Biopsychosocial Risk and Protective Factors for Adolescents’ Psychological Wellbeing during COVID-19: A Scoping Review

Rationale

As a result of the COVID-19 pandemic, several measures have been taken which have directly impacted the lives of adolescents, including school closures, quarantines, lockdowns, social distancing, mask mandates, and limitations on movement [1, 2]. As such, recent research has placed increasing emphasis on the potentially long-lasting effects of COVID-19 and related restrictions and lifestyle changes on psychological wellbeing [3]. The impact of COVID-19 on adolescent psychological wellbeing, in particular, is an increasing concern among both academics and practitioners. Given the increasing attention to the issue of psychological wellbeing, in particular, this study adopts a scoping review protocol for the evaluation of the potential risk and protective factors which are evidenced to play a role in the relationship between the pandemic and adolescents’ psychological wellbeing. While several studies have already been published, focusing on specific psychological, biological/physical, or social factors, there is a lack of an updated review of the literature from a biopsychosocial perspective.

Objectives

As such, the present study intends to (a) identify protective and risk factors related specifically to adolescent psychological wellbeing during the COVID-19 pandemic, (b) evaluate the roles of biological, psychological, and social factors, and (c) provide relevant findings that can inform healthcare policy and practice, as well as to contribute to the growing literature on adolescent psychological wellbeing during COVID-19.

Review Protocols

The scoping review outlined in this report follows the JBI guidelines for scoping reviews [4]. The protocol follows the Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) checklist provided for scoping reviews [5]. The design of a scoping review was deemed appropriate due to the advantages of addressing a wide range of research from an exploratory perspective in order to provide practical implications from a relatively complex body of literature [6].

Eligibility Criteria

Following the PICOS design of SriHaran, et al. [7], the eligibility criteria included population, intervention, comparator, outcome, and study design. In terms of the population, this study focused on adolescents. In alignment with a contemporary understanding of adolescence, the age range of 10 to 24 years was selected [8]. In terms of intervention, inclusion criteria included empirical studies related to COVID-19 and psychological outcomes among adolescents. Only primary, quantitative studies were considered. As with SriHaran, et al. [7], comparators were not included in the scoping review. As for outcomes, the review focused on biological (physical), psychological, and social risk and preventative factors in the context of psychological wellbeing during the COVID-19 pandemic, including constructs of psychological wellbeing, which also included negative aspects of psychological distress, based on the Depression, Anxiety and Stress Scale-21 (DASS-21) subscales of depression, anxiety, and stress [9]. In terms of study design, manuscripts using quantitative and empirical methods, including those with structural models or clear inferential statistics were selected.

Search Method and Sources

In order to conduct an expedient and exploratory review of the literature most relevant to psychological wellbeing the PubMed database (offered by the National Library of Medicine, and including literature from MEDLINE as well as other life science journals and online books) was used for the collection of abstracts using the aforementioned keywords. Any data which included the search term “COVID” were included in the analysis, regardless of time. Within the PubMed database, articles were included on the basis of the abstracts containing the key terms of “COVID” and “adolesc*” with the asterisk serving to broaden the search to include terms such as “adolescent” or “adolescence” based on the root, and “AND” being used as a Boolean search operator requiring that both terms be included in the search results. In addition the following terms were also added, in addition to the Boolean search operator of “AND” to yield results specific to the a priori constructs specified by the outcomes aspect of the PICOS model [7], were used in order to collect the initial set of articles by searching the abstracts within PubMed. The specific inclusion terms are as follows: anxiety, biology*, depress*, distress, protect, psych*, risk, social, and stress. As discussed in the results below, in order to exclude non-English and non-empirical studies from the analysis, EndNote9 was used to filter and eliminate irrelevant articles. As such, according to the intervention aspect of the PICOS model [7], the following exclusion terms were used to narrow the results: protocol, review, editorial, and qualitative. The remaining abstracts were further screened (See Figure 1), to ensure that all remaining studies were relevant to adolescents, within the age range of 10 to 24 years [8], and specifically mentioned risk and/or protective factors.

Search Results

Based on the search items mentioned above in the eligibility criteria section, a total of 13,212 abstracts were collected. After deleting 6,516 duplicates, a total of 6,696 abstracts were retained for further analysis. As shown in Figure 1, articles were excluded in the case of missing data, not being available in English, using non-empirical methods, and not being clearly related to the adolescent population of interest to this study or not including clear risk or protective factors. At this point, the full text from 281 articles was scrutinized to ensure that the content met the inclusion criteria. Based on a review of these texts, a total of 32 articles were selected for inclusion in this scoping review.

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Characteristics of the Selected Studies

A list of the 32 selected studies is provided in Table 1, along with the lead author, sample size, study type, risk factors, and protective factors. 11 of the studies conducted longitudinal research, with the other 21 studies conducting cross-sectional research, largely through the use of questionnaires. The scales used by these studies included the Hopkins Symptoms Checklist-25, Multidimensional Perceived Social Support-12 instrument, the Kessler-10 Psychological Distress scale, the COVID-19 Phobia Scale (C19P-S), the Revised Children’s Anxiety and Depression Scale (RCADS), a 9-item Patient Health Questionnaire, a 7-item Generalized Anxiety Disorder Scale, a short form of the Childhood Trauma Questionnaire, the Connor-Davidson Resilience Scale, the Strengths and Difficulties Questionnaire, among others. Self-designed questionnaires were developed for some studies. All studies were empirical in nature, adopting quantitative analysis, and included paired sample t-tests, bivariate analyses, logistic and multinomial logistic regression, mixed model panel regression, cluster analysis, and structural equation modeling.

In general, more risk factors (72) were found than protective factors (41). However, many of these factors overlapped, in that protective factors, when absent or lacking, became risk factors. After categorizing these factors in terms of biological, psychological, and social risk and protective factors, the principle results are reported in the following section.

having siblings, physical activity, home-schooling, reading, talking with others (mental health disorders)

Biopsychosocial Risk Factors

Biological Risk Factors: Mixed results were found in terms of sex, with one study suggesting that males at greater risk of negative feelings [27], but with a total of seven studies identifying females as being at greater risk of several mental health issues [2, 11, 14, 26, 34, 40]. Findings related to age are likewise mixed, with some evidence for higher risk of anxiety and depression among primary and middle school students [11], with other studies reporting greater risk, over time, for older adolescents [33, 40] and high school students [30]. Pre-existing physical diseases are a risk factor for distress, anxiety, and depression [13, 14], including ADHD [17], autism [27], neurodevelopmental disorder [32], and eating disorders [36]. Sleep is another commonly reported risk factor [22, 34, 36, 37] in terms of depression, mood and psychological disorders, and psychosocial and behavioral problems). Likewise, lack of exercise [30], and a sedentary lifestyle [37], are considered as risk factors for distress and psychosocial and behavioral issues.

Psychological Risk Factors

While coping strategies are generally considered protective factors, problem-focused [12], or negative coping strategies [39], may serve as risk factors for mental distress. In a related manner, cognitive aspects, such as low executive control [1], negative emotional regulation [28], negative cognitive style [19], and dysfunctional attitudes [19], were reported as risk factors in the literature. Worry is a risk factor for psychological distress [13, 18, 25], including financial worries [28]. Just as physical disease served as a risk factor for psychological distress, mental disease [13, 14] and special educational needs [32] are psychological risk factors. Emotional abuse [15], is associated with anxiety and depression.

Social Risk Factors

Several social risk factors have been reported, many of which relate to being exposed to COVID-19, such as having a diagnosed family member [2, 34], having cases in their community [12, 27, 33], or experiencing events or concerns related to COVID-19 [21], or related stressors [35], as well as taking the risk of meeting friends in person [14], and undergoing COVID-19 testing [14]. Given the risk of COVID-19 in the community, the role of social support becomes important, with lack of support resulting in distress [13], social disadvantages [31], loss of income or parents’ employment [26, 27], and low subjective school or social status [34], serving as risk factors for mental health and mood disorders. The role of the family in offering positive social support is, likewise, a tangible need for adolescents. As such, risk factors for psychological stress include arguments or conflict with parents [23, 25, 36, 37], poor family functioning [38], over-protective parenting [26], and having mentally burdened or distressed parents [31, 32]. One important factor related to family life is that of routine, with adolescents lacking routine being at greater risk for anxiety or depression [23]. Interestingly, other family and community factors, such as having a healthcare worker in the residence [14], siblings [15, 29], and belonging to stem families [29], also serve as risk factors for anxiety and depression. Social behaviors such as attending reopened schools, as compared to being home- schooled [37], having increased screen time or video game play [27], and not wearing masks [36], as per mandates are additional risk factors for adolescents.

Biopsychosocial Protective Factors

Biological Protective Factors: As with risk factors, sex as a protective factor was not reported consistently in the literature, with studies associating the male sex with risk of negative feelings [2], or the female sex with risk of mental health [31]. While one study reported that older adolescents were less at risk of mental health issues (age as a protective factor) [31], as with the findings from biological risk factors, it is difficult to make clear interpretations. However, in terms of biological well-being factors related to healthy behaviors, there is ample evidence of the importance of sports and physical activity [11, 22, 29, 33, 36], time spent in natural environments [35], regular diet [13], and sufficient sleep [1316, 22, 25], as protective factors in terms of adolescents’ psychological wellbeing during COVID-19.

Psychological Protective Factors

In line with several recent studies emphasizing resilience, the role of resilience as a protective factor was a common theme among the articles selected for this scoping review [15, 19, 20, 21, 39], as with related constructs such as character strengths [24]. Additionally, positive coping was found to be a protective factor overall [17, 39], as well as in terms of cognitive reappraisal and humor [21], behavioral disengagement [12], and talking with friends or others [16, 27]. Other behaviors that were reported as protective factors include reducing passive screen time [35], reading [27], avoiding exposure to news [35], and compliance with lockdown orders [25].

Social Protective Factors

In terms of social protective factors, emotional and social support, family relationships, and routines are key to mitigating the effects of COVID-19 on adolescent psychological well-being. Emotional support [12], and social support and connectedness [31], were reported as protective factors. In terms of adolescents’ home life, protective parent-child relationships [15], positive perceptions of home life [18], positive relationships with parents [19], positive family climate [31], and home-schooling [27], were reported as protective factors. Daily life routines [17, 33] and structured routine [35], were also predictive of more positive psychological outcomes for adolescents during the COVID-19 pandemic.

Summary of Findings

From a pool of 281 potential articles, 32 studies with quantitative research designs related to adolescent psychological wellbeing, which reported risk and protective factors during the COVID-19 pandemic, were evaluated in this scoping review. Overall, in terms of physical factors influencing adolescent psychological wellbeing, it appears that females are more at risk as compared to males, although the results are somewhat mixed. Pre-existing physical and mental conditions also serve as clear risk factors during the pandemic, as individuals with both physical and mental disorders or either physical or mental disorders are disproportionately impacted by the COVID-19 pandemic [41]. Awareness of this risk may also be known to individuals with physical or mental conditions, which may compound the psychological impact through increased fear of COVID-19 [42]. In terms of biological well-being factors related to healthy behaviors, there is evidence of the importance of sports and physical activity, diet, and sufficient sleep. In terms of psychological factors, negative coping strategies, such as those that are problem-focused, and other cognitive factors, including low executive control, emotional regulation and dysfunctional or negative attitudes can increase the risk of psychological distress during the pandemic. Worry and mental disease were also clearly linked to risk of psychological distress. Alternatively, resilience, positive coping strategies, and other steps to avoid COVID-19 news and reduce screen time were protective factors for adolescents. Finally, in terms of social factors, having COVID-19 cases in the community or family were strong risk factors for psychological distress. Lack of social support, including negative family functioning or conflicts in the home, was also predictive of psychological distress among adolescents during the pandemic. On the other hand, emotional and social support, family relationships, and routines were key to mitigating the effects of COVID-19 on adolescent psychological well-being.

Limitations

The scoping review was conducted by the author and without assistance by other raters. This limits the reliability and validity of the protocol. While the PRISMA-ScR Checklist (see the Appendix) was followed as closely as possible, data charting was not clearly discussed.

Moreover, while each of the retained articles was read carefully, there were no clearly stated standards of critical appraisal adopted, such as the rigor of the statistical analysis. Likewise, the use of a single database (PubMed) limited the number of potential quantitative studies available for analysis. As the content of a single database introduces the potential for bias, further research addressing risk and protective factors in the context of COVID-19 should include other databases, such as PsycINFO and ERIC. As the resulting articles included in this analysis may not be completely representative, and potentially skewed towards more biological/physical and psychological-oriented journals, future studies can index databases and journals that may include more social risk and protective factors through a more thorough and expansive search of relevant literature.