Skip to main content

Increased symptoms of post-traumatic stress in school students soon after the start of the COVID-19 outbreak in China

Abstract

Background

The outbreak of Coronavirus Disease 2019(COVID-19) caused psychological stress in Chinese adults population. But we are unaware of whether the pandemic causes psychological stress on children.

Methods

We used the Children’s Impact of Event Scale questionnaire (CRIES-13) to investigate the degree of Post-traumatic Stress (PTSD) symptoms caused by the pandemic in students selected from schools in Sichuan, Jiangsu, Henan, Yunnan, and Chongqing provinces of China.

Results

A total of 7769 students(3692 male and 4077 female), aged 8–18 years, were enrolled in the study, comprising 1214 in primary schools, 2799 in junior high schools and 3756 in senior high schools. A total of 1639 students (21.1%) had severe psychological stress reactions. A large proportion of senior high school students (23.3%) experienced severe psychological stress, and they had the highest median total CRIES-13 score. Female students were more likely to experience severe psychological stress and had higher median CRIES-13 total scores than males.

Conclusion

COVID-19 has placed psychological stresses on primary and secondary school students in China. These stresses are more likely to reach severe levels among female students and senior high school students.

Peer Review reports

Background

Studies have shown an increased incidence of post-traumatic stress in survivors of large-scale disasters compared with the general population [1,2,3,4]. Disasters can be defined as destructive occurrences that disrupt and overwhelm entire communities and affect millions worldwide in a given year [5]. Children who have experienced disasters are more vulnerable than adults to mental and psychological disorders, including post-traumatic stress disorder (PTSD) [6,7,8]. Disasters can severely affect their emotional status, resulting in stress reactions that are different from those experienced by adults. Unlike adults who are able to regulate their emotions, children are more likely to limit or suppress their emotions [9, 10]. In addition, children may develop serious psychological and mental illnesses that occur sooner and last longer than those in adults [11,12,13]. And there is ample evidence of gender differences in post-traumatic symptomatology and women are found more likely to develop symptoms than men [3].

In the twenty-first century, a number of infectious diseases have challenged global public health [14].

During the epidemic of severe acute respiratory syndrome in February 2003, many adult patients developed post-traumatic stress symptoms, PTSD, anxiety, depression, and other mental illnesses [15,16,17,18]. The current Coronavirus Disease 2019(COVID-19) pandemic also has constituted a global public health disaster [19]. After COVID-19 outbreak in China, our governments issued the first-level public health alert and recommended that all citizens staying at home [20]. The Ministry of Chinese Education estimated that more than 220 million children and adolescents were confined to their homes. In such crisis time, it is necessary to explore whether the COVID-19 pandemic would cause psychological stress on children and adolescents.

Therefore, we investigated the prevalence of post-traumatic stress symptoms in primary and secondary school students from several provinces and regions in China at one month after the start of the COVID-19 outbreak in order to elucidate the effects of the pandemic on the psychological stress in children and adolescents.

Methods

Subjects

We recruited 7769 students, from those in first grade of primary school (8 years) to those in the third grade of senior high school (18 years), in Sichuan(6727 students, 2 elementary school, 3 middle school), Jiangsu(767 students, 3 elementary school,1 middle school), Shandong(159 students, 1 elementary school,1 middle school), Henan(10 students, 1 elementary school), Yunnan(43 students, 1 middle school), and Chongqing(63 students, 2 elementary school). Participants were stratified into primary school students (grades1–6), junior high school students (grades7–9), and senior high school students (grades10–12). We excluded students with a history of substance abuse and those suffering from mental illnesses (totally 4.5%), as well as those who could not understand the questionnaire.

The minimal sample size required for this study was calculated based on the typical sample size for questionnaire-based surveys of the occurrence of post-traumatic stress after disasters. Based on a PTSD prevalence of 32.2% in China after the outbreak of COVID-19 [19], we calculated a minimal sample of 2097 for a power of 0.8, type I error of 0.05 and allowable error of 0.02. We increased this by 10% to 2330 to compensate for missing or uncooperative participants. Ultimately, our sample was much larger (7769).

Measurement

Between 1 February 20 and 1 March 12,020, approximately one month after the outbreak of COVID-19 in China, we collected demographic data including age, sex, grade, family structure, occupation of parents and family members, etc. Psychopathological data was collected using the Children’s Revised Impact of Event Scale (CRIES) [21]. After obtaining the informed consent of the participants and their parents, the questionnaire were distributed by parents. Questionnaires couldn’t be submitted until they completed all questions, so there is no missing value in our sample.

The CRIES-13 measures symptoms of intrusion (4 items), avoidance (4 items), and arousal (5 new items). Answer item is set as “not at all”, “rarely”, “sometimes”, and “often” [21, 22] . The CRIES-13 total score is used to judge the severity of the psychological impact caused by a traumatic event. A total score ≥ 30 is considered to indicate severe psychological stress [22,23,24].

Statistical analysis

All statistical analyses were performed using SPSS 25.0(IBM, Armonk, NY, USA), and the significance level was set as α = 0.05.We analyzed participant data and compared CRIES-13 scores across groups using the Chi-squared, Mann-Whitney U, and Kruskal-Wallis H tests. Post-hoc comparisons were conducted after adjusting the level of significance using Bonferroni correction.

We performed stepwise binary logistic regression using the forward likelihood ratio (LR) method in order to identify factors influencing perceived stress. We considered the influence of sex, age, grade, family structure, occupation of parents, past history of psychological illness (history of psychological consultations or use of psychotropic drug therapy), recent diagnosis of COVID-19, and exposure to coronavirus infection within the previous 30 days. Questions about infection exposure addressed the number of visits to Hubei province and surrounding areas, contact with patients diagnosed with COVID-19, incidence/occurrence of cold, fever, cough, nasal congestion, runny nose, sore throat, and diarrhea, and participation in large gatherings, such as dinner parties. Exposure was also assessed based on contact with family members who were doctors and frontline workers, as well as relatives within three generations who had been diagnosed with COVID-19 or were suspected of COVID-19. We also included data on whether participants had received therapy against COVID-19, or had fever and other mild symptoms.

In order to reduce information bias, we used blind method (blinded to data analyst) to collect data, and two psychiatrists carried out strict quality control of the questionnaire. Because we strictly enforce the inclusion criteria and exclusion criteria, there are such restrictions on participants to avoid confounding bias due to other diseases. At the same time, our study did logical regression analysis to minimize the impact of confounding factors.

Results

Demographic and clinical characteristics of subjects

Our survey included a total of 7769 students (4077 female) from 5 different provinces in China (Table 1). All participants were between 8 and 18 years old (median 15 years), and were stratified into three groups based on their grade: primary school students (15.62%, median age 11 years), junior high school students (36.03%, median age 13 years), and senior high school students (48.35%, median age 16 years). In total, 24 participants (13 males and 11 females) were diagnosed with COVID-19, and 27 (16 males and 11 females) were suspected of being infected with the disease. There were significant differences in gender distribution among different grades(x2 = 32.234, p < 0.001).

Table 1 Demographic characteristics of school students, stratified by sex and grade

We collected information about the family structure and occupation of the parents of all participants. A large proportion of participants lived in three-generational households (35.6%) and in families with three individuals including the respondent (33.6%),and lived with single parents (10.2%). Others had different family structures such as living in more than three-generational households (20.7%). The most frequent parental occupations were freelancers (23.7%), self-employed workers (20.4%), migrant workers (20.3%), and farmers (13.8%). A smaller proportion were medical workers (2.1%), police officers (0.7%), civil servants (3.7%), and teachers (2.5%).A total of 165 students had family members who had been diagnosed with COVID-19.Participants were also exposed to the virus via family members who were doctors (272 students) and frontline workers (111 students).

Total CRIES-13 score

The stress response of participants to the COVID-19 pandemic was measured based on CRIES-13 total score. A total of 1639 (21.1%) students experienced severe symptoms of psychological stress (total score ≥ 30; Table 2). These symptoms were more serious in senior high school students (23.3%) compared to primary students (20.3%) and junior high school students (18.4%) (χ2 = 23.5, p < 0.001). A higher proportion of female students suffered severe psychological stress than male students (22.3% vs 19.7%; χ2 = 8.03, p = 0.005).

Table 2 CRIES-13 scores of students, stratified by sex and grade

To understand the degree of impact of COVID-19, we compared total CRIES-13 scores among primary school, junior high school, and senior high school students using the Kruskal-Wallis H test. We found a significant difference among the three groups (H = 75.512, p < 0.001; Table 2); median total CRIES-13 score was the highest for senior high school students (21), followed by the junior high school(19) and primary students (18).

After adjusting the level of significance using Bonferroni correction, a post-hoc comparison found that total CRIES-13 scores were significantly lower for primary school students (Z = -7.469, adjusted p < 0.001) and junior high school students(Z = − 6.616, adjusted p < 0.001) than for senior high school students. However, total scores were not significantly different between primary school and junior high school students (Z = -2.368, adjusted p = 0.054; Table 3). Across all three student groups, female students had higher total scores than males (median 21 vs 19; Z = -5.739, p < 0.001; Table 2).

Table 3 The post-hoc comparison of CRIES-13 scores by grade

Factor scores on the CRIES-13

We observed significant differences among the three groups of students in intrusion (H = 103.14, p < 0.001), arousal (H = 183.669, p < 0.001), and avoidance factor scores (H = 45.492, p < 0.001) (Table 2). Post-hoc comparisons of the intrusion factor showed that junior high school students had higher scores than primary students (Z = -7.933, adjusted p < 0.001), while senior high school students had higher scores than primary students (Z = -10.120, adjusted p < 0.001) and junior high school students (Z = -2.463, adjusted p = 0.041; Table 3).

Pairwise comparison of the arousal factor showed that junior high school students had higher scores than primary students (Z = -5.200, adjusted p < 0.001), and senior high school students had higher scores than primary students (Z = -12.382, adjusted p < 0.001) and junior high school students (Z = -9.214, adjusted p < 0.001). In contrast, primary school students had higher avoidance factor scores than junior high school students (Z = 6.7, adjusted p < 0.001) and senior high school students (Z = 4.327, adjusted p < 0.001), and the scores of junior high school students were lower than those of senior high school students (Z = -3.499, adjusted p < 0.001;Table 3).

Across all three student groups, we found that female students had higher intrusion factor (Z = -6.76, p < 0.001) and arousal factor scores (Z = -3.15, p < 0.001) than males, but lower avoidance factor scores (Z = -3.15, p = 0.002; Table 2).

Factors influencing individual stress response

We performed logistic regression to determine the factors affecting total CRIES-13 scores and stress responses. Our results showed that stress response was influenced by the sex of the participant(p = 0.024), school grade (p = 0.001), past history of psychological counseling (p < 0.001), exposure to infection via relatives (p = 0.009), and a recent diagnosis of COVID-19 (p = 0.006; Table 4). Individuals suffering from cold, fever, cough, nasal congestion, runny nose, sore throat, and diarrhea within 30 days of taking part in the survey also had a heightened stress response (p = 0.002).

Table 4 Logistic regression analysis to identify factors that influence risk of severe psychological stress in students

Discussion

In this study, we examined the early effects of the COVID-19 pandemic on the mental and psychological health of 7769 school students in China using the CRIES-13. Based on total CRIES-13 scores, 1639students (21.1%) experienced symptoms of severe psychological stress, indicating an urgent need to understand the impact of such events on the mental health of children and adolescents.

Women are more likely to experience acute stress reactions and to be at higher risk of PTSD than men [25,26,27,28,29,30,31]. In addition, women often show higher scores than men on the invasion and avoidance factors of the CRIES-13 [32, 33]. Studies had also found that women showed more active than men in neural networks associated with fear and arousal [34]. This is consistent with our findings.

Some studies have shown that older individuals respond differently to stressful events compared with younger ones [32, 33, 35,36,37,38,39]. Similarly, studies of children exposed to war violence showed older children more vulnerable to stress [40]. Consistent with these results, we found that the largest proportion of students experiencing severe psychological stress were in senior high school. However, a survey of 8236 US children in grades 4–12 at 6 months after the 9/11 attacks found that primary school students (grades 4–5) were at higher risk of post-traumatic stress symptoms than junior and senior high school students [41]. This discrepancy may reflect that different grades of students may have different degrees of stress disorder under the influence of different events. Future research should focus on more different events.

We found that senior high school students had higher scores on arousal and invasion factors on the CRIES-13, but primary school students had higher avoidance factor scores. This suggests that senior high school students are more likely to feel frightened or anxious, experience flashback reactions associated with the event, and manifest symptoms of arousal. The immaturity of the cognitive process in younger children can make them less susceptible to recurring intrusive thoughts and other cognitive impacts of trauma [42, 43]. A maladaptive cognitive style in adolescents and older children may compromise their ability to regulate emotions, rendering them more vulnerable to PTSD [44].

Based on the regression analysis, we found that the occurrence of cold-related symptoms within one month of participating in the survey significantly influenced stress response. Based on studies of the spread of various viruses, psychosocial factors are related to infection rates. C-reactive protein (CRP) is an acute-phase reactant downstream of the pro-inflammatory cytokines released during influenza infection [45]. Studies have shown that a marker of peripheral inflammation, plasma CRP, may be prospectively associated with PTSD symptom emergence, suggesting that inflammation may predispose to PTSD [46]. On the other hand, the increasing number of patients and suspected cases, and the increasing number of outbreak affected provinces and countries have elicited public worry about becoming infected [47]. As we know, the most common symptoms associated with COVID-19 are fever, cough, dyspnea, expectoration, headache, and myalgia or fatigue [48]. This is similar to the symptoms of the common cold [49]. Particularly, the relevance of perceived threat for health and life and the experienced feelings of vulnerability as mediating factors [50]. It was reported that mental health symptoms may have been common during the COVID-19 outbreak among the general population in China, especially among infected individuals, people with suspected infection, and people who might have contact with patients with COVID-19 [51]. This is consistent with our research results.

Although previous studies have explored the impact of the SARS epidemic on mental health, this is the first study addressing the post-traumatic symptoms of COVID-19 on children and adolescents. Using a relatively large sample ranging widely in age, we conducted a cross-sectional study of the psychological stress status of students who were not from Hubei province at one month after the outbreak of COVID-19 in China [19]. However, this may have caused a bias since the participants were selected from schools in certain regions in China, resulting in findings that may not be generalizable across all children and adolescents. In addition, the survey involved substantially more high school students than primary school students. No strict sampling was another bias of our research, but it was really difficult and almost impossible to do so in COVID-19 crisis.

Even though the timing of the survey may help identify participants who require psychological and clinical intervention, the cross-sectional design meant that we could not assess how persistent the post-traumatic stress symptoms are. Besides, the external validity of our survey is limited, the reasons are: Firstly, most of our samples were from Sichuan. Secondly, we did not use strict sampling and used only online self-rating method without structured mental health examination. These may reduce the representativeness and reliability of the results. But it was really difficult to conduct doctor rating scale and structured mental health examination in COVID-19 pandemic crisis. Lastly, our questionnaires were filled in voluntarily. Only those students whose parents would like to let their children fill in would fill in our questionnaire. In this way, parents and students who were not interested in mental health problems couldn’t be included. This, however, is also a feature of this survey as in a natural state, parents and students interested in their mental health were investigated. Our findings also may have some clinical implications for identification of children and adolescents with high risk for psychological stress after COVID-19.

Conclusions

In conclusion, our results showed that COVID-19 has placed psychological stresses on primary and secondary school students in China. These stresses are more likely to reach severe levels among female students and senior high school students.

Availability of data and materials

The data that support the findings of this study are available on request from the corresponding author (Li Yin, yli009@163.com). The data are not publicly available due to privacy or ethical restrictions.

Abbreviations

COVID-19\SARS-CoV-2:

Coronavirus Disease 2019

CRIES-13:

the Children’s Impact of Event Scale questionnaire

PTSD:

Post-Traumatic Stress Disorder

DSM-IV:

the Diagnostic and Statistical Manual of Mental Disorders IV

LR:

likelihood ratio

CRP:

C-reactive protein

References

  1. 1.

    Neria Y, Nandi A, Galea S. Post-traumatic stress disorder following disasters: a systematic review. Psychol Med. 2008;38(4):467–80. https://0-doi-org.brum.beds.ac.uk/10.1017/S0033291707001353.

    CAS  Article  PubMed  Google Scholar 

  2. 2.

    Zeng EJ, Bordeaux Silverstein L. China earthquake relief: participatory action work with children. Sch Psychol Int. 2011;32(5):498–511. https://0-doi-org.brum.beds.ac.uk/10.1177/0143034311402921.

    Article  Google Scholar 

  3. 3.

    Baum N, Rahav G, Sharon M. Heightened susceptibility to secondary traumatization: a meta-analysis of gender differences. Am J Orthop. 2014;84(2):111–22.

    Article  Google Scholar 

  4. 4.

    Furr JM, Comer JS, Edmunds JM, Kendall PC. Disasters and youth: a meta-analytic examination of posttraumatic stress. J Consult Clin Psychol. 2010;78(6):765–80. https://0-doi-org.brum.beds.ac.uk/10.1037/a0021482.

    Article  PubMed  Google Scholar 

  5. 5.

    International Federation of Red Cross and Red Crescent Societies. World disasters report. Oxford: Oxford University Press; 1998.

    Google Scholar 

  6. 6.

    Norris FH, Slone LB, Baker CK, Murphy AD. Early physical health consequences of disaster exposure and acute disaster-related PTSD. Anxiety Stress Coping. 2006;19(2):95–110. https://0-doi-org.brum.beds.ac.uk/10.1080/10615800600652209.

    Article  Google Scholar 

  7. 7.

    Becker-Blease KA, Turner HA, Finkelhor D. Disasters, victimization, and children's mental health. Child Dev. 2010;81(4):1040–52. https://0-doi-org.brum.beds.ac.uk/10.1111/j.1467-8624.2010.01453.x.

    Article  PubMed  Google Scholar 

  8. 8.

    Adams ZW, Danielson CK, Sumner JA, McCauley JL, Cohen JR, Ruggiero KJ. Comorbidity of PTSD, major depression, and substance use disorder among adolescent victims of the spring 2011 tornadoes in Alabama and Joplin, Missouri. Psychiatry. 2015;78(2):170–85. https://0-doi-org.brum.beds.ac.uk/10.1080/00332747.2015.1051448.

    Article  PubMed  Google Scholar 

  9. 9.

    Kenardy J, Smith A, Spence SH, Lilley PR, Newcombe P, Dob R, et al. Dissociation in children's trauma narratives: an exploratory investigation. J Anxiety Disord. 2007;21(3):456–66. https://0-doi-org.brum.beds.ac.uk/10.1016/j.janxdis.2006.05.007.

    Article  PubMed  Google Scholar 

  10. 10.

    Pfefferbaum B. Posttraumatic stress disorder in children: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 1997;36(11):1503–11.

    CAS  PubMed  Google Scholar 

  11. 11.

    Pynoos RS, Steinberg AM, Layne CM, Briggs EC, Ostrowski SA, Fairbank JA. DSM-V PTSD diagnostic criteria for children and adolescents: a developmental perspective and recommendations. J Trauma Stress. 2009;22(5):391–8. https://0-doi-org.brum.beds.ac.uk/10.1002/jts.20450.

    Article  PubMed  Google Scholar 

  12. 12.

    Fairbank JA, Fairbank DW. Epidemiology of child traumatic stress. Curr Psychiatry Rep. 2009;11(4):289–95. https://0-doi-org.brum.beds.ac.uk/10.1007/s11920-009-0042-9.

    Article  PubMed  Google Scholar 

  13. 13.

    Alisic E, van der Schoot TA, van Ginkel JR, Kleber RJ. Looking beyond posttraumatic stress disorder in children: posttraumatic stress reactions, posttraumatic growth, and quality of life in a general population sample. J Clin Psychiatry. 2008;69(9):1455–61. https://0-doi-org.brum.beds.ac.uk/10.4088/JCP.v69n0913.

    Article  PubMed  Google Scholar 

  14. 14.

    Laaser U, Brand H. Global health in the 21st century. Glob Health Action. 2014;7(1):23694. https://0-doi-org.brum.beds.ac.uk/10.3402/gha.v7.23694.

    Article  PubMed  Google Scholar 

  15. 15.

    Cheng SK, Tsang JS, Ku KH, Wong CW, Ng YK. Psychiatric complications in patients with severe acute respiratory syndrome (SARS) during the acute treatment phase: a series of 10 cases. Br J Psychiatry. 2004;184(4):359–60. https://0-doi-org.brum.beds.ac.uk/10.1192/bjp.184.4.359.

    Article  PubMed  Google Scholar 

  16. 16.

    Chua SE, Cheung V, McAlonan GM, Cheung C, Wong JW, Cheung EP, et al. Stress and psychological impact on SARS patients during the outbreak. Can J Psychiatr. 2004;49(6):385–90. https://0-doi-org.brum.beds.ac.uk/10.1177/070674370404900607.

    Article  Google Scholar 

  17. 17.

    Cheng SK, Wong CW, Tsang J, Wong KC. Psychological distress and negative appraisals in survivors of severe acute respiratory syndrome (SARS). Psychol Med. 2004;34(7):1187–95. https://0-doi-org.brum.beds.ac.uk/10.1017/S0033291704002272.

    CAS  Article  PubMed  Google Scholar 

  18. 18.

    Wu KK, Chan SK, Ma TM. Posttraumatic stress, anxiety, and depression in survivors of severe acute respiratory syndrome (SARS). J Trauma Stress. 2005;18(1):39–42. https://0-doi-org.brum.beds.ac.uk/10.1002/jts.20004.

    Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497–506. https://0-doi-org.brum.beds.ac.uk/10.1016/S0140-6736(20)30183-5.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  20. 20.

    Guerriero RM, Pier DB, de Gusmao CM, Bernson-Leung ME, Maski KP, Urion DK, et al. Increased pediatric functional neurological symptom disorders after the Boston marathon bombings: a case series. Pediatr Neurol. 2014;51(5):619–23. https://0-doi-org.brum.beds.ac.uk/10.1016/j.pediatrneurol.2014.07.011.

    Article  PubMed  Google Scholar 

  21. 21.

    Lau JT, Yeung NC, Yu XN, Zhang J, Mak WW, Lui WW, et al. Validation of the Chinese version of the Children's revised impact of event scale (CRIES) among Chinese adolescents in the aftermath of the Sichuan earthquake in 2008. Compr Psychiatry. 2013;54(1):83–90. https://0-doi-org.brum.beds.ac.uk/10.1016/j.comppsych.2012.06.007.

    Article  PubMed  Google Scholar 

  22. 22.

    Perrin S, Meiser-Stedman R, Smith P. The children’s revised impact of event scale (CRIES):validity as a screening instrument for PTSD. Behav Cogn Psychother. 2005;33:487–98.

    Article  Google Scholar 

  23. 23.

    Dyregrov A, Kuterovac G, Barath A. Factor analysis of the impact of event scale with children in war. Scand J Psychol. 1996;37(4):339–50. https://0-doi-org.brum.beds.ac.uk/10.1111/j.1467-9450.1996.tb00667.x.

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    Zhang N, Zhang Y, Wu K, Zhu Z, Dyregrov A. Factor structure of the Children's revised impact of event scale among children and adolescents who survived the 2008 Sichuan earthquake in China. Scand J Psychol. 2011;52(3):236–41. https://0-doi-org.brum.beds.ac.uk/10.1111/j.1467-9450.2010.00867.x.

    Article  PubMed  Google Scholar 

  25. 25.

    Pine DS, Cohen JA. Trauma in children and adolescents: risk and treatment of psychiatric sequelae. Biol Psychiatry. 2002;51(7):519–31. https://0-doi-org.brum.beds.ac.uk/10.1016/S0006-3223(01)01352-X.

    Article  PubMed  Google Scholar 

  26. 26.

    Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open. 2020;3(3):e203976. https://0-doi-org.brum.beds.ac.uk/10.1001/jamanetworkopen.2020.3976.

    Article  PubMed  PubMed Central  Google Scholar 

  27. 27.

    Liu N, Zhang F, Wei C, Jia Y, Shang Z, Sun L, et al. Prevalence and predictors of PTSS during COVID-19 outbreak in China hardest-hit areas: gender differences matter. Psychiatry Res. 2020;287:112921. https://0-doi-org.brum.beds.ac.uk/10.1016/j.psychres.2020.112921.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  28. 28.

    Christiansen DM, Hansen M. Accounting for sex differences in PTSD: a multi-variable mediation model. Eur J Psychotraumatol. 2015;6(1):26068. https://0-doi-org.brum.beds.ac.uk/10.3402/ejpt.v6.26068.

    Article  PubMed  Google Scholar 

  29. 29.

    Alisic E, Jongmans MJ, van Wesel F, Kleber RJ. Building child trauma theory from longitudinal studies: a meta-analysis. Clin Psychol Rev. 2011;31(5):736–47. https://0-doi-org.brum.beds.ac.uk/10.1016/j.cpr.2011.03.001.

    Article  PubMed  Google Scholar 

  30. 30.

    Ma X, Liu X, Hu X, Qiu C, Wang Y, Huang Y, et al. Risk indicators for post-traumatic stress disorder in adolescents exposed to the 5.12 Wenchuan earthquake in China. Psychiatry Res. 2011;189(3):385–91. https://0-doi-org.brum.beds.ac.uk/10.1016/j.psychres.2010.12.016.

    Article  PubMed  Google Scholar 

  31. 31.

    Perrin M, Vandeleur CL, Castelao E, Rothen S, Glaus J, Vollenweider P, et al. Determinants of the development of post-traumatic stress disorder, in the general population. Soc Psychiatry Psychiatr Epidemiol. 2014;49(3):447–57. https://0-doi-org.brum.beds.ac.uk/10.1007/s00127-013-0762-3.

    Article  PubMed  Google Scholar 

  32. 32.

    Hampel P, Petermann F. Age and gender effects on coping in children and adolescents. Journal of Youth and Adolescence. 2005;34(2):73–83. https://0-doi-org.brum.beds.ac.uk/10.1007/s10964-005-3207-9.

    Article  Google Scholar 

  33. 33.

    Tekin A, Karadag H, Suleymanoglu M, Tekin M, Kayran Y, Alpak G, et al. Prevalence and gender differences in symptomatology of posttraumatic stress disorder and depression among Iraqi Yazidis displaced into Turkey. Eur J Psychotraumatol. 2016;7(1):28556. https://0-doi-org.brum.beds.ac.uk/10.3402/ejpt.v7.28556.

    Article  PubMed  Google Scholar 

  34. 34.

    Felmingham K, Williams LM, Kemp AH, Liddell B, Falconer E, Peduto A, et al. Neural responses to masked fear faces: sex differences and trauma exposure in posttraumatic stress disorder. J Abnorm Psychol. 2010;119(1):241–7. https://0-doi-org.brum.beds.ac.uk/10.1037/a0017551.

    Article  PubMed  Google Scholar 

  35. 35.

    Ahmad N, Hussain S, Munir N. A tale of internal displacement: post traumatic stress disorder (PTSD) among school students in swat, Pakistan. Rawal Med J. 2018;43(3):511–4.

    Google Scholar 

  36. 36.

    Vindegaard N, Benros ME. COVID-19 pandemic and mental health consequences: systematic review of the current evidence. Brain Behav Immun. 2020;89:531–42. https://0-doi-org.brum.beds.ac.uk/10.1016/j.bbi.2020.05.048.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  37. 37.

    Yun-Li YE, Ya L, Min C. Trajectory and the related factors of PTSD in secondary school students after earthquake. Chin J Sch Health. 2011;32:166–7.

    Google Scholar 

  38. 38.

    Felton JW, Cole DA, Martin NC. Effects of rumination on child and adolescent depressive reactions to a natural disaster: the 2010 Nashville flood. J Abnorm Psychol. 2013;122(1):64–73. https://0-doi-org.brum.beds.ac.uk/10.1037/a0029303.

    Article  PubMed  Google Scholar 

  39. 39.

    Xu W, Yuan G, Liu Z, Zhou Y, An Y. Prevalence and predictors of PTSD and depression among adolescent victims of the summer 2016 tornado in Yancheng City. Arch Psychiatr Nurs. 2018;32(5):777–81. https://0-doi-org.brum.beds.ac.uk/10.1016/j.apnu.2018.04.010.

    Article  PubMed  Google Scholar 

  40. 40.

    Ulset VS, Czajkowski NO, Kraft B, Kraft P, Wikenius E, Kleppesto TH, et al. Are unpopular children more likely to get sick? Longitudinal links between popularity and infectious diseases in early childhood. PLoS One. 2019;14(9):e0222222. https://0-doi-org.brum.beds.ac.uk/10.1371/journal.pone.0222222.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  41. 41.

    Hoven CW, Duarte CS, Lucas CP, Wu P, Mandell DJ, Goodwin RD, et al. Psychopathology among New York city public school children 6 months after September 11. Arch Gen Psychiatry. 2005;62(5):545–52. https://0-doi-org.brum.beds.ac.uk/10.1001/archpsyc.62.5.545.

    Article  PubMed  Google Scholar 

  42. 42.

    Galea S, Nandi A, Vlahov D. The epidemiology of post-traumatic stress disorder after disasters. Epidemiol Rev. 2005;27(1):78–91. https://0-doi-org.brum.beds.ac.uk/10.1093/epirev/mxi003.

    Article  PubMed  Google Scholar 

  43. 43.

    Guthrie R, Bryant R. Attempting suppression of traumatic memories over extended periods in acute stress disorder. Behav Res Ther. 2000;38(9):899–907. https://0-doi-org.brum.beds.ac.uk/10.1016/S0005-7967(99)00120-5.

    CAS  Article  PubMed  Google Scholar 

  44. 44.

    Ehlers A, Mayou RA, Bryant B. Cognitive predictors of posttraumatic stress disorder in children: results of a prospective longitudinal study. Behav Res Ther. 2003;41(1):1–10. https://0-doi-org.brum.beds.ac.uk/10.1016/S0005-7967(01)00126-7.

    CAS  Article  PubMed  Google Scholar 

  45. 45.

    Vasileva D, Badawi A. C-reactive protein as a biomarker of severe H1N1 influenza. Inflamm Res. 2019;68(1):39–46. https://0-doi-org.brum.beds.ac.uk/10.1007/s00011-018-1188-x.

    CAS  Article  PubMed  Google Scholar 

  46. 46.

    Eraly SA, Nievergelt CM, Maihofer AX, Barkauskas DA, Biswas N, Agorastos A, et al. Assessment of plasma C-reactive protein as a biomarker of posttraumatic stress disorder risk. JAMA Psychiatry. 2014;71(4):423–31. https://0-doi-org.brum.beds.ac.uk/10.1001/jamapsychiatry.2013.4374.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  47. 47.

    Bao Y, Sun Y, Meng S, Shi J, Lu L. 2019-nCoV epidemic: address mental health care to empower society. Lancet. 2020;395(10224):e37–8. https://0-doi-org.brum.beds.ac.uk/10.1016/S0140-6736(20)30309-3.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  48. 48.

    Acter T, Uddin N, Das J, Akhter A, Choudhury TR, Kim S. Evolution of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as coronavirus disease 2019 (COVID-19) pandemic: a global health emergency. Sci Total Environ. 2020;730:138996. https://0-doi-org.brum.beds.ac.uk/10.1016/j.scitotenv.2020.138996.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  49. 49.

    Halstead P, Arbuckle R, Marshall C, Zimmerman B, Bolton K, Gelotte C. Development and content validity testing of patient-reported outcome items for children to self-assess symptoms of the common cold. Patient. 2020;13(2):235–50. https://0-doi-org.brum.beds.ac.uk/10.1007/s40271-019-00404-8.

    Article  PubMed  Google Scholar 

  50. 50.

    Lee SM, Kang WS, Cho AR, Kim T, Park JK. Psychological impact of the 2015 MERS outbreak on hospital workers and quarantined hemodialysis patients. Compr Psychiatry. 2018;87:123–7.

    Article  Google Scholar 

  51. 51.

    Shi L, Lu ZA, Que JY, Huang XL, Liu L, Ran MS, et al. Prevalence of and risk factors associated with mental health symptoms among the general population in China during the coronavirus disease 2019 pandemic. JAMA Netw Open. 2020;3(7):e2014053. https://0-doi-org.brum.beds.ac.uk/10.1001/jamanetworkopen.2020.14053.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

We would like to acknowledge the contribution of all of colleagues and volunteers for their support in this study.

Funding

This work was supported by the National Nature Science Foundation of China (81801357), the Science and Technology Education Program of the Sichuan Province (2020JDKP0013, 2020YFS0259), and the Chengdu Key Technology R&D Program (2019-YF05–00284-SN). The above mentioned funding bodies had no further role in the study design, collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Author information

Affiliations

Authors

Contributions

LY conceived and designed the experiments. HM X, HZ, LJ H, XL W, XW T, YP W, QQ X, PX, RQ J, JZ, FD, MY Y, DL, XJ L, CL Z, WJ W, LL, HM C, WC Z, HP Z, WW helped collect the data. HM X, HZ analyzed the data. HM X, HZ and LY wrote and revised the manuscript. All authors have read and approved the manuscript.

Corresponding author

Correspondence to Li Yin.

Ethics declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of West China Hospital of Sichuan University. The research had been performed in accordance with the Declaration of Helsinki. Written informed consents had been attained from all the participants and their guardians based on the principle of self determination. The participants’rights were fully respected and preserved in the whole process of this study.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Xu, H., Zhang, H., Huang, L. et al. Increased symptoms of post-traumatic stress in school students soon after the start of the COVID-19 outbreak in China. BMC Psychiatry 21, 330 (2021). https://0-doi-org.brum.beds.ac.uk/10.1186/s12888-021-03339-3

Download citation

Keywords

  • Post-traumatic stress
  • COVID-19
  • School students
  • CRIES-13
  • Stress
  • China