Adolescents’ health in times of COVID-19: a scoping review A saúde do adolescente em tempos da COVID-19: scoping review La salud del adolescente en tiempos de la COVID-19: scoping review

COVID-19, the disease caused by SARS-CoV-2 (novel coronavirus), emerged in China in December 2019 and spread quickly throughout the world. In this scenario, the current study aimed to identify the impact or effects of the COVID-19 pandemic on adolescents’ health. This is a scoping literature review based on the following databases: Web of Science, CINAHL, PsycINFO, SciELO, and PUBCOVID19. The study adopted the stages proposed by the Joanna Briggs Institute for scoping reviews, and the question orienting the procedures consisted of the acronym PCC (population; concept; context). Eleven articles were included in the review. Clinically, adolescents present the same COVID-19 symptoms as adults. The pandemic and the health measures taken to control transmission were found to be associated with mental health problems in adolescents. Specifically, adolescents have a negative experience with social distancing measures and closing of schools. These measures can also favor situations of violence or aggressive behaviors in the home environment. Healthcare services that treat the adolescent population had to reorient their practices, adopting a virtual model to replace face-to-face care, and even research projects involving adolescence had to be rethought. This scoping review addressed an emerging theme in relation to a population that has received little attention in studies on COVID-19. The results suggest that the pandemic can be considered a determinant that affects different dimensions of adolescents’ lives. COVID-19; Pandemics; Quarentine; Adolescent Health; Health Vulneralibility REVISÃO REVIEW This article is published in Open Access under the Creative Commons Attribution license, which allows use, distribution, and reproduction in any medium, without restrictions, as long as the original work is correctly cited. Oliveira WA et al. 2 Cad. Saúde Pública 2020; 36(8):e00150020 Introduction Adolescence is a period of development marked by biological, psychological, and social changes. The characteristics of this life phase are complex, and multiple approaches seek to respond to and describe this period of the life cycle situated between childhood and adulthood. One way to demarcate adolescence is based on age. A current discussion by European and Australian researchers suggests that the chronological definition of adolescence should be expanded, compared to demarcations from past decades, and now including the period from 10 to 24 years 1. The age expansion tends to correct distortions in previous definitions, including social changes and the resulting need for prolonged investments in healthcare for this population. These aspects influence policies and programs in adolescents’ health, and in Brazil’s case they are exemplified by the School Health Program, launched in 2007, and by the National Policy for Comprehensive Healthcare for Adolescents and Youth for the promotion, protection, and recovery of health in 2010 2. The interventions stemming from these documents emphasize the importance of not viewing the adolescent (and the process of transitioning into adolescence) as problems, but as a window of opportunities for a subject in development inserted in social, cultural, and collective contexts 2. The most widely explored topics in health promotion or health education activities with adolescents involve mental health, sexual and reproductive health, oral health, and violence 2. According to the scientific literature, interventions in this population group should respond to the needs of adolescents as protagonists in the initiatives 3. COVID-19, the disease caused by SARS-CoV-2 and that emerged in late 2019 in Wuhan, China, was declared by the World Health Organization (WHO) as the sixth public health emergency that required attention as a pandemic 4. The health measures to control transmission and guarantee the population’s protection, flatten the transmission curve, and prevent the health services’ collapse altered people’s daily lives 5,6. Specifically, according to the WHO, the closing of teaching institutions as a measure to contain COVID-19 cases removed 1.5 billion children and adolescents from schools 7. Schools closed, tests and exams postponed, and suspension of academic semesters and school years have interrupted the students’ routines, and confinement at home can trigger fears, uncertainties, and anxiety in adolescents, besides social distancing from their classmates and friends, issues that affect their well-being and quality of life and increase their vulnerability to different forms of violence at home 8. Although COVID-19 affects all people regardless of age, socioeconomic status, sex, and ethnicity, vulnerability to the disease is closely related to social determinants of the health-disease process. This vulnerability increases according to living conditions, financial instability, and lack of access to essential services such as health, education, and social protection 9. Many adolescents thus experience conditions of high vulnerability, especially on the outskirts of large cities. Dealing with a new disease and pandemic requires considering the perceptions, meanings assigned to the disease, health, and risk, culture, access to prevention, care, and treatment, all aspects that are present in the approach to adolescents 9. In this scenario, the current study aimed to perform a scoping review to identify the impacts or effects of the COVID-19 pandemic on adolescents’ health.


Introduction
Adolescence is a period of development marked by biological, psychological, and social changes. The characteristics of this life phase are complex, and multiple approaches seek to respond to and describe this period of the life cycle situated between childhood and adulthood. One way to demarcate adolescence is based on age. A current discussion by European and Australian researchers suggests that the chronological definition of adolescence should be expanded, compared to demarcations from past decades, and now including the period from 10 to 24 years 1 . The age expansion tends to correct distortions in previous definitions, including social changes and the resulting need for prolonged investments in healthcare for this population.
These aspects influence policies and programs in adolescents' health, and in Brazil's case they are exemplified by the School Health Program, launched in 2007, and by the National Policy for Comprehensive Healthcare for Adolescents and Youth for the promotion, protection, and recovery of health in 2010 2 . The interventions stemming from these documents emphasize the importance of not viewing the adolescent (and the process of transitioning into adolescence) as problems, but as a window of opportunities for a subject in development inserted in social, cultural, and collective contexts 2 . The most widely explored topics in health promotion or health education activities with adolescents involve mental health, sexual and reproductive health, oral health, and violence 2 . According to the scientific literature, interventions in this population group should respond to the needs of adolescents as protagonists in the initiatives 3 .
COVID-19, the disease caused by SARS-CoV-2 and that emerged in late 2019 in Wuhan, China, was declared by the World Health Organization (WHO) as the sixth public health emergency that required attention as a pandemic 4 . The health measures to control transmission and guarantee the population's protection, flatten the transmission curve, and prevent the health services' collapse altered people's daily lives 5,6 . Specifically, according to the WHO, the closing of teaching institutions as a measure to contain COVID-19 cases removed 1.5 billion children and adolescents from schools 7 . Schools closed, tests and exams postponed, and suspension of academic semesters and school years have interrupted the students' routines, and confinement at home can trigger fears, uncertainties, and anxiety in adolescents, besides social distancing from their classmates and friends, issues that affect their well-being and quality of life and increase their vulnerability to different forms of violence at home 8 .
Although COVID-19 affects all people regardless of age, socioeconomic status, sex, and ethnicity, vulnerability to the disease is closely related to social determinants of the health-disease process. This vulnerability increases according to living conditions, financial instability, and lack of access to essential services such as health, education, and social protection 9 . Many adolescents thus experience conditions of high vulnerability, especially on the outskirts of large cities. Dealing with a new disease and pandemic requires considering the perceptions, meanings assigned to the disease, health, and risk, culture, access to prevention, care, and treatment, all aspects that are present in the approach to adolescents 9 . In this scenario, the current study aimed to perform a scoping review to identify the impacts or effects of the COVID-19 pandemic on adolescents' health.

Type of study
This is a systematic literature review of the scoping review type. Taking an exploratory approach, a scoping review aims to identify and summarize scientific evidence on emerging questions, serving as a preliminary exercise for performing a systematic review 10 . What follows is an appropriate protocol for each database consulted, to identify eligible studies. In the case of this study, the scoping review model is valid, since some specific questions related to adolescents' health and the current COVID-19 pandemic are still not clear.

Methodological procedures
The following steps were adopted, proposed by the Joanna Briggs Institute for scoping reviews: development of the title, objective, and underlying question; definition of the studies' inclusion and exclusion criteria; selection of data sources; collection and organization of results; and presentation of the review 10 . The titles were reviewed for adequacy to the study's conclusion. The review's procedures were performed by two independent researchers, who met to reach consensus in cases of disagreement on the articles' inclusion or exclusion in the review. The review was performed in May 2020.

Underlying question
This is the research question that orients all the procedures in the scoping review. It thus followed the acronym PCC (P = population; C = concept; C = context) 10 to define the following underlying question: "What are the COVID-19 pandemic's impacts or effects on adolescents' health?".

Inclusion and exclusion criteria
As for the study population, the review included studies on adolescents or that recorded data on this group. We used the age frame proposed by researchers from the Centre for Adolescent Health (Melbourne, Australia), which recommends demarcating adolescence from 10 to 24 years of age 1 . The central concept or target phenomenon provided for the selection of studies on the impacts and effects in the context of the COVID-19 pandemic. The following were also inclusion criteria: qualitative and quantitative scientific articles; results of literature reviews; theoretical studies; and publications in Portuguese, English, or Spanish. Studies were excluded that focused on other life phases (children or elderly, for example), besides and letters to editors or points of view. No time limit was set in advance. However, given the current nature of the pandemic, only studies from 2020 were considered.

Selection of data sources
The following databases were selected for consultation: Web of Science, CINAHL, PsycINFO, SciELO, and the PUBCOVID19 platform, which covers articles published on COVID-19 and indexed in PubMed and EMBASE. The selection of these databases is based on their multidisciplinary reach and specificity of some areas, such as health, for example.

Data collection and organization
Initially, for recognition of the descriptors or keywords related to COVID-19, a nonsystematic search was conducted in PUBCOVID19 and Web of Science. This exercise showed that the words used most extensively for indexing studies on the current pandemic context were: "COVID-2019", "SARS-CoV-2", "coronavirus", and "severe acute respiratory syndrome coronavirus-2". To demarcate the target population, the following terms were included: "adolescence" and "adolescent". The terms "health" and "mental health" were also included in the cross-analysis to cover the COVID-19 pandemic's possible impact on these dimensions. The combination of search terms used the Boolean terms AND and OR. In SciELO, the terms were also used in Portuguese. For example, in Web of Science the following cross-analyses were performed: coronavirus OR "severe acute respiratory syndrome coronavirus-2 AND adolescence" OR "adolescent AND health" OR "mental health". In the PUBCOVID19 platform, the articles are organized in thematic areas, and only the areas "child" and "mental health" yielded results on adolescents.
The study followed the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) to systematize the studies' inclusion 11 . Figure 1 shows the flow in this process, following the model proposed by the Joanna Briggs Institute for scoping reviews.
To extract the data included in the review, two independent researchers used an Excel (https:// www.microsoft.com) spreadsheet to complete the following information: authors, periodical, year of publication, country where the study was conducted, study's objective, population/sample, methodological design, and main results. One study published in French was excluded. The sample also excluded, in the first selection stage, letters to the editors or points of view, which were the majority of the publications. No information was identified on financing of the studies, which prevented assessment of this issue. The reviewed results are presented in table and narrative formats on bibliometric aspects and that respond to the underlying question in the scoping review.

Ethical aspects
Literature review studies do not acquire approval by institutional review boards. However, it is important for this type of study to faithfully reproduce the original studies' data and to cite all the references of the consulted studies and to apply scientific rigor to the data treatment. The current study complied with these ethical aspects.

Figure 1
Flowchart of the scoping review process (PRISMA).

Results
After evaluation and selection, 11 scientific articles were included in the scoping review. The small number of articles identified in the initial search and included in the study may be explained by the current nature and limited scientific output on COVID-19 focusing on adolescence, which is an existing gap, considering the proportional amounts of studies addressing other age brackets, such as children and the elderly. The review included ten studies in English and one in Portuguese, all published in 2020. The United States was the country with the largest share of the articles (45.4%). Box 1 shows the studies' data.
In clinical terms, the COVID-19 pandemic has many nuances to be explored. In relation to respiratory diseases in adolescents, there is still no consensus on the risks, although the data collected in adults indicate that asthma is a risk factor for COVID-19 morbidity and mortality 12 . Physicians and families should monitor the control of asthma in adolescents given the uncertainties concerning this condition in relation to COVID-19 13 . Asthmatic adolescents can also maintain their prescribed medication and augment hand hygiene and social distancing 12 .
One of the reviewed studies presented the state-of-the-art on clinical, diagnostic, therapeutic, and prognostic aspects in children and adolescents 13 . The authors found that the majority of patients presented clinical symptoms, especially fever and cough 13 . Only one case of severe infection required assisted ventilation 13 . The prognosis was largely good in the studies, and only one death was reported in the age bracket from 10 to 19 years 13 .
Another study, reviewing the case of two adolescents with orbital cellulitis (inflammation of the eye tissues behind the orbital septum), sinusitis, and SARS-CoV-2 infection, indicated a temporal association and the absence of previous chronic symptoms in the two adolescents 14 . The authors suggested the possibility that secondary respiratory congestion caused by COVID-19 aggravated the orbital cellulitis, in one case leading to intracranial spread with subsequent epidural abscess 14 .
Mental health is determined by multiple factors, including the COVID-19 pandemic. A crosssectional epidemiological study in China found a high prevalence of depressive symptoms (43.7%) and anxiety (37.4%) as well as a combination of these symptoms (31.3%) associated with the pandemic in the general population 15 . Female gender was the largest risk factor for depressive symptoms or anxiety. Awareness-raising on COVID-19 (access to information, knowledge on the illness process, and preventive measures) was considered a protective factor against depressive symptoms or anxiety 15 .
A study in a sample of 584 Chinese adolescents and young adults two weeks after WHO declared COVID-19 a pandemic found that 40.4% were prone to psychological problems and that 14.4% already manifested symptoms of post-traumatic stress disorder 16 . According to the authors, the fact that COVID-19 had been declared a pandemic, alongside an increase in information on the disease and an overload of news on cases of infection and death, influenced the participants' mental health 16 .
The pandemic can also cause irritability and fear that family members may become infected. Analyzing the changes caused by puberty and social distancing (closing of schools and no activity involving peer interaction, for example) mean that adolescents have a negative assessment of their own status in the group and interpersonal relations 8 . These two aspects are essential in adolescence, which normally involves a tendency towards alienation from the family and closer engagement with peers. However, the pandemic can cause frustration, irritation, emotional disconnect, nostalgia, and boredom due to social distancing 8 .
On social distancing specifically, a cross-sectional survey found that adolescents tend to adhere to the measure 17 . The adolescents justified this tendency on personal grounds (fear of getting sick) and social grounds, including recognition that social distancing is a collective responsibility and that it helps guarantee that other people will not become infectd 17 . In the study, when social distancing occurred to prevent personal contamination or to avoid social judgments, there were more reports of anxiety. Cases in which friends asked the adolescents to social-distance, there were also reports of depressive symptoms 17 .
Meanwhile, vulnerability to domestic violence in the family context can also increase during social distancing. Since schools have been closed, adolescents may be in closer proximity to abusive parents who use physical punishment to control unwanted behaviors 7  more irritable due to restrictions on their mobility and the impossibility of spending time with their friends. This reality may result in aggressive behaviors or disobedience and an increase in virtual contact with friends via digital technologies 7 . Family contact may also increase the tensions in interpersonal relations and favor the emergence of preexisting mental disorders 7 .
The health measures to control SARS-CoV-2 transmission changed the health services' routine, as occurred in the Adolescent and Young Adult Medicine Clinic at University of California, San Francisco (United States). Researchers reported the rapid transition from face-to-face care to virtual care 18 . The study described the steps followed by the team and each professional. The most frequent challenges were resistance or discomfort by adolescent users in adhering to the new treatment proposal 18 . The general adolescent health problems that are easier to address by telemedicine include follow-up of chronic headache, skin problems, and some musculoskeletal complaints 18 . Follow-up of mood disorders, maintenance of medication for attention deficit/hyperactivity disorder, orientation on sexual and reproductive health, and monitoring of eating disorders were also perceived as easily managed via telemedicine 18 .
Concerning the logic of treatment protocols, a Brazilian study attempted to present a standardized format for treatment of children and adolescents severely ill with COVID-19 19 . The researchers collected epidemiological information and the criteria for differential diagnosis to assist healthcare professionals in decision-making in severe cases that can appear in the health services 19 . According to the researchers, it is important to work on treatment management in the health services, but also Cad. Saúde Pública 2020; 36(8):e00150020 to orient parents on the need to quickly mobilize adequate medical transportation when the situation worsens due to complications of the disease 19 .
Research development has also been affected by the COVID-19 pandemic. One of the reviewed studies evaluated a research network with adolescents and young people at risk or living with HIV and found that changes were needed in the implementation of interventions and questions on COVID-19, added to the research protocols 20 . The study found that these measures were capable of increasing the understanding of how the pandemic affects individuals at risk or living with HIV 20 .
In short, the main data extracted from the 11 articles on adolescents' health refer mainly to mental health, human development, and clinical factors related to COVID-19. Figure 2 summarizes these findings.
The main limitations reported by the studies in the review involved the cross-sectional study design 16,17 , use of self-report questionnaires 15, 16,17 , and relatively small samples or their characteristics 15, 16,17 . The one systematic review study reported limitations involving the short publication period, simplicity of the reviewed studies, and the inclusion of studies only conducted in China 13 . Additional studies with a longitudinal design or larger samples and conducted in different contexts and with multiple information sources were suggested.

Figure 2
Summary of the main results of the 11 studies in the review.

Discussion
The current study aimed to identify the impacts and effects of the COVID-19 pandemic on adolescents' health. Respiratory diseases such as asthma thus merit attention, since they can be a risk factor for SARS-CoV-2 infection. The review also found problems with the adolescents' mental health related to the disease and to the health measures implemented to control transmission. Specifically, social distancing measures and closing of schools have been experienced negatively. Social distancing measures can also favor the occurrence of violence or aggressive behaviors in the home setting. Health services that treat the adolescent population also had to reorient their patient care practices, and even the research had to be rethought.
Cad. Saúde Pública 2020; 36(8):e00150020 Asthma prevalence is high in Brazilian adolescents. A nationwide study with 74,589 adolescents found 13.1% prevalence in the sample 21 . The 2015 edition of the Brazilian National School Health Survey (PeNSE) collected data on 102,072 nineth-grade schoolchildren from all states of Brazil and the Federal District and found that 17.92% of the students had reported at least one lifetime episode of asthma 22 . Cases of chest wheezing were also recorded as a common symptom (23.52%) in adolescents 22 . These results highlight the importance of health professionals and teams monitoring cases of adolescents with a history of respiratory diseases and who may be at increased risk of COVID-19.
In addition, during the pandemic, there has been a documented increase in the risk of development of symptoms of anxiety, depression, and other psychological problems. This is due to the increasing stress from the characteristics of the pandemic itself, the decrease in mobility, the economic slowdown, and closing of schools, which are widely adopted measures to control transmission of the novel coronavirus and prevent health systems' collapse 5 . In this scenario, people tend to become more anxious and depressed and may adopt extreme health risk behaviors such as suicidal ideation or suicide attempts and self-mutilation 23 .
This kind of interpretation of the aggravation of mental health conditions results from other moments of pandemics or catastrophes in recent human history. Even considering that they are different periods, the study of these moments may signal what happens and how to act in the post-COVID-19 pandemic period. For example, during the SARS outbreak in 2003, there were reports of mild to severe psychiatric symptoms and conditions of anxiety, loneliness, boredom, rage, preoccupation with the quarantine's effect, and fear of infection in family and friends 24 . From another perspective, two to three years after the 9/11 attacks in New York City in 2001, adolescents were among the most emotionally affected groups 25 .
These experiences of adversity related to extreme situations extends to individuals' personal history. The coronavirus pandemic in 2020 may have similar long-term emotional and psychological benefits 24 . For adolescents, besides the pandemic itself, there are social distancing measures and interruption of daily routines, excluding them from school attendance and spending time with their peer group. In terms of development, adolescence is a time of greater distancing from parent figures and family and greater proximity to classmates and friends, which is impossible in pandemic periods due to the need to stay at home 8 . Social distancing can also mobilize internal changes or issues underlying the pandemic that precipitate the emergence of psychiatric conditions. Psychological and mental health problems are thus frequent topics in the literature on adolescents' health. An overall prevalence of 30% of common mental disorders has been documented in Brazilian adolescents 26 . The most common symptoms involve depression, anxiety, unspecific complaints, and somatization. Families may trigger processes of crisis, mainly when the family dynamic is marked by violence 27 , which can be amplified during social distancing. Meanwhile, family interactions based on trust and emotional and social support 27 can be protective factors for mental health, a model that should be further elaborated in initiatives for family care.
Health services targeted to the adolescent population should also consider these issues, even when it is impossible to provide face-to-face care. The 11 studies reviewed here show how the pandemic has affected the services' routine and the need for rapid implementation of complementary models to avoid interrupting care. The possibility of online care or telemedicine is a valid trend, especially among adolescents that are familiar with the use of the technologies and the different medias, favoring adherence to digital health interventions, including those that address preventive behaviors or the care itself 20 . However, there have been some reports of negative and aggressive reactions to the change in the modality of care from face-to-face to virtual 28 .
Prolonged time in the home environment may also favor an increase in situations of violence against adolescents. This analysis emerges from initial studies on domestic violence that include adolescents in the risk groups, besides women and children 7 . Domestic violence against adolescents is also considered a public health problem 29 . It is characterized by the use of physical punishment to discipline or correct unwanted behaviors, through physical, psychological, or sexual aggression and cases of parental neglect 30 . As a social phenomenon, domestic violence is viewed as the result of dynamic and psychosocial processes based on family interaction 29 . Thus, with social distancing during the pandemic, abusive parents and guardians may increase such aggressions.
Cad. Saúde Pública 2020; 36(8):e00150020 Adolescents themselves may also display aggressive or delinquent behaviors while confined at home with their families. Adolescence is a time of development marked by psychobiological changes that can lead to an increase in emotional instability and greater irritability 31 . This period also includes the process of definition of self-identity, which depends largely on peer relations 32 . During the COVID-19 pandemic, meetings with friends and classmates decrease or disappear entirely, which can increase the stress, triggering negative or unruly behaviors or excessive use of digital technologies. Future studies are needed to examine the facets and impact of this time of social distancing for adolescents.
Parents and guardians can support their adolescent children in this moment, helping them understand cognitively or emotionally the importance of the health measures that are being adopted to control COVID-19. However, many parents are unprepared for this task. Explaining details in the transmission curve and its effect on public health is an alternative as a cognitive approach. Emotionally, adolescents can be sensitized concerning care for themselves, which can result in the prevention of transmission to others, including both the family and strangers. One of the studies in the review confirmed that adolescents tend to be internally disposed to adhere to and understand the importance of social distancing19. Adolescents should also be included in household activities, since this helps restore their sense of self-efficacy, characterized by the assessment that they are capable of performing something successfully at a moment of a radical break with their school or social routine.
Finally, although the evidence reviewed here is important, it should be interpreted in light of three main limitations. First, the studies' level of evidence was not measured, as assumed in the guidelines for scoping reviews. Second, there have been few studies on the COVID-19 pandemic's impact on adolescence, and much of the documented information is based on hypotheses concerning other adverse experiences. Third, the inclusion criterion for language of publication can also be considered a limitation, to the extent that the epidemic started in China, and studies published exclusively in Mandarin may have been overlooked.

Final remarks
With an exploratory approach, this scoping review aimed to identify scientific evidence on the impact of the emerging COVID-19 pandemic on adolescence. The review found that adolescents' experiences with the COVID-19 pandemic have received relatively little attention in studies thus far, leaving various knowledge gaps. Adolescents present the same clinical symptoms as adults when infected with the novel coronavirus. Mental health problems and domestic violence in this time of development were associated with the pandemic itself or with social distancing, which adolescents understand and accept to some extent. The study's original contribution lies in the approach to adolescents' health during the pandemic. Thus, considering the expanded definition of adolescence, the review highlighted the need for studies with the capacity to assess the societal characteristics that individually and collectively influence the health of adolescents and their families during this time of prolonged cohabitation with social distancing.
Epidemiological studies with the adolescent population are recommended, along with studies capable of capturing nuances in adolescents' subjective experiences with a problem that causes fear, uncertainties, and insecurity. In terms of action and healthcare practices, primary healthcare teams should develop activities in health education and promotion with adolescents, even on virtual platforms, since adolescents have shown good adherence to these complementary modalities of care. Such modalities aim to raise adolescents' awareness of the health measures used to control transmission, beside encouraging the development of social responsibility, which assumes self-care and care for others.