Characteristics of included studies and mental health issues
The search identified 3,390 articles, of which 53 met the inclusion criteria. Most of the included studies had quantitative observational design (N = 48). Among them, five were conducted after the COVID-19 pandemic. A descriptive summary of the observational studies conducted during the pandemic is presented in supplementary Table 1. Other observational studies conducted before the pandemic were summarised according to the categories of target population: general (N = 24, supplementary Table 2), refugees (N = 16, supplementary Table 3), and others (N = 3, supplementary Table 4). In addition, three interventional studies (supplementary Table 5) and two qualitative studies (supplementary Table 6) were included. Of the 48 quantitative observational studies, 42 and six had cross-sectional and longitudinal designs, respectively. Regarding the sampling methods, 22 of 48 used random sampling, whereas the others employed convenience sampling. The mental health issues identified in the literature included depression (N = 21), emotional/behavioural symptoms (N = 9), anxiety (N = 8), post-traumatic stress disorder (PTSD, N = 6), attention-deficit/hyperactivity disorder (ADHD, N = 3), eating disorders (N = 3), substance use (N = 3), and others (suicidality, internet addiction, social phobia, psychological stress, health, and wellbeing; N = 8). The findings for each mental health issue are mentioned in the following sections.
Depression
Of all studies (N = 53), 20 quantitative observational studies and one qualitative study investigated depression. The estimated prevalence of depression was reported in 16 studies; however, three studies used the same cohort data. The prevalence of depression in the general population varied greatly from 9.5 to 73.8% [11, 13]. Studies on refugees reported the prevalence of depression from 28.3 to 40.4% in Syrian children and adolescents [8, 14] and 39.5% in teenage married Palestinian girls [15]. Studies during the pandemic also showed depression prevalence rates of 31.5 to 40.4% in the general population [16, 17] and 19.3% in refugees and vulnerable Jordanian populations [18]. Furthermore, a study on adolescent mothers revealed a prevalence of postpartum depression (28.5%) [19].
Depression was associated with several demographic factors: female sex, lower family income, living with a single parent, domestic violence, peer relation problems, physical health problem, and low peer support [8, 12, 20]. Moreover, it was associated with psychopathologies such as anxiety disorders [21], substance use [22], and internet addiction [11]. Stigma may moderate help-seeking behaviors in adolescents with depression. The results showed that lower personal stigma was associated with a higher likelihood of seeking professional support, such as psychotherapy and psychiatric consultation, while higher stigma was associated with more help-seeking from a school counselor or family member [23]. This association was consistent with a qualitative study reporting that adolescents with depression were reluctant to seek psychiatric treatment because of personal stigma, such as being called crazy [24].
Emotional/behavioural symptoms
The second-most frequent mental health issues in the studies were emotional and behavioural symptoms, typically measured using the Child Behavior Checklist (CBCL), Youth Self Report (YSR), or Strength and Difficulties Questionnaire (SDQ) (N = 9). As these symptoms are not necessarily related to a psychiatric diagnosis, their prevalence was seldom reported despite one study reporting emotional/behavioural difficulties of 11.7% among adolescents aged 14 to 16 years [25]. Some longitudinal studies reported factors that might affect children's emotional and behavioural symptoms. For example, paternal disrespectful psychological control and maternal punitive parenting were associated with emotional symptoms [26, 27], whereas corporal punishment and parental rejection were associated with behavioural symptoms [28]. Moreover, keeping secrets from parents was associated with both emotional and behavioural symptoms [29].
Anxiety disorders and PTSD
Anxiety disorders (N = 8) and PTSD (N = 6) followed emotional and behavioural symptoms. Of all the studies investigating anxiety disorders, the prevalence in the general, refugee populations before the pandemic, and the general population after the pandemic ranged from 16–42% [11, 13], 19–36% [8, 15], and 30–44% [16, 21], respectively. Four studies reported the prevalence of PTSD among refugees in the range of 31–77% [30–33], while one study examined it in the general population (16%) [32]. Older age, female sex, internet addiction, perceived discrimination, and low hope were associated with anxiety disorders [8, 11, 21]. Moreover, parental death and low family support were associated with PTSD [31, 34].
ADHD, eating disorders, and substance use
There were relatively minor but crucial mental health issues such as ADHD, eating disorders, and substance use. The prevalence of ADHD among primary school students ranged from 19–41% based on teachers' assessments [35, 36]. Younger age, having more siblings, and male sex were associated with ADHD [36]. Two studies reported the prevalence of eating disorders (12–29.4%) among teenage girls [37, 38]. Female sex, urban residence, messages from parents, peers, and mass media about body weight and shape, and body shape were associated with eating disorders [39]. For substance use, one study reported the prevalence of stimulant use (9%), sedative tranquiliser (13%), and hypnotic agents (18%) among teenagers [40]. Furthermore, approximately one in five adolescents smoked, including waterpipe cigarettes [22]. High psychological distress, low family support, and depression were associated with substance use [22, 40].
Impact of COVID-19 on child and adolescent mental health
Five studies have been conducted since the COVID-19 pandemic [16, 18, 41, 42]. All studies used convenience sampling, and four employed online surveys. Among high school students and young adults, the prevalence of depression and anxiety ranged from 40.4 to 55% and 30.3 to 44%, respectively [16, 43]. Among Syrian and Palestinian refugees, and vulnerable Jordanian adolescents, the prevalence of depression and anxiety was 19.3% and 12.4%, respectively [18]. According to the meta-analysis, the pooled prevalence of depression in the general population during the pandemic was higher (48.3%, 95% confidence intervals [CIs]) than that before the pandemic (31.7%, 95% CIs[21.9–41.6]) (Fig. 2). Similarly, the pooled prevalence of anxiety in the general population during the pandemic was higher (36.9%, 95% CIs[33.4–40.4]) than that before the pandemic (29.2%,95% CIs[18.8–39.7]) (Fig. 3). However, the reported prevalence of depression (19.3%) and anxiety (12.4%) in refugees and vulnerable Jordanians after the pandemic were lower than the pooled estimates (depression: 35.7%; anxiety: 24.5%) before the pandemic.
Female sex, exposure to a person with COVID-19, and difficulties with online education were associated with depression and anxiety [16, 41]. In addition, parents recognised that their children had become more irritable, nervous, argumentative, and distractive after the pandemic [17]. Parental divorce and unemployment due to the pandemic were associated with parental perceptions of children's emotional and behavioural changes [17].
Empirical MHPSS
We identified three interventional studies [44–46] which examined the Child-Friendly Space (CFS), an 8-week programme informed by a Profound Stress and Attunement (PSA) framework, and the Community-Family Integration Teams (C-FIT) diversion programme. The design adopted for each study was quasi-experimental with meta-analysis (CFS), a randomised controlled trial (RCT) in combination with a quasi-experimental trial (8-week PSA-informed programme), and a pretest-posttest design without a comparison group (C-FIT). The CFS is a safe place in a humanitarian emergency, where children's basic needs can be met. It helps children return to normalcy by offering activities such as games and informal education. According to the meta-analysis, CFS attendance was associated with better wellbeing among children aged 6–11 years with the effect size of Cohen's d (0.18, 95% CI:0.03, 0.33) [44]. The 8-week PSA-informed programme was run by local community facilitators to enhance safety and psychological support for both Syrian refugees and Jordanian youth. They could choose a variety of activities, including fitness, arts/crafts, and vocational skills. The quasi-experimental part of the study demonstrated significant decrease in perceived stress (Cohen's d = 1.13), depression, and anxiety (Cohen's d = 1.21) in the intervention group; however, the RCT did not confirm these results [45]. The C-FIT program addresses behavioural and mental health treatment for adolescents involved in the justice system. It comprises three components: cognitive behavioural therapy, parent management training, and task-centered case management. The C-FIT programme showed a decrease from baseline to follow-up in emotional symptoms (26–13% at borderline/clinical levels) but not in behavioural symptoms (10–20% at borderline/clinical levels) [46].