Introduction
COVID-19 as a global pandemic has created new stressors for humans worldwide. The extended period of quarantine increased psychological problems, such as post-traumatic stress symptoms, anxiety, depression, low mood and irritability in adults and children [1]. Meanwhile, people with disabilities, including physical, mental, intellectual, or sensory disabilities, are highly likely to experience worse outcomes and greater health needs during the COVID-19 [2].
In these groups, children and adolescents should be provided with adequate support and may be more sensitive to the psychosocial health effects of the COVID-19 pandemic than others [3], because they are in a golden time of their development. Furthermore, approximately half of all mental health conditions are developed before the age of 14 years. One study performed a systematic review of the prevalence of mental health problems among children and adolescents during the COVID-19 pandemic. Meta-analysis results showed the prevalence of depression was 29%, anxiety was 26%, sleep disorders were 44%, and post-traumatic stress symptoms were 48%. Children and boys had a lower prevalence of depression and anxiety compared to adolescents and girls [4]. Children and adolescents with a background of mental health disorders, such as autism spectrum disorders (ASD), attention deficit hyperactivity disorder (ADHD) and so on, may have more mental health problems during the pandemic [5]. Studies have shown that long school closures, extreme social isolation, and its consequences have caused mental health problems and these factors may have imposed elevated levels of emotional distress [6]. Also, sudden changes in daily routines were associated with various outcomes in children’s mental health [7, 8, 9]. Based on our investigations and findings, most of the available studies in this field are about the typically developing subjects [10]. Therefore, comprehensive knowledge and resources about mental health issues in children and adolescents with developmental disabilities are essential to support them and their caregivers as well as to manage such crises in the future.
The purpose of this review is to determine the prevalence, correlations, and predicting factors of mental health problems in three groups of children and adolescents with developmental disabilities, namely ASD, ADHD, and other developmental disabilities, including cerebral palsy, learning disabilities, Down syndrome, and so on, during the COVID-19 pandemic and their comparison pre- and post-COVID-19 pandemic.
    
Materials and Methods 
This was a scoping review study. Scope review is a type of article review suitable for more general-purpose reviews. Therefore, reports should be different from systematic reviews [11]. The main goal of the research is to study mental health outcomes in children and adolescents with developmental disabilities during the COVID-19 pandemic. We reviewed articles according to the preferred reporting items for systematic reviews and meta-analyses- scoping review guidelines [11]. We included experimental and observational studies published between January 1, 2020, and September 1, 2022. We systematically searched the ISI, PubMed, and Scopus databases. We used MeSH terms and entered the terms into the title/abstract search. The language of the included studies was English. The search terms were as follows: “COVID-19”, “SARS-CoV-2”, “Mental Health”, “Intellectual Disability”, “Developmental Disabilities”, “Learning Disabilities”, “Neurodevelopmental Disorders”, “Autistic Disorder”, “Autism Spectrum Disorder”, “Attention Deficit Disorder with Hyperactivity”, “Cerebral Palsy”, “Stuttering”, “Language Disorders”, “Mental Retardation”, “Communication Disorders”, “Dyslexia”, “ADHD”, “Cognition Disorders”, “Dyscalculia”, and “Agraphia”.
We selected self-report or caregiver report scales that were specifically designed for mental health assessment. In addition, we excluded studies about adults with disabilities or typically developing children. Articles that were not in our research timeline were excluded from the study.
By searching the three selected databases, a total of 883 articles were obtained. Duplicate articles (n=261) were removed. Subsequently, two reviewers independently (Zahra Ghorbanpour, Zahra Nobakht) screened the titles and abstracts of the remaining articles (n=622) in two stages. First, the titles and abstracts of articles were screened. Finally, if the two researchers did not agree, the third researcher (Fatemeh Hassanati) made the final decision.
The articles were divided into three categories as follows: articles about the mental health of children with ADHD, ASD and other developmental disabilities. Tables 1, 2 and 3 shows the results of the selected studies by two reviewers (Fatemeh Hassanati, Fatin Soleimani).




















The extracted data, such as the name of the first author, study design, sample size, age, measurement tools and outcomes included prevalence, correlations, and predictive factors by reporting mean differences, mean percentages, P, odds ratios and so on.

Results
Search results 
We used preferred reporting items for systematic reviews and a meta-analyses flow diagram for searching and selecting appropriate studies. The diagram is shown in Figure 1. 
Characteristics of included studies
Tables 1, 2 and 3 present the characteristics of all 40 included articles [5, 7, 8, 9, 12-47]. The total number of participants in all 40 studies was about 14 212 people without a control group and about 15 279 people with a control group. Six studies (15%) were published in 2020, 24 articles (60%) in 2021 and 10 studies (25%) in 2022. Most studies were published in the United States (n=10[25%]) and Italy (n=6[15%]). Figure 2 shows the distribution of articles published in each continent.
Mental health outcomes among children and adolescents with and without ADHD
The results showed that 22.5% (n=9) of studies provided data about mental health status among children and adolescents with and without ADHD during the COVID-19 pandemic (Table 1). Across most of the studies, the prevalence of behavior problems during COVID-19 was significantly increased compared to pre-COVID-19 [9, 12, 14, 15]. One longitudinal study reported significant change across these time points for every mental health symptom domain. Hyperactivity did not show the change [5] (more details are in Table 1). One study showed no differences in the emotion/worry status in the ADHD group compared with the control group [7]. On the other hand, a few studies reported that about two third of children don’t experience any worsening behaviors [8], or have positive changes in their behaviors [9]. Dvorsky et al. performed a longitudinal study in the spring, summer, and fall of 2020. The results suggested mixed patterns of adjustment during the COVID-19 (Table 1) [13]. The prevalence of moderate to severe anxiety was 14.1% [15] to 81.9% [14] and low anxiety was 18.1% [14] in ADHD. There were significant differences between the ADHD and control groups’ anxiety (P=0.004). Anxiety can affect sleep (P=0.001) and executive functions (P=0.001) [14]. In addition, the prevalence of change in sleep patterns was from 15.4% to 77.5% [14, 15]. Furthermore, the prevalence of inattention, hyperactivity and oppositional symptoms were 73.7%, 66.8% and 38.6%, respectively [15]. Another study revealed that reduced sleep time and increasing the processed food were positively correlated with hyperactivity as well as ADHD symptoms (P<0.01) [15]; however, the reduced exercise was negatively correlated with hyperactivity (P<0.05) [15]. Increasing watching TV and video gaming were positively correlated with inattention (P<0.05) [15]. Some factors predicted the children’s ADHD behaviors, such as the general temperament of children (B=0.17, 95% CI, 0.11%, 0.23%), parents’ general temperament state (B=0.13, 95% CI, 0.06%, 0.20%) and the length of time the child studies (B=−0.09, 95% CI, −0.15%, −0.02%) [12]. Emotion regulation abilities in pre-COVID-19 were predictive of all mental health symptoms before COVID-19 (Table 1) [5].

Mental health outcomes among children and adolescents with and without ASD
According to Table 2, a total of 15 studies (37.5%) provided data about the consequences of mental health among children and adolescents with and without ASD during the COVID-19 pandemic.
Some studies reported a higher level of some emotional status and autistic symptoms in children with ASD during the pandemic relative to the pre-pandemic [17, 18, 27]. One study reported that children with ASD were negatively affected by a change in routines more than three times [18]. Other studies showed that there were more negative mood changes than positive changes [18, 22, 24]; however, one study showed a decrease or no change in the grade of aggression during the pandemic, but this reduction was not significant (P=0.30) [19]. One of the mental health statuses reported in the included studies was anxiety, with prevalence ranging from 12% to 22% [26] that was significantly different between ASD and control groups (P<0.05) [17, 21]. The prevalence of sleep disruption was from 19% to 24% [26]. The findings of the included studies revealed that behavioral problems were correlated with changes in routines (r=0.446, P<0.01), decline in skills (r=0.750, P<0.01), and parental stress factors (r=0.370, P<0.05) [23]. In addition, a higher level of ASD severity be consistent with higher levels of disturbance or stress for ASD individuals [17]. In some studies, stress was higher during the restriction, which corresponded to higher ASD severity scores (P<0.0001), age (P=0.013) [17, 20] and schedule disturbance [24]. Moreover, the stress score was a significant difference between ASD and control groups (P<0.05) [17]. Furthermore, vasa et al. determined the risk factors for increased mental health symptoms that are presented in Table 2 [26].

Mental health outcomes among children and adolescents with other developmental disabilities 
The participants in 40% of studies (n=16) were from various developmental disabilities the mental health of various groups of developmental disabilities such as learning disabilities, intellectual disabilities, genetic syndromes, hearing loss, fragile X syndrome, cerebral palsy (CP), ASD, ADHD and so on. The results are summarized in Table 3.
Several studies investigated the various aspects of emotional and behavioral changes in diverse groups, so achieving a unique conclusion was difficult. The prevalence of sleep change ranged from 18.69% to 69.3% [33, 34, 36, 39, 42]. Parents reported more sleep disturbances in children during the COVID-19 pandemic (P=0.003) [36]. The well-being of children significantly decreases during the COVID-19 (B=−5.05, 95% CI, −6.63%, −3.47%) [36]. Two studies reported that the overall health of the child is affected by COVID-19 ranging from 58.5% [42] to 76.9% [39]. Furthermore, the prevalence of daily routine changes and worse emotions was from 69% to 76.5% [41] and from 42% to 60.61% [32, 33, 42]. 
Guller et al. (2021) investigated the associated factors with emotional and behavioral problems in children with specific learning disorders, intellectual disabilities, and communication disorders (Table 3) [33]. Another study reported that negative mood change was associated with increasing pre-existing abnormal repetitive movements and the incidence of new repetitive movements in children with a chronic condition, learning disabilities, ASD, and multiple conditions [34]. A study reported that stress problems and pervasive developmental problems in children with emotional behavioral disorders aged 1.5 to 5 years old significantly deteriorated. Although, anxiety problem was observed in the group of neurodevelopmental disorders. More details about other groups are provided in Table 3 [31]. A study that included children with mental disorders, reported that age was negatively associated with psychological status. Female gender and depressive symptoms were predictors of psychological distress [36]. One study with various groups of developmental disabilities such as anxiety disorder, ASD, genetic disorders, intellectual disabilities, and obsessive-compulsive disorders reported correlated factors with a child’s well-being, including increased disruption of routines, stress about restrictions, and stress about home isolation (P<0.001) [42]. 
Some studies reported that sleep quality decreased during the pandemic [34, 37, 39, 41]. Dondi et al. (2021) determined the associated factors in sleep disorders that were presented in Table 3 [34]. 

Discussion
This scoping review was regarding the mental health status of children and adolescents with developmental disabilities during the COVID-19 pandemic. The results indicated that COVID-19 and its restrictions impacted psychological behaviors (i.e. anxiety, sadness, psychological well-being), changes in lifestyles (i.e. sleep, eating, relations, exercise, screen time, social media, routines, and coping strategies), and some special symptoms (i.e. hyperactivity, attention deficit, and oppositional symptoms) in children and adolescents with ADHD [7, 9, 12, 15, 16]. These results are consistent with Bobo et al. (2022) [8]. Despite this, the longitudinal studies did not show a stable pattern of behaviors and mental status in adolescents with ADHD during this time [5, 13]. On the other side, some studies reported the deterioration of behaviors and their related factors in children and adolescents with ADHD [5, 12-15]. Individuals with ADHD have poor adaptability to stressful situations, such as COVID-19. Quarantine and staying at home caused a decrease in routines. In addition, they are susceptible to having poor coping strategies. Changes in routines and poor coping strategies may influence their behaviors; therefore, they need more time to adjust to the changes in situations [7]. 
This review also highlighted the presence of several mental health changes such as disruptive behavior, anxiety disorder, irritability, sleep problems, and disruptive behavior in children and adolescents with ASD during COVID-19 [18]. These results are consistent with Narzisi et al. (2013) study in which ASD individuals were more vulnerable to routine disruptions [48], so parents had difficulty managing their children’s activities. The difficulty of managing children’s routines will cause greater stress for parents. Studies showed that routine disruption [24] and parental stress [23] were the predictors of mood change and behavioral problems. Another reason for the increasing autistic maladaptive behavior of these children is an unexpected lack of access to healthcare during the COVID-19 [18].
The certain behaviors observed in individuals with ASD, such as sensory issues, stimming behaviors, and repetitive behavior were worsened [17, 21, 22]. The presence of these behaviors can be a compensatory mechanism against internal or external difficulty, such as anxiety [17, 21, 24]. Younger age was a predictor of appearing positive mood changes and reduction of behavioral problems [22]. It may be because younger children naturally are less aware of the condition than older children. Besides that, establishing new routines is more acceptable and tolerable in younger children [22]. In addition, children with ASD get information about COVID-19 through news, social media, and hearing from family members. Achieving the correct information and understanding the news can be difficult for them, thereby causing some psychiatric problems such as anxiety [26]. Other reasons for increasing psychiatric symptoms in children with ASD included low income, parental depression, and anxiety [26]. This finding is consistent with evidence in other populations during COVID-19 [26, 49]. Breaux et al. (2021) reported that low income was related to increased inattention, and high income is related to increased oppositional symptoms in adolescents with ADHD [5]. Families with low income may be more vulnerable to being jobless, so the level of parental depression and sense of worry may increase the child’s psychiatric symptoms [20]. Furthermore, low family income is associated with difficulty in accessing healthcare services.
In the field of other neurodevelopmental disabilities, one study has shown a higher prevalence of emotional and behavioral problems (64.1% and 77.1%) in ASD and (51.5% and 61.2%) in ID groups during the COVID-19 [33]. Previous studies reported fewer emotional and behavioral problems (about 50%) in children with ASD and ID [50]. According to the Guller et al. (2021) study, the disruption of sleep routines is a key predictor of emotional and behavioral problems [33]. Poor quality sleep has negative effects on behavioral and emotional symptoms, especially in children with neurodevelopmental disorders [51]. In addition, school closures and social isolation disrupted children’s daily patterns, which reduced the quality of children’s sleep [33, 34, 39], a poorer diet [39], reduced physical activity, and increasing the use of social media, TV and gaming [39]. Another reason for the decrease in their mental health status could be the homeschooling [42] and inaccessibility to facilities and specialist teams such as the rehabilitation team [44].

Limitations
In this review, we found some shortcomings in the existing studies; Most of the studies focused on ASD and ADHD. We suggested that more specific studies on unique groups of developmental disabilities are essential; Most studies were cross-sectional; Therefore, future longitudinal research is needed to increase knowledge and examine the long-term effects of the epidemic on the mental health of children and adolescents with developmental disabilities. In addition, a systematic review is useful to obtain detailed information in this field.

Conclusion
The present scoping review showed that most children and adolescents with developmental disabilities experienced deterioration in their mental health status due to restrictions during the COVID-19 pandemic. Facilitation of access to rehabilitation and educational services, and parental training is essential to manage these stressful situations. In addition, the role of financial issues in managing mental health problems and increasing the well-being of children and adolescents and their caregivers is crucial. Governments and policymakers should think about long-term post-COVID-19 psychological consequences and provide proper intervention support for vulnerable groups and their families.

 Ethical Considerations
Compliance with ethical guidelines
This research was approved by the Ethics Committee of the University of Welfare and Rehabilitation Sciences (Code: IR.USWR.REC.1400.314).

Funding
This article was financially supported by the University of Welfare and Rehabilitation Sciences (Grant No. 2871).

Authors' contributions
Idea of the article: Farin Soleimani; Conceptualization and writing–original draft: Fatemeh Hassanati, Peymaneh Shirinbayan and Somayeh Amiri-Arimi; Record screening and extraction: Zahra Ghorbanpour, Zahra Nobakht and Farin Soleimani; Methodology: Mohammad Saatchi; Final approval: All authors.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors of this article are grateful for the financial support of the University of social welfare and rehabilitation sciences for this project.



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