The COVID-19 pandemic and the measures taken to control its spread have wreaked havoc worldwide, resulting in more than 3 million deaths and forcing billions of people into isolation, profoundly affecting all aspects of daily life. Numerous studies have reported on the consequences of the COVID-19 crisis on mental health [1], but few have focused on children and adolescents [2, 3].

In April 2020, the European Society for Child and Adolescent Psychiatry (ESCAP) Research Academy, a network of young clinician–scientists in child and adolescent psychiatry (CAP) [4], and the ESCAP Board launched the CovCAP longitudinal survey to estimate the impact of COVID-19 on CAP services in Europe and to assess their ability to meet the new challenges brought on by the crisis. Heads of CAP university services in ESCAP member countries were contacted by email and invited to complete a self-report online questionnaire survey (detail of the methods have been published previously [5]; some questions were modified, removed or added in the second survey of the CovCAP study). The first stage of the study (i.e., March/April 2020) yielded surprisingly consistent results, showing a substantial reduction in the number of both outpatient visits and hospital admissions and a moderate effect on psychopathology. In contrast, the effect on the organization of CAP services appeared profound, with a clear acceleration in the adoption of new technologies, including telepsychiatry [5]. In this brief report, we briefly present the main findings from the second step of the survey, 1 year after the COVID-19 pandemic began to hit Europe (i.e., February/March 2021).

The survey was distributed to 266 heads of CAP university services in 32 countries by email between February 19th and March 25th, 2021. In total, 72 responded (27.1%), among which, 60 filled in the questionnaire completely (first and last response received: 19 February and 28 March 2021, respectively). Twenty-two countries were represented, among which, Germany had the highest number of responses (12 respondents; 16.7%). We did not obtain replies from Albania, Cyprus, Finland, Iceland, Israel, Luxemburg, Norway, Romania, Serbia and Sweden.

A selection of answers with a comparison between the two time periods (if possible) is presented in Table 1. The full data set is available on request (paul.klauser@chuv.ch). In general, the overall perception of the impact of the crisis on the mental health of children and adolescents has changed markedly between the two study periods, from an impact mainly (> 50%) perceived as “medium” in April/May 2020 to an impact perceived as “strong” or “extreme” by 80% of respondents in February/March 2021 (Fig. 1a). In comparison to before the pandemic, while 61% of respondents reported a decrease in referrals or requests for assessment in March/April 2020, 91% of respondents reported an increase in February/March 2021. Accordingly, the impact on psychopathology appeared much more marked during this second phase of the study, with four nosographic entities particularly impacted: suicidal crises (83%), anxiety disorders (70%), eating disorders (64%) and major depressive episodes (61%) (Fig. 1b). Similarly, the pandemic seems to influence the psychopathology patients present with (e.g., fear of contamination) in a higher proportion of patients in February/March 2021 than in April/May 2020 (Fig. 1c). Not surprisingly, the mental health determinant most frequently reported for both children and adolescents was school closure. However, there are differences in the other factors: parental stress appears to be the second most important determinant for children, while for adolescents, home confinement and assembly restrictions are more frequently reported (Fig. 1d).

Table 1 Most relevant results from the second stage (February/March 2021) of the ESCAP CovCAP survey
Full size table
Fig. 1
figure 1

Impact on psychopathology of the COVID-19 crisis as evaluated by European heads of child and adolescent psychiatry departments. The respective percentages were calculated on a total number of 64 respondents

Full size image

While the provision of services to patients and their families was initially affected to a major degree (affirmed by 68% of respondents in 2020), the majority of respondents (59%) reported only a minor impact on care provision in this second CovCAP survey. The use of telemedicine has remained important (91%), but guidelines to accompany its usage did not generalize (35% in 2020; 40% in 2021). Specific measures to support bereaved children to deal with COVID-19-related grief or trauma have not become widespread either (16% in 2020; 20% in 2021). While 59% of respondents had a portion of their services closed or transformed to accommodate COVID-19 patients in April/May 2020, this proportion dropped to 20% in February/March 2021. Respondents' major pandemic-related service delivery concerns for this second phase of the survey were not being able to maintain specific treatment groups for distinct groups of patients (70%), not being in sufficient contact with patients and families in need (60%), and having to manage the absence of some of their staff (33%).

Although the perception of their team's mental readiness to handle this crisis did not really change from April/May 2020 to February/March 2021 (60–63, respectively, on a scale from 0 to 100), a subjective improvement was noted between the two study periods in terms of the equipment of the services' infrastructures to manage COVID-positive patients (42 in April/May 2020 to 57 in February/March 2021, on a scale of 0–100). Interestingly, the level of acceptance of COVID-19 vaccination was perceived as high in team members of nearly three quarters of respondents and 23% of them reported a vaccination rate higher than 50% in their respective services.

Respondents’ major concerns related to CAP for when the pandemic is over were difficulties in managing the increased numbers of patients (83%), difficulties in managing families in situation of high psychosocial precariousness (83%) and reduced financial resources for CAP services (48%).

Analysis of the free comments section of the questionnaire confirmed the contrast between a reduced activity in CAP services at the beginning of the pandemic in Europe and a dramatic increase in referrals for assessment and/or hospitalization as of the end of 2020. The impact on young people's schooling as well as an increased incidence of anxiety, depression, self-harm and suicide attempts were also highlighted. While high levels of stress and even feelings of burnout among care teams were reported, some respondents also emphasized the effectiveness of certain stress management and coping techniques and the fantastic achievement of their teams in terms of adaptability and flexibility. Finally, concerns about the future of young people's mental health also emerged, particularly for very young children and children from low socio-economic backgrounds, which should lead, according to some heads of CAP service, to strong political support for mental health policies in Europe. The complete free comments are available as supplementary material.

As previously highlighted [5], this study is not without limitations. First, the overall response rate was significantly lower than in the first part of the survey (27% vs. 50%), and only 22 countries were eventually represented, despite sending 4 reminders in total. This severely restricted the scope of our results and the possibilities of comparison between countries. The lower response rate probably reflects a degree of weariness on the part of heads of department in the face of the multiplication of questionnaire studies, but it could also represent the intensity of their workload in this period of crisis. Second, the respondents in both surveys only partially overlap. Hence, comparisons between the two time points provided in the text and the table are based on cross-sectional data and should be interpreted accordingly. Finally, most of the questions were subject to personal interpretation and some answers also required rough estimates, which means that the data collected represent only general impressions of the heads of service.

On the one hand, the results of this second phase of the CovCAP study show a more moderate effect after 1 year of the pandemic on the organization of CAP services, with the implementation of structural adjustments and the continued use of new technologies, notably telepsychiatry. On the other hand, the perceived impact on the mental health and psychopathology of children and adolescents seems major and associated to a very substantial increase in the number of referrals or requests for assessments. Finally, heads of the CAP departments expressed strong concerns regarding the management of the long-term consequences of this crisis, especially regarding the provision of care in light of the perceived increase in referrals.