantly increasing over the length of time that the pandemic continues.75 Some argue that it is not so much the health risks associated with COVID-19 that have impacted on the mental health and wellbeing of children and young people, but the indirect effect of changes such as disruption to schooling and loss of social connections.76 Similarly, a 2021 survey by ReachOut of more than 1,000 young people aged 14–25 found that the number of young people reporting poor mental health or wellbeing as a result of study stress has doubled from 25% in previous years to 56% this year.77 132 | According to a United Nations policy brief early in the pandemic, existing emotional difficulties among children and adolescents have been exacerbated by factors relating to the pandemic. These include increased family stress, social isolation, some children facing greater risk of abuse, disrupted education and uncertainty about their futures, all of which are happening at critical stages of their brain development.78 Other literature supports this, reporting that the pandemic has brought on feelings of loneliness, psychological distress, anger, irritability, boredom, fear, and stress in children and young people.79 Some research identified school closures as a key stressor for some young people.80 In 2020, the Australian Human Rights Commission (AHRC) released its report on the Impacts of COVID-19 on children and young people who contact Kids Helpline.81 This report analysed Kids Helpline data between January–April 2020. Mental health concerns arising from COVID-19 was a key reason for children and young people contacting the Kids Helpline during this period. The other most common reasons related to social isolation, educational impacts, impacts on family life, changes to plans and usual activities, changes to essential services and support, and economic impacts. This finding is commensurate with the findings of an international study which found that young people were concerned about the toll of the pandemic on their mental health, over and above other basic needs such as employment, income, education and relationships with family and friends.82 In its report, the AHRC recommended government investment in child and youth-focused mental health services and supports to assist the wellbeing of children and young people going forward.83 Each year, Mission Australia conducts a national survey of young people aged 15–19, asking them about issues that concern them. While the survey is not representative of all young people in Australia, it provides an indication of some views and experiences over time. Prior to the pandemic, Mission Australia found an increase in the proportion of young people aged 15–19 reporting psychological distress from 18.7% in 2012 to 24.2% in 2018.84 This increased to 26.6% in 2020 in the middle of the pandemic.85 In 2020, 25,800 young people participated in the survey, and rated COVID-19 as one of the top three issues weighing on their minds.86 According to a report by the Victorian Agency for Health Information, an average of 342 children, aged up to 17 years, presented to Victorian emergency departments each week suffering mental health emergencies between April and May 2021. This represented a 57% increase from the same time in 2020.87 Similarly, data by NSW Health indicates that selfharm presentations by children have increased during the pandemic, with suicide rates remaining unchanged.88 For some adolescents, their eating and exercise habits changed during the pandemic which had negative impacts on their mental health. International research reports that individuals with previous eating disorders have been among the most poorly affected in the pandemic, with some experiencing a reactivation or exacerbation of severity.89 In Australia, there has been a sharp increase in the number of adolescents seeking treatment for anorexia nervosa, and other eating disorders since the commencement of the pandemic and associated restrictions. One clinic in Melbourne noted a rise of 63% during 2020 compared to the previous three years in patient presentations for restrictive eating disorders from the ages of 9–18.90 40% of anorexia nervosa patients being treated at the Royal Children’s Hospital in Melbourne reported COVID-19 restrictions as the primary trigger for their disordered eating behaviours.91 Isolation, loneliness and boredom have previously been identified as common triggers for the onset of eating disorders and also in exacerbating pre-existing disease.92 More generally, in the Royal Children’s Hospital’s National Child Health Poll in mid-2020, more than one-third of parents reported the pandemic as having negative consequences on their children’s mental health.93 In 2021, surveys were conducted to gather the views of 4,078 young people aged 7 to 20 years old for the UNICEF Young Ambassadors Report. It was reported that 24% of young people aged 13–17 years viewed pandemics as one of the greatest threats to the future wellbeing and livelihood of Australian children and young people.94 This report also suggested that the wellbeing of children and young people aged 13–17 may be beginning to recover, with two thirds (65%) saying that their ability to cope right now is ‘good’. While this proportion remains lower than the 81% who felt their ability to cope at the beginning of 2020 was good, it is higher than in April 2020, when less than half (45%) felt their ability to cope was good.95 1.3 What are some of the common signs of poor mental health and wellbeing in children and young people? Poor mental health in children and young people can present in many different forms and can be difficult to understand due to the inherent changes that occur during child development.96 Signs of poor mental health and wellbeing can vary depending on age. In younger children, signs of poor mental health can include feeling sad, appearing to have less fun, being fidgety and unable to sit still, and not understanding other people’s feelings.97 A recent study of child mental health found that, following Victoria’s second COVID-19 lockdown in 2020, parents reported a significant increase in child irritability and anger, sadness and withdrawal and children demonstrating ‘attachment seeking activities’, including demanding more attention and support.98 ‘Mental health shapes my life’: COVID-19 & kids’ wellbeing • 2022 | 133