Association between COVID-19 risk-mitigation behaviors and specific mental disorders in youth

The COVID-19 pandemic constitutes an ongoing global public health threat. SARS-CoV-2 is a highly contagious virus that transmits mainly through inhalation of airborne droplets and transfer from direct contact with surfaces that are contaminated. Public health officials across the world initially responded to this threat by urging people to follow several risk-mitigation strategies to reduce the chance of infection and transmission. Adults and children alike were urged to avoid close contact, maintain at least 6-feet of physical distance from others, wear face masks in public, engage in frequent and intensive hand washing, adhere to stay-at-home orders, and self-isolate when exhibiting symptoms of infection [1]. Despite facing some resistance, such efforts have been associated with a reduction in COVID-19 transmission [2‐4].

There is growing evidence regarding the potential impact of mental health disorders on COVID-19 risk. Studies of adults show that pre-existing mental disorders are associated with increased risk of COVID-19 infection [5], severity [6‐9], and mortality [7‐12]. A recent study showed that individuals with substance use disorders are also at increased risk of COVID-19 infection, hospitalization, and death [8, 9]. These findings have been largely confirmed by several meta-analyses [7‐9, 13].

Accordingly, the Centers for Disease Control and Prevention (CDC) designated mental and behavioral health disorders among the pre-existing conditions that increase vulnerability to COVID-19 illness [14]. An important effect of this recognition is greater priority in receiving vaccines and boosters to protect individuals and reduce community spread. Included in this list are disorders that typically affect children, such as neurodevelopmental disorders like autism spectrum disorder and ADHD. However, there is scant research on the role of mental disorders in COVID-19 vulnerability among youth. One recent study of electronic health records among patients (aged 2 months to 103 years) in Israel found that COVID-19 infection was associated with ADHD (but no other psychiatric diagnosis examined), male gender, age below 20 years, and low-medium SES group [15]. Interestingly, the association between ADHD and COVID-19 infection in this sample was especially elevated among youth (ages 5–20) and untreated ADHD cases of any age. Additional research on youth with a range of mental disorders is needed to understand the potential mechanisms associated with COVID-19 vulnerability. In particular, the ability of youth to adhere to risk-mitigating practices may differ by the key phenomena underlying mental disorders such as inattention, anxiety, fear, impulsivity, etc. To our knowledge, no studies have investigated COVID-19 risk-mitigation adherence among youth with mental disorders. This study examined associations between parent-reported COVID-19 risk-mitigation practices and specific mental disorders among female and male youth from the Healthy Brain Network (HBN) in the New York City metropolitan area.

Table 1 presents the number and percentages of youth who “very often/always” engaged in the 7 risk-mitigation behaviors, by demographic characteristics. Overall, the percentage of mask wearing “very often/always” was high (90%), and higher among females and among African American and Hispanic youth. The overall percentage of “very often/always” maintaining social distance, using hand sanitizer, and washing hands was 46%, 46%, and 59%, respectively. These behaviors differed significantly by race, as the percentages were elevated among African Americans and Hispanics and lower among Caucasians. Further, maintaining social distancing “very often/always” was positively associated with age and negatively associated with SES, as was washing hands “very often/always.” The overall percentages of avoiding other people’s homes, avoiding in-person groups, and avoiding indoor public places “very often/always” was 58%, 46%, and 43%, respectively. These were similar across demographic factors.

The correlations among the risk-mitigation items appear in Fig. 1. All correlations were positive and ranged from 0.09 to 0.63. Mask wearing correlated weakly (r < 0.31) with all other items. Maintaining social distance correlated moderately (r = 0.38 to r = 0.44) with using hand sanitizer, avoiding other people’s homes, avoiding in-person groups, avoiding indoor public places, and washing hands. Using hand sanitizer correlated strongly (r > 0.63) with washing hands and weakly (r < 0.14) with avoiding other people’s homes, avoiding in-person groups, and avoiding indoor public places. Washing hands correlated weakly (r < 0.21) with avoiding other people’s homes, avoiding in-person groups, and avoiding indoor public places. The three avoidance items—avoiding other people’s homes, avoiding in-person groups, and avoiding indoor public places—were moderately to strongly intercorrelated (r = 0.53 to r = 0.60).

Results from the parallel analysis (Fig. 2) show that a two-factor model was the best-fitting solution. That is, a two-factor solution explained more variance than what would be expected due to chance based on a null distribution of eigenvalues. Results from the factor analyses are shown in Fig. 3. The first factor (avoidance behaviors) included avoiding groups, indoor settings, and other peoples’ homes. This factor accounted for 27.7% of the cumulative variance. The second factor (hygiene behaviors) included using hand sanitizer, washing hands, and maintaining social distance. The addition of this factor increased the cumulative variance explained to 49.8%. Mask wearing loaded poorly on each factor, a finding consistent with the weak individual correlations with this item. Further, its inclusion to the model did not meaningfully improve the fit or the amount of variance explained. For these reasons, mask wearing was analyzed subsequently as a separate item.

Table 2 presents the results from the regression analyses of associations between the two resulting factors (and, separately, mask wearing) and mental disorders. The table presents results from the unadjusted model, model (a) that adjusted for demographics, and model (b) that adjusted for demographic variables and comorbid mental disorders. Focusing on the fully adjusted model (b), several of the demographic variables were significant covariates (results not shown). African American race was positively associated with both avoidance behaviors and hygiene behaviors. Age, Hispanic race/ethnicity, other race/ethnicity, or nondisclosed race/ethnicity were positively associated with hygiene behaviors. Female sex was positively associated with mask wearing. As shown in Table 2, the two factors were associated with specific mental disorders. The avoidance behavior scores were higher among youth with any anxiety disorder, across all three models. No other disorder was significantly associated with this factor. The hygiene behavior scores were lower among youth with ADHD-C across all three models. Analyzed as a separate item, mask wearing was less frequent among youth with ADHD-C in the unadjusted model (p = 0.03). However, this association was not significant after adjusting for demographics and comorbid disorders. No other mental disorder was significantly associated with mask wearing.

The importance of risk-mitigation measures in reducing exposure and severe disease have been one of the most important public health measures in response to the prolonged nature of the COVID-19 pandemic, now in its third year. Physical distancing, avoiding touch, washing hands frequently and intensively, wearing a face mask in public, staying at home, and maintaining quarantine have been particularly challenging for youth with mental disorders. Here we report two key findings regarding the association between compliance with different risk-mitigation factors and mental disorders. First, the COVID-19 risk-mitigation behaviors tended to cluster into two factors: avoidance behaviors (avoiding groups, indoor settings, and other peoples’ homes) and hygiene behaviors (using hand sanitizer, washing hands, and maintaining social distance). Second, the frequency with which parents reported that youth practiced these behaviors differed by specific mental disorders. Avoidance was higher among youth with any anxiety disorder, whereas practicing hygiene was lower among youth with ADHD-C. Mask wearing was largely unrelated to other risk-mitigation behaviors and, when examined as a separate item, was not associated with mental disorders after adjusting for demographic factors or comorbid mental disorders.

Our findings add to the limited research on the role of mental disorders in COVID-19 risk among youth, despite ample evidence showing that youth with mental disorders are at increased risk of myriad physical diseases [21]. In particular, ADHD has been shown to increase risk of inflammatory and immune-related disorders including asthma, eczema, certain allergies [22‐25], respiratory infections and influenza [12], and several preventable negative outcomes including sexually transmitted infections, accidental injuries, and injury-related mortality [26‐28]. Psychosocial stress, anxiety, negative affect, and depression are also associated with increased risk of acute respiratory infections as well as poorer clinical prognosis [29]. Depression has been associated with an increased risk of a developing a wide range of infections [30] including sexually transmitted diseases and poorer outcomes thereof [31, 32]. Children and adolescents with autism spectrum disorders are at increased risk of several medical conditions including immunological, gastroenterological, neurological, and other medical complaints [23]. Although the current work did not examine COVID-19 infection directly, it is consistent with the broader literature in demonstrating that youth with specific mental disorders may require more (or less) support to adhere to certain COVID-19 risk-mitigation behaviors.

There are several potential mechanisms for our findings. Youth with anxiety disorders, who were more likely to practice avoidance behaviors, may be so inclined because avoidance is a central characteristic of many anxiety disorders including social phobia, agoraphobia, social anxiety disorder, and generalized anxiety disorder. Avoidance-related manifestations of anxiety disorder may serve to mitigate COVID-19 vulnerability by reducing social contacts with others in groups, indoor settings, and other peoples’ homes. The failure to comply with hygiene behaviors among youth with ADHD-C may occur through other mechanisms. Youth with ADHD-C, where both inattention and hyperactivity/impulsivity are present, may find it more challenging to comply with 6-foot distance rules and hand-cleaning practices. This may help explain the finding reported by Merzon and colleagues [15] that youth with ADHD are at increased risk of COVID-19 infection, and that the association was greater for untreated than treated ADHD. Several non-significant findings are notable as well. Although youth with ASD can sometimes struggle with daily living skills including maintaining personal hygiene [33] that may lead to lower compliance with hand washing and using hand sanitizer, we did not observe this finding. Youth with oppositional defiant disorder or conduct disorder, who tend to disregard social rules, were no more or less likely to consistently engage in harm-mitigation behaviors. We similarly found no independent association between depressive disorders and risk-mitigation behaviors. These interpretations are suggestive and warrant further research.

Aside from risk-mitigation compliance, there are other mechanisms by which pre-existing mental and behavioral health disorders may increase COVID-19 vulnerability. These include increased exposure to COVID-19 at home or at school due to greater household or community density, greater susceptibility due to enhanced physical disease vulnerability as described above, or poorer general health status related to obesity, physical inactivity, or familial exposure to smoking. Future research on COVID-19 vulnerability should incorporate the full range of risk factors for COVID-19 infection as well as compliance with COVID-19 risk-mitigation behaviors.

To further reduce COVID-19 incidence and community transmission, it is crucial to identify risk factors for COVID infection in youth. Although some research shows that young children are less susceptible to infection than adults [34‐36], other research shows that children may be as likely as adults to become infected with COVID-19 [37]. In fact, a recent epidemiologic study [38] of a pediatric sample in Virginia reported a SARS-CoV-2 infection rate (8.5%) that was higher than a sample of adults (2.4%) from a similar region and period [39]. Further, children appear to play a role in community transmission through their social interactions and hygienic habits [34], a finding that underscores the importance of risk-mitigation strategies among youth especially as the COVID-19 pandemic continues to evolve and become even more transmissible, as in the case of the most recent circulating variant (Omicron). Indeed, a recent experiment found that the Omicron variant survives longer than other variants on plastic and skin, a factor that may have contributed to the rapid community spread of Omicron [40]. Taken together, findings further underscore the importance of being vigilant about risk-mitigation behaviors to combat vulnerability to COVID-19 infection and transmission.

Study findings should be considered preliminary and with several limitations in mind. Although the current study accounted for several demographic factors and psychiatric comorbidity, other factors potentially associated with risk-mitigating behaviors were unmeasured; their role as confounders are unknown and should be examined by future research. The study relied solely on parent reports; information from self- and other-reports (e.g., teachers) may provide additional valuable information. Because HBN participants were selected for mental health concerns, the generalizability of the findings may be limited to youth from families seeking treatment. Study findings should be interpreted cautiously to avoid unintended (Additional file 1) stigmatization of youth with mental disorders. the previous sentence includes (Additional file). This should be deleted because it is not correct.  No additional file should be mentioned. First, the associations between risk-mitigation behaviors and mental disorders, while statistically significant, were limited in number and modest in magnitude; as such, we caution against overstatement. Second, our synthesis is intended to underscore the importance of being vigilant about risk-mitigation behaviors (e.g., social distancing, hand washing) both generally for all youth and specifically for youth who may need frequent reminders. Focusing on behaviors rather than mental disorders, when possible, may further minimize the potential for undue scrutiny and stigmatization.

This work provides novel information on the associations between mental disorders and COVID-19 risk-mitigation behaviors in youth. Reduced practice of prevention measures among those with specific types of disorders highlights the need to provide extra support to youth with ADHD, and their parents, regarding risk-mitigation behaviors to minimize the risk of COVID-19 among this vulnerable population. It may also be worthwhile to consider prioritizing vaccinations among individuals with mental and neurodevelopmental disorders [41] that may reduce their ability to prevent exposure.