The most talked phenomenon and sui generis of the modern time, the coronavirus diseases-2019 impacted individuals in a variety of ways. Older adults had a higher risk of vulnerability, while there were negative ramifications among children due to indirect impact. The preventive measures, including closing down of schools, malls and playgrounds as well as practising social distancing served as a shield against the hazard of outbreak. On the contrary, these strategies inculcated fear, anxiety, ambiguous communication and manifestation of externalizing behaviours in children. Children living in dysfunctional families in underprivileged circumstances were more susceptible to abuse during the pandemic, and had increased risk of behavioural symptomology and psychological morbidities. Challenges brought by the new normal for children requires redefining the role of parenting for effective monitoring and intervention to mitigate the symptoms. Preventive strategies outlined by international scientific communities include reflective listening, debriefing and psychological first aid for effective parenting during the ongoing pandemic.
Keywords: Children, Anxiety, Appetite, Sleep, Mental health, COVID-19, First aid.
Opening of schools would lead to recovery of routines that was disrupted in March, 2020 as the World Health Organisation (WHO) declared the coronavirus disease-2019 (COVID-19) as a pandemic. COVID-19, as the most addressed and talked about phenomenon of the modern era, has been conceptualised and conceived differently by all age groups. The trajectory of uncertainty stemming from epidemic and infodemic globally impacted human lives.1 COVID-19 affected individuals regardless of age, race, gender and socio-economic status. Moreover, children conceptualised COVID-19 in a fearful manner due to social seclusion, disruption of routines and repetitive warning related to the epidemic.2
In 193 countries, schools and educational institutions were closed at national or local levels, impacting 99.4% of the students' population worldwide due to lockdowns.3 According to an estimate by the United Nations Educational, Scientific and Cultural Organisation (UNESCO), around 1.38 billion children are affected due to school closure, unable to access group activities, social interaction or playgrounds. The routines and education for 1.5 billion children got disrupted due to COVID-19.4
Impact on social development of children
Child developmental stages are crucial in reference to their effective communication and its significance amplifies in times of crisis.5 Communication with children that lack emotion-focussed conversation increases vulnerability of apprehension regarding the safety of their family and the loved ones. This state of apprehension generates unconscious pattern of avoidance and hesitation in sharing their fears in order to shield them by turning to silence.6 Unspoken pain and psychological tension among children start to build a toll which manifests itself later in the form of externalising behaviours. It could be depiction of pain and stress not dealt through effective communication.
Children are more vulnerable against environmental risk factors during the initial developmental years as this sets the milestones for prospective physical, psychological and social wellbeing. When children are exposed to trauma in terms of environmental circumstances at a younger age, they are likely to face consequences in terms of emotional and neurobiological dysregulation along with mental health issues. A longitudinal study reported that adverse childhood experiences were associated with long-lasting detrimental impact. The findings demonstrated that approximately 64% of participants experienced one-time traumatic exposure, and 69% reported twice or more incidents of past childhood trauma. Childhood trauma is associated with high-risk behaviours, chronic illness as well as early death.7 To prevent these detrimental consequences, it is important to be aware of the aetiological factors as well as the warnings associated with such triggers.8
There is scarce literature on impact on children in the wake of pandemic-induced partial and prolonged lockdowns. The quarantine state interacted negatively with lifestyle, causing psychosocial stress. Home confinement exacerbated detrimental effect on the physical, social as well as psychological wellbeing of a child consequently into a vicious cycle of maladaptive behavioural immune system.9 Indirect effect of the pandemic on children exhibited in terms of emotional, psychological impairment along with the onset of psycho-pathologies associated with the aftermath. The reported behaviour of children due to social distancing and quarantine included sedentary behaviours, procrastination, somatic issues, dysregulated eating and sleeping patterns, etc.10,11
Fear and uncertainty
Children during the pandemic constantly listen to content that has illness, ambiguity, alarming news and stress-related sub-text. There could be serious repercussions due to marked deprivation of social stimuli as they are unable to play or socialise. Traumatic events, emergencies and disasters increase probability among children for emotional and cognitive impairment and psychopathology. Previous researches reported that 30% of health-related disasters fulfill the criteria for post-traumatic stress disorder (PTSD).12 Long-term future of children, especially those from the marginalised groups, like orphans, child labourers, the disabled, in underdeveloped countries, or part of ethnic, racial and sexual minority, like females, would encounter further decline in the domains of health, education and safety.
Externalising behaviours and clinical manifestations in children
In times of crisis, externalising behaviours and psychological dysfunctionality among children seeking clinical attention were found to be correlated with psycho-social stressors. The frequently reported clinical symptoms were reduced appetite, hindered interaction, lethargy, anxiety as well as depression. The cognitive functioning was fraught due to stress which increased fear, frequent nightmares, low mood, somatic complaints, attention deficit, nail-biting, bed-wetting, emotional disturbances along with PTSD criterion.13,14 This highlights the negative impact brought by stress encountered by children and its manifested behaviour symptomatology that could intensify if not addressed.
As the children have little voices to advocate their needs, they mostly remain unheard and neglected emotionally as they are indirect victims of pandemic compared to the adults. The European Paediatric Association-Union of National, European Paediatric Societies and Associations (EPA-UN-EPSA) came up with a publication, demonstrating that children aged 3-18 years manifested symptoms related to clinginess and fear of family members getting infected by COVID-19, whereas the symptoms frequently reported among older children were disturbed sleep patterns, distress, separation-related anxiety, nightmares and inattentiveness along with constant inquiring about the pandemic. The types of symptoms manifested by children were quite a few (Figure).15
Social isolation, home confinement and school closure completely changed the life of children in the acute phase of the pandemic. Scant attention was given to how they were feeling and thinking about the new phases of progressive reduction of lockdowns. Prolonged quarantine impact on quality of life among children augmented uncertainty which has not been focussed so far16. Existing studies have focussed on the direct effect caused by the pandemic during the acute phase while expecting that the situation will get normalised as the quarantine situation subsides.
Long term impact of COVID-19 on psychological health of children
A World Health Organisation (WHO) report has urged that all stakeholders, including, parents, governments and schools, should focus on adopting a holistic strategy and try to prevent the pandemic's long-term impact on children's physical and mental wellbeing.17
In the current circumstances, the focus should be on effective open communication among parents and children as this can play a vital role in this crucial stage and can prevent irrevocable consequences.18 The concept of open communication is not a widespread and acceptable approach in Asian societies. The approach, if adopted, would lead towards a strong bond between parents and children, and it will be easier to identify the behavioural changes associated with stress in the current circumstances. In an extremely stressful situation, a secure family environment created by parents is an imperative protective factor. The parental coping practices play a vital role in children's post-disaster psychological wellbeing.19
Mental health intervention
The constant theme the children have been hearing throughout this pandemic is death, illness and disease. Early and timely interventions may stave off a mental health crisis. The strategy adopted in dealing with post-disaster trauma should be synchronised with the developmental age of the child. The acronym of 4As can be used by parents, care-givers and teachers to help the children in managing as well as preventing long-term consequences.
i. Awareness: Norwegian Prime Minister Erna Solberg prompted hope and awareness by saying, "It's OK to be SCARED", in a conference comprising only children.20 It is crucial to listen to what children believe about COVID-19 and risk factors, providing children with an accurate yet simple explanation that is meaningful while ensuring that they do not feel unnecessarily alarmed or guilty.
At first, it is crucial to make children aware about COVID-19 through simple terminologies and guiding basic preventive measures to curb the risk. Children should be guided about the disease through simple presentation or through WHO or UNSECO websites. Animated cartoons, pictures and group discussions shall be part of the drill once schools open.
ii. Attention: Secondly, children in any stress prone situation require more reassurance than routine. Parents need to attend to children through their presence and by devoting time to them.21 Parents should be attentive towards the behavioural signs which are deviating from the usual pattern of the child. If they can identify signs like clinginess, nail-biting, bed-wetting, etc. at an earlier stage, rectifying them would be easier. The second objective, apart from addressing psychological needs, is to keep a log and monitor any unusual behaviour, emotion or activities exhibited by the children.
iii. Acceptance: Parents should make children accept the emotional state experienced by them during the pandemic. In routine, parents or siblings usually shun away the complaint or apprehension reported by children or make them believe that stress and tension would go way on their own. Parents should make children learn how to accept the vulnerability, stress and anxiety felt or reported. These are most reported when children are about to sleep alone or scared. Teaching coping behaviours by accepting these thoughts would lead towards adaptive functioning.
iv. Alleviating stress and inconsistency from routine: Lastly, by alleviating stress and inconsistency in routine, it is important to make children practice a healthy routine regarding attending online classes, using screen or sleep patterns. Children must have limited exposure to news in this uncertain situation and, if needed, only fact-based simple information shall be shared with them.22 The lesser inconsistency would lead children to exhibit high productivity and optimal adaptive functioning. The routine regarding meal times and sleep must be rigorously followed.
The distal stressor and proximal family processes entail an interplay and impact the mental health of children. It affects both the pathways and trajectories within children since the time the pandemic was declared.23 Meyer's triage serves as foundation for scientific communities and support services to develop and devise strategies in the face of emergencies.24 It encapsulates preparedness, resilience and response factors. On the basis of this triage, the following recommendations are made to cater to mental health issues among children:
1.Psychological First Aid: The first level of intervention is to screen out and identify vulnerable children. Children exposed to direct or indirect trauma of the pandemic develop fleeting psychological responses. This psychological first aid is modified by experts as low-intensity and high-intensity interventions. The revised strategy involves contacting and engaging children into supportive counselling by clinical practitioners, parents and teachers.25 The aim is to reduce the distress resulting from acute to prolonged epidemic and to foster adaptive functioning.
2. Debriefing: It involves prevention from psychopathology in trauma-exposed children. It serves as an effective tool if implemented in a group form with children reporting similar clinical manifestation, like nightmares, obsessive compulsive tendencies, bed-wetting etc. In groups they confront their fear, share feelings and serve as support for others. Due to the current risk of the pandemic, it could be administered through virtual groups. Psychological debriefing has not been effective if provided individually.26
3. Structured psychotherapy: In response to prolonged lockdowns, if children develop any psychiatric symptoms, structured psychotherapy needs to be pursued immediately.27,28 Supportive counselling would be the best in the current epidemic as the effects in children are less acute and indirect.
With the surge of one wave after another in Pakistan and deteriorating conditions in neighbouring India, it has become all the more important to collect and publish data on psychological indicators of mental health problems among children. In the context of calamity, there is high probability that children's mental health could be disproportionately affected and overlooked. Telehealth services, scientific communities, parents and teachers can provide as enormous relief in mitigating the challenges faced by children during COVID-19. By talking to children at age-appropriate level about preparedness, resilience and response can save them from psychological vulnerability and harmful effects. It is important for the helpers to initially comprehend the anxieties and questions children are struggling with. By administering psychological first aid, debriefing and structured psychotherapy, mental health issues could be monitored and curbed in uncertain conditions and prolonged lockdowns. Prolonged lockdowns may affect children in acute or chronic externalising behaviours or maladaptive cognitive patterns. In any such scenario, parents need to closely monitor changes. The 4As could serve as the basic primary intervention for parents, caregivers and teachers to address the commonly reported symptoms among children to ensure their adaptive functioning and coping.
Acknowledgement: We ae grateful to all the international and national researchers as well as to parents and teachers for sharing their concerns and observations regarding children during the pandemic.
Conflict of Interest: None.
Source of Funding: None.
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