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RESEARCH ARTICLE
Promoting youth mental health during the
COVID-19 pandemic: A longitudinal study
Maya L. RosenID
1
*, Alexandra M. Rodman
1
, Steven W. Kasparek
1
, Makeda Mayes
2
, Malila
M. Freeman
1
, Liliana J. Lengua
3
, Andrew N. MeltzoffID
2,3
, Katie A. McLaughlin
1
1Department of Psychology, Harvard University, Cambridge, Massachusetts, United States of America,
2Institute for Learning & Brain Sciences, University of Washington, Seattle, Washington, United States of
America, 3Department of Psychology, University of Washington, Seattle, Washington, United States of
America
*mayalrosen@fas.harvard.edu
Abstract
The COVID-19 pandemic has introduced novel stressors into the lives of youth. Identifying
factors that protect against the onset of psychopathology in the face of these stressors is
critical. We examine a wide range of factors that may protect youth from developing psycho-
pathology during the pandemic. We assessed pandemic-related stressors, internalizing and
externalizing psychopathology, and potential protective factors by combining two longitudi-
nal samples of children and adolescents (N = 224, 7–10 and 13–15 years) assessed prior to
the pandemic, during the stay-at-home orders, and six months later. We evaluated how fam-
ily behaviors during the stay-at-home orders were related to changes in psychopathology
during the pandemic, identified factors that moderate the association of pandemic-related
stressors with psychopathology, and determined whether associations varied by age. Inter-
nalizing and externalizing psychopathology increased substantially during the pandemic.
Higher exposure to pandemic-related stressors was associated with increases in internaliz-
ing and externalizing symptoms early in the pandemic and six months later. Having a struc-
tured routine, less passive screen time, lower exposure to news media about the pandemic,
and to a lesser extent more time in nature and getting adequate sleep were associated with
reduced psychopathology. The association between pandemic-related stressors and psy-
chopathology was reduced for youths with limited passive screen time and was absent for
children, but not adolescents, with lower news media consumption related to the pandemic.
We provide insight into simple, practical steps families can take to promote resilience
against mental health problems in youth during the COVID-19 pandemic and protect against
psychopathology following pandemic-related stressors.
Introduction
The COVID-19 pandemic has introduced unprecedented changes in the lives of children and
adolescents. These changes brought a sudden loss of structure, routine, and sense of control.
Families faced unique stressors ranging from unexpected illness, sudden unemployment and
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PLOS ONE | https://doi.org/10.1371/journal.pone.0255294 August 11, 2021 1 / 21
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OPEN ACCESS
Citation: Rosen ML, Rodman AM, Kasparek SW,
Mayes M, Freeman MM, Lengua LJ, et al. (2021)
Promoting youth mental health during the COVID-
19 pandemic: A longitudinal study. PLoS ONE
16(8): e0255294. https://doi.org/10.1371/journal.
pone.0255294
Editor: Helena R. Slobodskaya, Institute of
Physiology and Basic Medicine, RUSSIAN
FEDERATION
Received: March 26, 2021
Accepted: July 13, 2021
Published: August 11, 2021
Peer Review History: PLOS recognizes the
benefits of transparency in the peer review
process; therefore, we enable the publication of
all of the content of peer review and author
responses alongside final, published articles. The
editorial history of this article is available here:
https://doi.org/10.1371/journal.pone.0255294
Copyright: ©2021 Rosen et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All data are available
on open science framework https://osf.io/y7cmj/.
financial stressors, difficulty accessing basic necessities, and increased caretaking responsibili-
ties paired with the shift to remote work, among others [1,2]. Social distancing guidelines
have limited youth’s contact with friends, extended family, and teachers, which may increase
isolation and loneliness. Schools traditionally provide resources that may buffer youth against
the negative consequences of stressors—including supportive social interactions, physical
exercise, consistent meals, and a structured routine—that were unavailable to many U.S. youth
for a prolonged period of time during the pandemic. These disruptions and pandemic-related
stressors are likely to increase risk for depression, anxiety, and behavior problems in youth.
Here, we identify factors that may protect against increases in mental health problems during
the COVID-19 pandemic in a longitudinal sample assessed both prior to the pandemic and
during the stay-at-home order period. We focus on simple and practical strategies that families
can take in an effort to promote positive mental health outcomes in children and adolescents
during the pandemic.
Exposure to stressors is strongly related to the onset of internalizing and externalizing psy-
chopathology in children and adolescents [3–8]. The powerful association between stress and
psychopathology has been replicated in longitudinal studies [7,9,10], including following
community stressors, such as natural disasters [11,12] and terrorist attacks [13–15]. Numer-
ous pandemic-related experiences reflect novel stressors for youth and families, including
unpredictability and daily routine disruptions [16,17], unexpected loss of family members,
friends, and loved ones [18], chronic exposure to information about threats to well-being and
survival in situations that were previously safe [19], and social isolation [20]. Thus, exposure to
pandemic-related stressors is likely to be associated with increases in anxiety, depression, and
behavior problems in children and adolescents [1,21,22]. Indeed, emerging data demonstrates
that youth psychopathology has increased during the COVID-19 pandemic [23].
Identifying factors that may promote youth well-being during the pandemic is a critical pri-
ority and has clear benefits for parents, pediatricians, and medical professionals. Leading theo-
retical models of resilience posit that factors that promote resilience exist across multiple levels
including the individual, family, school, community, and broader cultural systems [24–26].
Critically, during the early period of the COVID-19 pandemic when schools were closed, stay-
at-home orders were in place, and many community resources were shuttered, children were
cut off from many common sources of resilience, particularly those occurring at the school
and community levels. As such, home and family-level factors may have been of even greater
importance than in normal circumstances. Furthermore, given the constraints faced by many
families with children, we focus on a set of simple and practical strategies that are easily acces-
sible, inexpensive, and require no specialized resources or services outside the home. We
selected factors that have previously been associated with reduced child psychopathology or
buffer against mental health problems following exposure to stressors, including: higher levels
of physical activity [27–29]; access to nature and the outdoors [30–33]; a consistent daily rou-
tine providing structure and predictability [16,34]; getting a sufficient amount of sleep, which
is often disrupted following stressors [35–37]; and lower levels of passive screen time and news
media consumption, given that higher use has been associated with elevations in child psycho-
pathology [38], particularly following community-level stressors, like terrorist attacks [39–42].
We also assessed the degree to which youth engaged in adaptive coping strategies during times
of distress (e.g., exercising, seeking support from loved ones, or practicing mindfulness or
meditation) [43–45]. Finally, providing help for others in need is associated with reduced anxi-
ety and depression [46,47]. Here, we evaluated whether these nine simple and inexpensive
strategies are (a) associated with reduced psychopathology symptoms during the pandemic
and (b) buffer against the negative mental health consequences of pandemic-related stressors
in children and adolescents.
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Funding: Funding/Support: This work was
supported by the Bezos Family Foundation (to
ANM) for collection of data. This work was also
supported by the National Institute of Child Health
and Human development (F32 HD089514 and K99
HD099203 to MLR) and the National Institute of
Mental Health (R01 MH106482 to KAM).
Competing interests: The authors have declared
that no competing interests exist.
We examined these questions by combining two longitudinal samples of children and ado-
lescents whose mental health was assessed prior to the COVID-19 pandemic in Seattle, Wash-
ington. This aspect of this study is critical because one of the strongest predictors of
psychopathology during the pandemic is likely to be psychopathology prior to the pandemic.
By controlling for pre-pandemic psychopathology, we are able to investigate changes in psy-
chopathology that occurred during the pandemic. We then assessed pandemic-related stress-
ors, internalizing and externalizing symptoms, and potential protective factors during six
weeks between April and May of 2020—a period when the Seattle area was particularly hard-
hit by the pandemic and stay-at-home orders were in place. We also followed up with partici-
pants six months later, between late November of 2020 and early January of 2021, to assess
mental health. During this second follow-up, schools in the Seattle area were still operating vir-
tually, social distancing guidelines were still in place, and new COVID-19 cases had reached a
second peak. We examined whether exposure to pandemic-related stressors were associated
with increases in internalizing and externalizing psychopathology, both concurrently and pro-
spectively, controlling for pre-pandemic symptoms. We explored whether the potential protec-
tive factors were associated with changes in psychopathology during the pandemic or
moderated the association of pandemic-related stressors with changes in psychopathology
both during the stay-at-home orders and six months later. Finally, we tested whether these
associations varied as a function of age, to determine whether the associations of potentially
protective factors with psychopathology were similar for children and adolescents both con-
currently and prospectively. Given the unique context of the COVID-19 pandemic, we did not
have strong hypotheses about which particular protective factors would be more beneficial to
children or adolescents. However, we did hypothesize that adolescents would show a stronger
association between pandemic-related stress and psychopathology given previous work that
shows that adolescence is a period of particular vulnerability to mental health problems follow-
ing stressful life events [6,7,48–50].
Methods
Participants
Participants were recruited from two ongoing longitudinal studies of children and adolescents
in the greater Seattle area. A sample of 224 youth aged 7–15 (M
age
= 12.65, SD = 2.59, range:
7.64–15.24, 47.8% female) and a caregiver completed a battery of questionnaires to assess
social behaviors and experiences and pandemic-related stressors. Participants also completed
assessments of symptoms of internalizing and externalizing psychopathology. Two partici-
pants did not complete these mental health assessments and therefore were excluded from
analyses. Six months later, 184 of these youth (82% of the initial pandemic sample) and a care-
giver again completed an assessment of internalizing and externalizing symptoms. Ten partici-
pants did not complete these mental health assessments and therefore were excluded from
analyses at T2. The racial and ethnic background of participants reflected the Seattle area, with
66% of participants identifying as White, 11% as Black, 11% as Asian, 8% as Hispanic or
Latino, and 3% as another race or ethnicity.
Children from the first sample were recruited from a study of younger children (N= 99)
originally recruited between January 2016 and September 2017 [51,52]. Between March 2018
and November 2018, a subset of the original sample (N= 90) participated in a follow-up assess-
ment of mental health. All participants who participated at baseline were contacted for the cur-
rent study during the period of stay-at-home orders of the pandemic. From this sample, 68
youths (68.9% of the original sample; M
age
= 8.88, range: 7.64–10.21, 53% female) and a care-
giver participated in the first time point of current study (during the stay-at-home orders) and
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53 completed the six-month follow-up. Mental health assessments obtained at age 6–8 years
were used to control for pre-pandemic psychopathology. Three participants did not complete
the most recent assessment, and mental health assessments at age 5–6 were used to control for
pre-pandemic psychopathology.
Adolescent participants were drawn from a longitudinal study of children followed from
early childhood to adolescence and their mothers [53]. Participants completed the most recent
assessment at age 11–12 years (N= 227) between June 2017 and October 2018. These partici-
pants were re-contacted for assessment for the current study. From this sample, 154 youths
(M
age
= 14.3, range: 13.12–15.24, 46% female) and their caregiver completed the current study
(67.8% of the most recently assessed sample) and 121 completed the six-month follow-up.
Mental health assessments at age 11–12 were used to control for pre-pandemic
psychopathology.
These two samples came from the same general population (youth in the Seattle area from a
wide range of socioeconomic backgrounds). Critically, these two samples did not differ with
regards to socioeconomic status, as measured by the income-to-needs ratio, sex distribution
(ps >.8), or in exposure to pandemic-related stressors (p = .907).
Participants were excluded from the parent studies based on the following criteria: IQ <80,
active substance dependence, psychosis, presence of pervasive developmental disorders (e.g.,
autism), and psychotropic medication use. Across both samples, legal guardians provided
informed consent and youths provided assent via electronic signature obtained using Qualtrics
(Provo, UT). All study procedures were approved by the Institutional Review Board at Har-
vard University. Youth and their caregivers were each paid $50 for participating in the first
wave of the study and $35 for the second wave.
Procedure
Parents and youth separately completed electronic surveys. Families contacted an experi-
menter if youth had trouble completing the surveys on their own, and an experimenter then
called via phone or video chat and read the questions aloud and recorded their responses (this
experimenter was blind to all data from the previous assessments). Data were collected during
a six-week period between mid-April, 2020 and May 31
st
, 2020 (T1), during which schools
were closed and stay-at-home orders were in place. A follow-up (T2) was conducted between
late November 2020 and early January 2021 in which youth mental health was assessed again.
Pandemic-related stressors
We developed a set of questions to assess pandemic-related stressors (https://osf.io/drqku/; see
S1 File). The assessment included health,financial,social,school,and physical environment
stressors that occurred within the preceding month, based on both caregiver and child report
(See Table 1). Given that the COVID-19 pandemic presented a wide range of unique stressors
that have not occurred in prior community-wide disruptions, it was necessary to create a novel
measure to assess these types of experiences. It is standard practice in the field to do so when
novel events occur for which existing stress measures do not adequately capture the full extent
of specific types of stressful experiences (e.g., to understand the unique hurricane-related
stressors that occurred during Hurricane Katrina or experiences specific to the terrorist attacks
on September 11
th
or the Oklahoma City bombing [12,41,54,55].
We created a composite of pandemic-related stressors using a cumulative risk approach,
[56] by determining the presence of each potential stressors (exposed versus not exposed), and
creating a risk score reflecting a count of these stressors (18 maximum). Importantly, many
previous studies demonstrate the utility and convergent validity of cumulative stress measures
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Table 1. COVID-19 pandemic-related stressors and potential protective factors.
Stressor Domain Description Number of Items
Health Stressors Participant contracted COVID-19;
a parent, sibling or another relative
contracted COVID-19; a partner or
close friend contracted COVID-19;
the participant knew someone who
died of the virus; had a parent who
was an essential worker (e.g.
healthcare worker, grocery store
worker) who was still working
during the initial months of the
pandemic.
7
Social having a difficult relationship with
a parent or other member of the
household that had gotten worse
during the last month; experiencing
loneliness a few times per week or
more; and experiencing racism,
prejudice or discrimination related
to the pandemic.
4
Financial a parent was laid off or had other
significant loss of employment; the
family experienced food insecurity,
assessed using previously-validated
items [81,82]; the family was
evicted or otherwise were forced to
leave their home because of
financial reasons; the family
experienced significant financial
loss (e.g. due do loss of business, job
loss, stock market losses, etc.).
4
School experiencing difficulty getting
schoolwork done at home; the
environment where the child does
schoolwork is noisy.
2
Physical Environment crowding in the home based on the
total number of people in the home
divided by the approximate square
footage reported by the parent [32]
1
Potential Protective Factor Description of Measurement
Physical Activity Total minutes of physical activity per week
Time in Nature Days per week they spent time in natural green spaces
including parks, canals, nature areas, beaches,
countryside, and farmland.
Time Outdoors Days per week participants spend time outside of their
home (e.g. backyard or neighborhood street) for at
least 30 minutes
News Consumption Time spent watching news coverage about the
pandemic on a TV, computer, iPad or other electronic
device per day. Scored as a binary variable with less
than 2 hours per day being scored as 0, and 2 or more
hours per day being scored as 1.
Passive Screen Time Hours per day, on average spent watching video on an
electronic device, passively scrolling through social
media, looking at websites and online news, watching
movies and TV. Summed for total passive screen time
(Continued)
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in relation to health outcomes, with a greater number of stressors predicting higher levels of
mental and physical health problems [56]. Here, we provide additional evidence for conver-
gent validity by showing that the number of stressors is moderately associated with a measure
of perceived stress as measured by the Perceived Stress Scale in this sample (r = 0.399). This
value is similar to the correlation between stressful life events and perceived stress observed in
the original validity studies used to create the Perceived Stress Scale (r = 0.24-.35) [57].
We also assessed pandemic-related stressors at T2. Importantly we only asked about stress-
ors occurring between T1 and T2. If, for example, a participant had family member who
became ill with COVID-19 in April 2020, this would be counted in the pandemic-related
stressors at T1, but not at T2. We used pandemic-related stressors at T1 in all analyses (includ-
ing prospective analyses) but report on pandemic-related stressors at T2 to illustrate the ongo-
ing nature of the pandemic during the second wave of data collection.
Potential protective factors
We assessed nine potentially protective aspects of youth and family behavior during the prior
month: (a) physical activity, (b) time spent in nature, (c) time spent outdoors, (d) screen time,
(e) news consumption, (f) sleep quantity, (g) family routines, (h) coping strategies, and (i)
helping others (https://osf.io/drqku/,Table 1).
Internalizing and externalizing psychopathology
Psychopathology was assessed prior to the pandemic by parent and child report on the Youth
Self Report (YSR) and Child Behavior Checklist (CBCL) [58,59]. The CBCL scales are widely
used measures of youth emotional and behavioral problems and use normative data to gener-
ate age-standardized estimates of internalizing and externalizing psychopathology. We used
the highest T-scores from the caregiver or child on the Internalizing and Externalizing symp-
toms subscales as measures of pre-pandemic symptoms. The children who were 6–8 years old
at the pre-pandemic time point did not complete the YSR; only the CBCL was used to compute
their pre-pandemic symptoms at that time point. The use of the higher caregiver or child
report for psychopathology is an implementation of the standard “or” rule used in combining
Table 1. (Continued)
Stressor Domain Description Number of Items
Sleep Quantity Binary measure computed using CDC recommended
guidelines for children in this age range (9–12 hours
per night for children aged 8–10; 8–9 hours per night
for adolescents [83].
Daily Routine Participant report on a 4-point Likert scale about the
extent to which their days had a fairly consistent
routine.
Adaptive Coping Strategies Binary measure. Participants were given a 1 if they
endorsed any of the following ways of dealing with
distress related to the coronavirus: talked to family or
friends, exercised, meditated, or engaged in self-care
activities.
Helping in Community Binary measure. Participants were given a 1 if they
endorsed having participated in any of the following
activities: volunteering time at hospitals, donating or
preparing food, donating money or supplies, giving
shelter to displaced people, praying for others, writing
letters or contacting isolated people, cheering on
health care workers, or other ways of helping.
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caregiver and child reports of psychopathology. In this approach, if either a parent or child
endorses a particular symptom it is counted with the assumption that if a symptom is reported,
it is likely present. This is a standard approach in the literature on child psychopathology–for
example it is how mental disorders are diagnosed in population-based studies of psychopathol-
ogy in children and adolescents [60,61].
To assess psychopathology at T1 and T2, parents and youths completed the Strengths and
Difficulties Questionnaire, a widely-used assessment of youth mental health [62]. The SDQ
has good reliability and validity [63,64] and correlates strongly with the CBCL/YSR [65]. We
chose to use the SDQ to reduce participant burden, as it has substantially fewer items than the
CBCL/YSR. We used the highest reported value on the Internalizing and Externalizing symp-
toms subscales from the caregiver or child.
Family income
At T1, we asked caregivers to report their total combined family income for the 12 months
prior to the onset of the pandemic in 14 bins. The median of the income bins was used except
for the lowest and highest bins which were assigned $14,570 and $150,000, respectively. We
then calculated the income-to-needs ratio by dividing the family’s income by the federal pov-
erty line for a family of that size in 2020, with values less than one indicating income below the
poverty line. Nine caregivers did not provide information on family income and were thus
excluded from analyses. Median income-to-needs ratio was 4.19 (min = 0.35, max = 8.41).
Statistical analysis
We used linear regression to investigate the questions of interest. Continuous predictors were
standardized using a z-score. Analyses were performed in R using the lme4 package and stan-
dardized coefficients are presented. Continuous age, sex, income-to-needs ratio, and pre-pan-
demic symptoms measured using the CBCL/YSR prior to the pandemic were included as
covariates in all analyses. First, we examined the association of pandemic-related stressors with
internalizing and externalizing symptoms, both concurrently and prospectively. Next, we
examined the association of potential protective factors with internalizing and externalizing
problems, both concurrently and prospectively. Then, we tested whether these factors moder-
ated the association of pandemic-related stressors with psychopathology, both concurrently
and prospectively. Finally, we computed interactions of each protective factor with age predict-
ing psychopathology and the interaction of pandemic-related stressors, each potential protec-
tive factor, and age predicting psychopathology, both concurrently and prospectively. Simple
slopes analysis was used to follow-up on significant interactions using the R pequod package.
Stratification for simple slope analyses in analyses that used continuous moderators were con-
ducted using a median split. In the case of age analyses, because there was a gap in age between
the oldest children (10 years) and the youngest adolescents (13 years), stratifying by sample for
these purposes was equivalent to stratifying by a median split. False discovery rate (FDR) cor-
rection was applied at the level of hypothesis such that we corrected for comparisons at T1 and
T2 (e.g., association between physical activity and internalizing psychopathology at T1 and
T2). Listwise deletion was used to handle missing data at T2, excluding participants from anal-
ysis who did not complete the second follow-up during the pandemic.
Results
Prior to the pandemic, 71 participants (31.7% of the sample) were in the subclinical or clinical
range for internalizing problems and 39 participants (17.4% of the sample) were in the subclin-
ical or clinical range for externalizing problems. Internalizing and externalizing symptoms
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increased substantially during the early phase of the pandemic. Specifically, 127 (56.7%) were
in the subclinical or clinical range for internalizing problems and 126 (56.2%) were in the sub-
clinical or clinical range for externalizing problems at the beginning of the pandemic.
See S1 File for the frequency of different domains of stressors at T1 and T2 (S1 Table in S1
File), the distribution of potential protective factors and psychopathology symptoms before
and after the pandemic (S2 Table in S1 File), bivariate correlations between all study variables
(S3 Table in S1 File) and associations between individual stressors and psychopathology at T1
and T2 (S4 Table in S1 File).
As expected, one of the strongest predictors of psychopathology during the pandemic was
pre-pandemic psychopathology (see S3 Table in S1 File). Therefore, it is important to highlight
that all analyses controlled for pre-pandemic psychopathology to assess changes in psychopa-
thology specific to the pandemic period.
Pandemic-related stressors and psychopathology
The number of pandemic-related stressors was strongly associated with increases in both
internalizing (β= 0.345, p<.001), and externalizing symptoms (β= 0.297, p <.001) symp-
toms during the pandemic, controlling for pre-pandemic symptoms (Fig 1). As expected, pre-
pandemic symptoms were also strongly associated psychopathology during the pandemic in
this model (β= 0.279, p<.001 and β= 0.296, p<.001 for internalizing and externalizing psy-
chopathology, respectively).
Similarly, the number of pandemic-related stressors early in the pandemic was positively
associated with internalizing (β= 0.243, p= .001) and externalizing (β= 0.288, p<.001) symp-
toms later in the pandemic, controlling for pre-pandemic symptoms (Fig 1). Again, pre-pan-
demic symptoms were strongly associated with internalizing and externalizing problems at T2
(β= 0.260, p= .001 and β= 0.278, p<.001, respectively).
The association of pandemic-related stressors with internalizing symptoms varied by age (β
= 0. 0.602, p= .043), such that the association was stronger among adolescents (simple slope:
b = 0.437, p<.001) than children (simple slope: b = 0.220, p= .004) concurrently. There were
interactions between age and pandemic-related stressors in predicting externalizing symptoms
concurrently or prospectively.
Potential protective factors
Associations of potential protective factors with concurrent psychopathology and interactions
with stress and age are summarized in Table 2. Associations of potential protective factors
with prospective psychopathology and interactions with stress and age are summarized in
Table 3.
Physical activity. Physical activity was unrelated to psychopathology concurrently or
prospectively.
Time spent in nature and outdoors. Greater time spent in nature was marginally associ-
ated with lower internalizing problems both concurrently and prospectively (Fig 2A and 2B),
controlling for pre-pandemic symptoms. Time spent outdoors was unrelated to psychopathol-
ogy. Age did not moderate any of these associations.
News consumption and passive screen time. Early in the pandemic, youths who spent
less time on digital devices each day had lower externalizing symptoms (Fig 2C and 2D), con-
trolling for pre-pandemic symptoms. Consuming <2 hours of news per day was also associ-
ated with reduced externalizing symptoms early in the pandemic (Fig 2G).
The longitudinal association between screen time and internalizing symptoms varied by
age (S1 Fig in S1 File), such that children showed a positive association between screen time
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and internalizing psychopathology six months later (b = 0.572, p= .008), but adolescents did
not (b = -0.074, p= .512).
Age moderated the association between news consumption and internalizing psychopathol-
ogy prospectively. Specifically, while children showed a positive association between news con-
sumption and internalizing psychopathology at T2 (b = 0.438, p= 0.015), adolescents showed
a negative association between news consumption and internalizing psychopathology at T2
(b = -0.299, p= .015).
Fig 1. Main effects of pandemic-related stressors and psychopathology. All analyses control for age, sex, income-to-needs and pre-
pandemic psychopathology symptoms.
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Table 2. Associations of potential protective factors with psychopathology and interactions with stress and age at T1. Significant associations are presented in BOLD
and marginal associations are presented in italics.
Protective Factors Internalizing Externalizing Age Internalizing
Interaction
Age Externalizing
Interaction
βpβpβpβp
Physical Activity Main effect -0.120 0.132 -0.016 0.900 0.075 0.826 0.391 0.243
Stress Interaction -0.153 0.191 -0.146 0.448 0.151 0.790 0.609 0.588
Time in Nature Main effect -0.124 0.074 0.029 0.777 0.045 0.885 0.139 0.658
Stress Interaction -0.067 0.602 0.013 0.913 -0.580 0.271 0.218 0.682
Time Outdoors Main effect 0.000 0.999 0.018 0.779 -0.455 0.144 -0.215 0.484
Stress Interaction -0.088 0.846 -0.238 0.112 -0.146 0.793 0.613 0.381
Passive Screen Time Main effect 0.059 0.431 0.272 0.0004 -1.084 0.074 -0.979 0.087
Stress Interaction 0.561 0.002 0.329 0.050 -1.399 0.368 0.729 0.531
News Consumption Main effect 0.093 0.374 0.193 0.010 -0.741 0.083 -0.312 0.453
Stress Interaction 0.273 0.074 0.197 0.136 -1.474 0.028 0.389 0.771
Sleep Quantity Main effect -0.018 0.995 -0.061 0.370 0.674 0.130 0.551 0.126
Stress Interaction -0.171 0.326 0.094 0.762 -1.728 0.064 -0.623 0.451
Daily Routine Main effect -0.022 0.736 -0.122 0.058 -0.062 0.854 -0.011 0.974
Stress Interaction -0.197 0.211 -0.131 0.535 0.206 0.766 0.214 0.763
Adaptive Coping Main effect 0.061 0.688 0.124 0.102 -0.436 0.377 -0.040 0.906
Stress Interaction 0.177 0.276 -0.083 0.488 -0.587 0.630 1.225 0.078
Helping Main effect 0.002 0.978 0.012 0.848 0.401 0.231 0.186 0.575
Stress Interaction -0.059 0.623 -0.081 0.968 -0.348 0.571 0.674 0.281
https://doi.org/10.1371/journal.pone.0255294.t002
Table 3. Associations of potential protective factors with psychopathology and interactions with stress and age at T2. Significant associations are presented in BOLD
and marginal associations are presented in italics.
Protective Factors Internalizing Externalizing Age Internalizing
Interaction
Age Externalizing
Interaction
βpβpβpβp
Physical Activity Main effect -0.049 0.515 0.009 0.900 -0.126 0.826 0.534 0.243
Stress Interaction -0.241 0.179 0.028 0.816 0.712 0.686 -0.182 0.802
Time in Nature Main effect -0.136 0.074 -0.021 0.777 -0.264 0.885 0.371 0.516
Stress Interaction 0.077 0.602 0.069 0.913 -0.706 0.271 -0.869 0.300
Time Outdoors Main effect -0.048 0.999 0.066 0.750 -0.566 0.144 -0.351 0.484
Stress Interaction 0.029 0.846 -0.163 0.254 0.543 0.793 0.568 0.381
Passive Screen Time Main effect 0.097 0.431 0.157 0.076 -1.953 0.030 -1.264 0.087
Stress Interaction 0.401 0.049 0.606 0.003 -1.243 0.368 1.158 0.531
News Consumption Main effect -0.040 0.627 0.114 0.152 -1.743 0.004 -0.932 0.170
Stress Interaction 0.034 0.829 0.223 0.136 -2.199 0.018 0.238 0.771
Sleep Quantity Main effect 0.000 0.995 -0.158 0.080 0.299 0.479 0.682 0.126
Stress Interaction 0.045 0.761 0.043 0.762 -1.685 0.089 -1.562 0.184
Daily Routine Main effect 0.034 0.736 -0.164 0.049 -0.129 0.854 0.589 0.238
Stress Interaction -0.191 0.221 0.092 0.535 -0.648 0.766 -0.865 0.666
Adaptive Coping Main effect -0.015 0.845 0.103 0.156 -0.353 0.377 -0.152 0.906
Stress Interaction 0.099 0.506 0.153 0.488 -0.149 0.849 0.218 0.767
Helping Main effect 0.036 0.978 0.026 0.848 0.835 0.064 -0.237 0.575
Stress Interaction -0.088 0.623 -0.005 0.968 1.296 0.186 1.054 0.281
https://doi.org/10.1371/journal.pone.0255294.t003
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Screen time moderated the association of pandemic-related stressors with internalizing and
externalizing psychopathology concurrently and prospectively (Fig 3). Specifically, youths who
spent more time on screens showed a strong positive association of pandemic-related stressors
with concurrent (b = 0.513, p<.001) and prospective (b = .335, p<.001) internalizing symp-
toms as well as both concurrent (b = 0.285, p<.001) and prospective (b = .383, p<.001)
externalizing problems that was absent for youths who spent less time on screens at both time
points (b = 0.020–0.061, p= .445-.935).
A three-way interaction was observed between news consumption, age, and pandemic-
related stressors in predicting internalizing symptoms both concurrently and prospectively
(Fig 4). Pandemic-related stressors were unrelated to internalizing problems concurrently
(b = -.087, p= .502) or prospectively (b = -0.036, p= .808) among children who consumed <2
hours of news media per day, but were strongly associated with internalizing psychopathology
both concurrently (b = 0.39 2, p<.001) and prospectively (b = 0.328, p= .026) among children
with >2 hours daily news consumption. Among adolescents, pandemic-related stressors were
strongly associated with internalizing problems concurrently (b =0.409–0.452, p<.001),
regardless of news consumption. Adolescents who consumed low levels of news during the
stay-at-home orders showed a positive association between pandemic-related stressors and
internalizing psychopathology six months later (b = 0.509, p= .002), while adolescents who
consumed more news did not (b = 0.113, p= .346).
Fig 2. Main effects of protective factors on psychopathology. All analyses controlled for age, sex, income-to-needs, and pre-pandemic psychopathology symptoms.
https://doi.org/10.1371/journal.pone.0255294.g002
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Sleep quantity. Getting the recommended number of hours of sleep was unrelated to psy-
chopathology concurrently. However, getting the recommended amount of sleep during the
stay-at-home orders was marginally associated with lower levels of externalizing psychopathol-
ogy six months later, controlling for pre-pandemic symptoms (Fig 2H). These associations did
not vary by age.
Routine. Youths with a more structured daily routine had lower externalizing (Fig 2E and
2F) six months later. No associations of a structured routine were found with internalizing
symptoms, and no interactions with age or stress emerged.
Fig 3. Passive screen time x stress interaction. Low screen time use buffers against pandemic-related increases in internalizing and
externalizing psychopathology. All analyses control for age, sex, income-to-needs ratio, and pre-pandemic psychopathology symptoms.
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Coping strategies. There was no significant association between engaging in adaptive
coping strategies with psychopathology concurrently or prospectively.
Fig 4. Age x stress x news interaction. Low news consumption buffers children, but not adolescents, against pandemic-
related increases in internalizing psychopathology concurrently (A) and prospectively (B). All analyses control for age,
sex, income-to-needs ratio, and pre-pandemic psychopathology symptoms.
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Helping others. Helping in one’s community was unrelated to psychopathology concur-
rently or prospectively.
Discussion
The present study identifies simple and practical behaviors that are associated with well-being
among children and adolescents during the COVID-19 pandemic. Critically, this study
involved a longitudinal sample of children and adolescents for which mental health had been
assessed prior to the pandemic, during the stay-at-home orders, and six months later allowing
us to investigate psychopathology during the pandemic while controlling for pre-pandemic
symptoms. As expected, we found that youths who experienced greater pandemic-related
stressors had higher levels of internalizing and externalizing psychopathology. Importantly,
greater pandemic-related stressors during the stay-at-home orders were also prospectively
associated with higher levels of both internalizing and externalizing psychopathology six
months later. Critically, we identified several factors—including a structured daily routine, low
passive screen time use, low news media consumption about the pandemic, and to a lesser
extent spending more time spent in nature and getting the recommended amount of sleep—
that are associated with better mental health outcomes in youth during the pandemic. We
additionally demonstrate that the strong association between pandemic-related stressors and
psychopathology is absent among children with lower amounts of screen time and news media
consumption.
Youth who had a structured and predictable daily routine were less likely to experience
increases in externalizing problems during the pandemic than youth with less structured rou-
tines. A sudden loss of routine has occurred for many families during the pandemic related to
school closures, changes in parental work arrangements, and loss of access to activities outside
the home for youth and adolescents. These disruptions in daily routine are associated with
increased risk for behavior problems in youth during the pandemic, consistent with prior
work suggesting that lack of predictability is strongly linked to youth psychopathology [16,34,
66,67]. Moreover, a recent paper during the pandemic showed that preschoolers in families
that maintained a structured routine during the pandemic showed lower rates of depression
and externalizing problems, over and above the effect of food insecurity, socioeconomic status,
dual-parent status, maternal depression, and stress [68]. Our current findings extend this work
by demonstrating that a structured routine may also be important for older children and ado-
lescents. Although maintaining routine and structure is challenging as school closures con-
tinue and many aspects of daily life remain unpredictable, creating a structured daily routine
for children and adolescents may promote better mental health during the pandemic.
Greater passive screen time use was associated with higher levels of externalizing psychopa-
thology early in the pandemic, and greater passive screen time use was associated with higher
internalizing psychopathology later in the pandemic for children but not adolescents. Addi-
tionally, the strong association of pandemic-related stressors with internalizing and externaliz-
ing psychopathology both concurrently and prospectively was reduced in children and
adolescents with low passive screen time use. Previous studies have argued that the increases
in screen time use over the last decade may be responsible for rising levels of anxiety and
depression among children and adolescents [38]. However, others have suggested that greater
screen time use may not have negative impacts [69,70] and that psychopathology and digital
device use have a reciprocal association with one another [71]. During the pandemic, youths
were encouraged to use digital devices more than ever for school and social connection, which
are likely to be beneficial for their development. Here, we measured passive use of digital
devices, including watching videos on an electronic device, passively scrolling through social
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media, looking at websites and online news, and watching movies and TV—excluding more
active uses of digital devices for schooling and social communication. Greater research is
needed to determine whether the amount of passive screen time itself has negative effects on
youth mental health or whether this association simply reflects that greater time on digital
devices takes time away from other important behaviors such as exercise, sleep, or connecting
with friends or family. Indeed, in the present study, screen time was inversely related with
sleep quantity (S3 Table in S1 File). Therefore, one reason that youths with lower screen time
use may be buffered against pandemic-related increases in psychopathology is because they
are engaging in other behaviors that promote well-being such as getting sufficient sleep,
among others. Together, these findings suggest some potential benefits associated with limit-
ing passive screen time among youth during the pandemic.
Our findings also suggest that limiting news consumption about the pandemic may be ben-
eficial, particularly for younger children. Greater news media consumption about the pan-
demic was associated with higher levels of externalizing problem early in the pandemic.
Moreover, the strong association between pandemic-related stressors and internalizing psy-
chopathology was absent in children who consumed lower levels of news media, although pan-
demic-related stressors were positively associated with internalizing symptoms in adolescents
regardless of news consumption concurrently. This finding is broadly consistent with previous
studies observing strong associations between media exposure about community-level stress-
ors, including terrorist attacks and natural disasters, and higher rates of psychopathology in
children and adolescents [41,42,72–74]. Interestingly, the same pattern persisted for children
six months into the pandemic, while for adolescents who consumed more news during the
stay-at-home orders showed a weaker association between stress and internalizing psychopa-
thology six months later than those who consumed less news. Therefore, it is possible that for
adolescents, having more knowledge about the pandemic early on may have been beneficial
over time. Together these findings suggest that limiting certain types of news media exposure
may protect against pandemic-related increases in internalizing problems, especially among
young children. Importantly, this does not imply that parents should refrain from discussing
the pandemic or hide the realities from their children. In fact, previous studies have found that
honest conversations between parents and children provide an important protection against
the development of psychopathology in the wake of natural disasters [75]. Therefore, we sug-
gest limiting sensational news media consumption, in favor of talking to children about what
is happening, listening to their concerns, and answering their questions in an age-appropriate
manner.
Additionally, we found weaker and only marginally significant associations between time
spent in nature and getting the recommended amount of sleep with youth psychopathology
during the pandemic. We briefly discuss these findings here, as they highlight additional strat-
egies that could be beneficial to families when considering how to support the mental health of
their children during the pandemic. Greater time spent in nature was marginally associated
with lower increases in internalizing symptoms relative to pre-pandemic symptoms both con-
currently and prospectively. These findings are broadly consistent with prior evidence that
spending at least two hours in nature per week is associated with greater well-being in adults
[31] and better mental health in children [76]. Additionally, the association of stressors with
well-being is reduced among children with greater access to nature [77]. Encouraging youths
to spend time in nature may also be beneficial for mental health during the pandemic. In addi-
tion, children and adolescents who got the recommended amount of sleep at the beginning of
the pandemic showed marginally lower levels of externalizing psychopathology six months
later. These findings highlight the importance of encouraging youths to get an adequate
amount sleep. Given the negative association between screen time and sleep duration both
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here and in prior work [78], reducing access to digital devices prior to bedtime may be one
simple strategy parents can use to make it easier for their children to get an adequate amount
of sleep.
Limitations
The present study has several limitations which should be acknowledged. First, we relied on
self-report measures of behavior, which can be inaccurate due to recall bias. Future studies
may benefit from using actigraphy to assess physical activity and sleep, geolocation to measure
time spent in nature and outdoors, and direct reports of screen time use and news media con-
sumption from digital devices for more accurate measures of potential protective factors. Sec-
ond, while the longitudinal nature of the present study is a strength, it only included two
snapshots of youth behavior and mental health during the pandemic. It will be important to
continue to follow youths throughout the pandemic to determine factors that promote long-
term risk and resilience. Third, we used a different measure of psychopathology prior to the
pandemic (CBCL/YSR) than after the onset of the pandemic (SDQ). While it would have been
ideal to have the same measure at all time points, the CBCL/YSR is much longer than the SDQ
and we were focused on minimizing participant burden during a period of time when families
were facing numerous stressors and loss of access to typical childcare options. Thus, we chose
to use a shorter questionnaire that is strongly correlated with the CBCL/YSR [62,65,79,80].
Relatedly, we asked questions about potential protective factors in our COVID Experiences
Survey, rather than using longer validated scales for each of the factors (e.g. Pittsburgh Sleep
Quality Index, Physical Activity Questionnaire for Children, Media Parenting Practices, Fam-
ily Routines Inventory, German Coping Questionnaire for ‘Children and Adolescents, etc.).
This choice was made to maximize the information gained about each family, while minimiz-
ing participant burden and thus maximizing our sample size. Fourth, we combined data from
two separate samples of children (aged 7–10 and 13–15 at T1). Both samples were recruited
using similar methods from the same target population, and we had identical measures of pre-
pandemic psychopathology on both samples. Moreover, the samples did not differ in demo-
graphics, SES, or exposure to pandemic-related stressors. However, using two samples with a
gap in age limited our ability to understand age effects across the entire spectrum of childhood
and adolescence. Fifth, we demonstrate the predictive validity of the pandemic-related stress
measure via moderate associations with psychopathology at both waves as well as a measure of
perceived stress. However, this cumulative risk approach is limited in that it weights stressors
equally that could have variable impacts. Future work should investigate whether specific
stressors have been more strongly linked to changes in mental health during the pandemic
(see S4 Table in S1 File for associations of specific stressors and psychopathology at T1 and
T2). Finally, the present study is correlational and we are therefore limited in our ability to
make causal inferences about the factors that promote well-being during the pandemic. How-
ever, given the extensive literature about the links between these factors and youth mental
health, there is little reason to expect downsides to encouraging families to engage in these
types of protective behaviors with their children and adolescents during the pandemic.
Conclusions and practical implications
We identify practical and easily accessible strategies that may promote greater well-being for
children and adolescents during the COVID-19 pandemic. Based on these findings, we suggest
that parents encourage youth to develop a structured daily routine, limit passive screen time
use, limit exposure to news media—particularly for young children, and to a lesser extent
spend more time in nature, and encourage youth to get the recommended amount of sleep.
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Supporting information
S1 File. Please see the S1 File for frequencies of exposures to pandemic-related stressors by
domain (S1 Table), distribution of potential protective factors and psychopathology symp-
toms (S2 Table), bivariate correlation table of all study variables (S3 Table), associations
between individual stressors and psychopathology symptoms (S4 Table), age by screen
time interaction predicting internalizing symptoms (S1 Fig), and the full COVID experi-
ences surveys (caregiver and child).
(DOCX)
Acknowledgments
The authors would also like to acknowledge Reshma Sreekala for help with data collection and
Frances Li for help with compiling surveys.
Author Contributions
Conceptualization: Maya L. Rosen, Alexandra M. Rodman, Steven W. Kasparek, Andrew N.
Meltzoff, Katie A. McLaughlin.
Data curation: Steven W. Kasparek.
Formal analysis: Maya L. Rosen.
Funding acquisition: Andrew N. Meltzoff, Katie A. McLaughlin.
Methodology: Maya L. Rosen, Alexandra M. Rodman, Steven W. Kasparek, Malila M. Free-
man, Andrew N. Meltzoff, Katie A. McLaughlin.
Project administration: Maya L. Rosen, Alexandra M. Rodman, Steven W. Kasparek, Makeda
Mayes.
Supervision: Maya L. Rosen, Alexandra M. Rodman, Steven W. Kasparek.
Writing – original draft: Maya L. Rosen.
Writing – review & editing: Maya L. Rosen, Alexandra M. Rodman, Makeda Mayes, Malila
M. Freeman, Liliana J. Lengua, Andrew N. Meltzoff, Katie A. McLaughlin.
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