Emotional and behavioral problems in adolescents in the context of COVID-19: a mixed method study

Abstract Objective: to estimate the prevalence of emotional and behavioral problems in adolescents in the context of the COVID-19 pandemic e to explore adolescents’ perception of emotional and behavioral problems identified. Method: mixed-method explanatory sequential design. Participants were 479 adolescents aged 15 to 18 from a Brazilian Central-West region capital. Results: with a total of 479 participants, mean age was 16.03 years (SD=1.01). The prevalence of emotional and behavioral problems was 61.17%, and there was a difference between the sexes (ORb=2.93; p<0.01). The highest prevalence was related to peer relationship problems (54.49%) and emotional symptoms (52.40%). Adolescents noticed an increase in loneliness, anxiety, sadness, distancing from friends and difficulties in socializing during the pandemic. Conclusion: most of the investigated adolescents were classified as having emotional and behavioral problems, and girls were more likely to have them than boys. The adolescents’ statements reinforce the quantitative findings. In this way, there is a need to implement actions to promote and restore the adolescents’ mental health, in order to mitigate the COVID-19 pandemic socio-emotional impact on this population.

and circumstances capable of triggering emotional distress in adolescents, the COVID-19 pandemic stands out, which was identified in December 2019 in Wuhan, Hubei province, China, characterized by an acute infectious pneumonia (5) .
In a short period of time, a virus called SARS-CoV-2 spread around the world due to its high transmissibility, causing the coronavirus disease (5) . From then on, the WHO began to recommend limiting physical contact in order to reduce transmission and, therefore, an increase in cases, indicating the adoption of domestic quarantine and physical distancing as control strategies (6) .
Consequently, there was a loss of intimate and social contact, culminating in greater moments of stress with feelings of loneliness and/or anger (7)(8) , compromising the adolescents' emotions and behaviors.
Emotional and behavioral problems (EBP) are characterized by generalized depressed mood, the inability to establish satisfactory interpersonal relationships, behaviors or feelings considered inappropriate in certain circumstances, and a tendency to develop physical symptoms or fears associated with social problems (9) . Therefore, EBPs in adolescents should be seen carefully by health professionals, parents, family members and teachers, since the early identification of these problems can improve the prognosis and adolescents' quality of life.
It is necessary to bear in mind that sociocultural and economic contexts influence the development of EBPs. Thus, experiencing a major event such as the current crisis imposed by COVID-19 pandemic required adaptations from the whole society, especially from adolescents who face these unexpected changes in daily life with more difficulty, which can be the cause of EBP (10) .
With schools closed, restricted to the home environment, adolescents dealt daily with the fear of infection, uncertainty about the disease, frustration, boredom, inadequate information, family financial loss, family grief, and physical and social isolation. This had repercussions on various aspects of life, such as social, emotional, and behavioral ones, which can be internalized as suffering and collaborate to the development of psychoemotional changes (11)(12) .
Thus, it is essential to investigate EBP in adolescents, considering the context of the COVID-19 pandemic, and to understand the magnitude of this event in this population's life. Such findings are essential to guide health policies and practices aimed at this population, in order to ensure harm reduction and improve its socio-emotional health. These may also encourage mobilizations to prevent, identify, welcome, refer, and treat EBP in adolescents (13) . In addition, the relevance of this study for nursing is highlighted, since the clarification of EBP in adolescents in the pandemic context will allow nurses to provide care based on the patients' real psycho-emotional needs.
Therefore, the objectives of this study were: (1) to estimate the prevalence of emotional and behavioral problems in adolescents in the context of the COVID-19 pandemic; (2) to explore adolescents' perception of emotional and behavioral problems identified.

Study design
This is a mixed-method study, with a two-phase explanatory sequential design. In the first phase, an observational cross-sectional study (QUAN) was carried out, and then an exploratory-descriptive (qual) was developed. The representative diagram of the investigation design is shown in Figure 1.
Peterle CF, Fonseca CL, Freitas BHBM, Gaíva MAM, Diogo PMJ, Bortolini J In the explanatory sequential design adopted in this study, the research steps fell into clear and separate but combined phases. Therefore, the quantitative data (QUAN) with more weight were collected and analyzed in a first research phase, followed by qualitative data (qual) collection and analysis, developed from the initial quantitative results (QUAN). Sequentially, data connection and interpretation (QUAN-qual) were performed. This design (Figure 1) is highly valuable to deepen (qualitatively) initial quantitative data (14) .

Period
Data collection for the study quantitative phase took place between April and July 2021, and the qualitative phase in July 2021.

Population and selection criteria
The study population was composed of adolescents aged between 15 and 18 years, enrolled in secondary education at the schools included in the research.

Participants
To estimate the expected sample in Phase I, The recruitment was ended the sample held sufficient Information Power (15) .

Quantitative data collection and analysis
Prior to data collection, the adolescents were invited to participate in the study via messages in groups of instant messaging applications administered by schools and/or by emails directed to parents or guardians.  1= borderline, and 2= abnormal (16) .
For each of the five subscales, the score can vary from 0 to 10 points, with the total difficulty score being generated by the sum of the results of all subscales, except for sociability, which can vary from 0 to 40 points, since the prosocial behavior scale is not included in this score because is considered to be strength.
The classification of normal, borderline, and abnormal is also established for each subscale and a total difficulty score for posterior definition of cases and non-cases of mental health problems (16) .
On the difficulty subscales, at least 80% of adolescents in the community are considered to be normal, 10% borderline, and 10% abnormal. Guidance was followed for the interpretation of the scale symptom score to define cases of mental health issues. Thus, in this study, the cases considered were adolescents identified by high or borderline scores, since the proportion of classified as "abnormal" and "borderline" was greater than 10%. However, as the "borderline" classification was below 10% and the "abnormal" was 10% for strengths, adolescents classified as borderline and normal were considered non-cases (16) .
The answers provided by the adolescents, by completing the Phase I online form, resulted in a Microsoft Excel ® spreadsheet. Subsequently, data processing was performed before analysis. Then, the prevalence of "normal," "borderline," and "abnormal" classifications was calculated for each item of the SDQ and of the EBP cases. Crude odds ratios (Orb) were also calculated using simple logistic regression for each domain of the SDQ in relation to sex. Cronbach's alpha for the SDQ was α=0.77. All statistical analyzes were performed using STATA 16.0 ® software, with a 5% significance level.

Qualitative data collection and analysis
After Phase I of the research, 24 adolescents classified with EBP were selected for the focus groups Power is a pragmatic model that helps define the limits of participants in qualitative studies, and, for that, it considers some dimensions, namely: study objective, sample specificity, theory, dialogue quality, and analysis strategy (15) .  The statements from the FG were fully transcribed, organized by codes, and submitted to content analysis of Peterle CF, Fonseca CL, Freitas BHBM, Gaíva MAM, Diogo PMJ, Bortolini J Bardin (18) . Participants' statements were presented with fictitious names (chosen by the adolescents themselves), age, and the score obtained in the SDQ.

Quantitative and qualitative data integration
After quantitative and qualitative data collection and analysis, in clear and separate phases, integration was carried out through connection and joint appreciation of interpreted quantitative and qualitative results. For data integration presentation, the joint display technique was used to integrate quantitative and qualitative data during data collection, analysis and interpretation (19) . Figure 2 represents the synthesis of the methodological characteristics proposed for the study.  Regarding education network, 81% (n=388) were students from public schools and 19% (n=91) from private schools.    Most adolescents were classified as having emotional symptoms, which were intensified during the pandemic period, especially among girls.

Impulsivity and aggressiveness: "I can't control myself at the time of fight;" "I'm very rude"
Anger: "I get angry with the person" Difficulty in socializing: "I'm not that good at socializing;" "I avoid talking to people" Most of the adolescents had conduct problems. The pandemic context generated more impulsivity, aggressiveness and feelings of anger, in addition to a greater difficulty in socializing. The prevalence of the hyperactivity symptom was high among adolescents, and the COVID-19 pandemic intensified this symptom, especially in view of the emergency remote teaching adopted in this period. Girls were the most affected by these symptoms.
Peer relationship problems 261 (54.49%) Distancing from friends: "I distanced myself;" "I distanced myself form many friends;" "many friends distanced from me" Renewing friendships: "My cycle of friends changed" Most of the adolescents presented conduct problems. The pandemic has impacted these relationships and symptoms, generating emotional distress for adolescents.
Prosocial behavior 430 (89.77%) Participation in social movements: "I've always participated in social movements" Family cooperation: "I help my mother take care of my sister" Socio-economic support: "We bought basic food baskets;" "We also helped with the issue of providing Internet access to many students" Emotional support: "I've helped all my friends" Sharing knowledge: "teaching other people" Almost all adolescents presented prosocial behavior. With pandemic outbreak, adolescents began to value actions to benefit someone else even more.

Discussion
This study identified quantitatively that most of the investigated adolescents were classified as Another piece of research was conducted in Germany during the pandemic period (20) . The German study sought to investigate children's and young people's perception of Peterle CF, Fonseca CL, Freitas BHBM, Gaíva MAM, Diogo PMJ, Bortolini J the increase in psychological stress, and found that about 19% of those surveyed said they felt psychologically worse due to the pandemic (20) . Thus, it can be inferred that the COVID-19 pandemic had a negative impact on the adolescents' mental health, especially due to the domestic quarantine. A survey carried out with children and adolescents in India found a higher prevalence of EBPs among those who were in domestic quarantine compared to those who were not (21) . However, this measure was extremely necessary to control the transmission of the disease.
Most adolescents had emotional symptoms, especially girls, as shown by the quantitative results.
The qualitative phase emphasizes that the adolescents noticed important emotional changes in the pandemic period. Likewise, studies carried out in China, Australia, and the United Kingdom also found that girls are more affected by negative emotional symptoms than boys (22)(23)(24) .
Among them, the increase in depressive symptoms during the pandemic was associated with an increase in passive social media use and a decrease in connection with family members by phone or social media, which makes it difficult for adolescents to trust their networks for emotional support at stressful times (23,25) .
In addition, it was identified that boys practice more vigorous physical activity compared to girls, which may provide protection against negative mental health outcomes (26) . A meta-analysis study found that there was an increased prevalence of symptoms of depression and anxiety among young people (mean age 13 years), when comparing pre-pandemic to the pandemic period.
In the current scenario, one out of four young people has clinically severe symptoms of depression, and one out of five has clinically severe symptoms of anxiety (27) .
The quantitative results of this study showed that adolescents, especially girls, showed hyperactivity during the pandemic period. In line with this, a UK study also used the SDQ to assess the adolescents' mental health before and during the COVID-19 pandemic, and the researchers identified that adolescents with above-average mental health before the pandemic experienced a notable increase in hyperactivity (24) .
Concern about other people contracting COVID-19, changes in daily and school routines, and lack of personal contact with friends are among the main aspects that contribute to the development of mental health problems in young people, especially in relation to girls (25) .
According to the qualitative results, given the physical isolation and school closures, adolescents had difficulty in concentrating on a certain activity and in maintaining serenity. These effects were also observed in a study carried out with parents and guardians of children and adolescents in Italy, in which 85.7% of them perceived changes in their children's behavior during quarantine, and the most frequent symptoms were difficulty concentrating (76.6 %), boredom (52%), irritability (39%), and restlessness (38.8%) (28) .
Furthermore, the results of this study indicate that most adolescents manifested peer relationship problems, mainly due to physical distance, separation and frustration, affecting their relationships directly (29) .
Regarding the family context, similar to the results obtained with adolescents in this research, a study developed with young Brazilian adults identified that 80% of respondents reported some type of stress with the increased family socialization during the pandemic.
Among them, those that claimed to be experiencing family stress situations are the majority among those living with a greater number of people in the residence (30) , a common reality for many Brazilian families.
Studies carried out in other countries, such as Spain, Indonesia, and Bangladesh, have also detected an increase in conduct problems during the pandemic.
Also, a direct association of this increase with conflicts in relationships with family members, dysfunctional parenting, break in routine, and excessive time on screens is perceived (31)(32)(33) . The qualitative results identified in this research reinforce the increase in impulsivity, aggressiveness, and difficulty in socializing during the COVID-19 pandemic.
The high prevalence of prosocial behavior evidenced in this study was also described by other researchers (24,34) . Prosociality is essential to the formation and maintenance of bonds between people living in societies. Altruistic behavior is associated with reduced aggression, improved physical and mental health, longevity, and improved well-being. However, the decision to act in a prosocial manner is influenced by the environment and the circumstances experienced (24,34) .
In this sense, the context of the COVID-19 pandemic seems to have interfered positively with the adolescents' prosocial behavior, through care of family and friends and involvement with social issues intensified during the pandemic (35) , also identified in the qualitative analysis phase of this study.  (37) , as the timely identification of EBPs allows for appropriate interventions to restore a better mental health status (38) .
It is possible to note the importance of nurses working in partnership with adolescents to promote their mental health and the prevention of EBPs through the individual therapeutic project during nursing consultations, collective health actions, family support, and support for the environments they are inserted in, like school. In this sense, the promotion of socio-emotional skills, such as self-esteem, responsible decision-making, and expressive communication of emotions are essential for achieving better mental health (39) .
In this collaboration between nurses and adolescents, it is important to know the health history and possible protective factors that reduce the probability of developing EBP and that can be mobilized in the nursing care process.
Among these factors are: family intimacy/closeness, positive relationship with parents, development of effective interpersonal skills with peers, the feeling of belonging, good school performance, and creation of future expectations (40) .
Thus, nursing should seek to guide the adolescents so that they become emotionally capable of adopting increasingly healthy behaviors. Training is more than providing information, it is also intervening to promote the adolescent development so that they can make a realistic assessment of the consequences of their actions and can opt for more adaptive and healthpromoting behaviors (39) .
Finally, regarding the limitations of this research, the use of the cross-sectional study design in Phase I does not imply causality, and the self-report questionnaire used is susceptible to social desirability bias. Therefore, the inclusion of other sources of information in future studies may help to minimize these limitations. There were many refusals by schools, justified by the high demand generated by emergency remote teaching on management and teachers.
Therefore, one believes that outside this atypical period it is possible to obtain a greater adherence from schools. In addition, there was difficulty for adolescents to adhere to the FG in Phase II of the research.
In further studies, it will be possible to employ other recruitment methods and data collection techniques in order to improve participant adherence.

Conclusion
This study found that most adolescents presented EBP, and the girls were the most affected. Furthermore, results show that emotional symptoms and problems with peer relationship problems were the most prevalent among the EBPs.
The adolescents' perception of EBP corroborated the quantitative results, since reports such as increased loneliness, anxiety, sadness, distancing from friends, and socialization difficulties were frequent. It was evident that the COVID-19 pandemic and the period of social seclusion had a negative impact on the adolescents' mental health. On the other hand, there was an increase in participation in social movements, family cooperation, socioeconomic and emotional support for third parties, which demonstrates that adolescents, despite experiencing many negative aspects during the pandemic, also began to value more actions in benefit of other people, recognizing them as fundamental to social well-being.
For this reason, one understands the importance of proposing and implementing actions to promote and recover the adolescents' socio-emotional health, with the objective of reducing the harmful pandemic effects on these young people's mental health to the minimum possible, considering the difference between sexes.