A ‘parallel pandemic’: The psychosocial burden of COVID‐19 in children and adolescents

Abbreviations

COVID‐19

Coronavirus disease of 2019

SARS‐CoV‐2

Severe acute respiratory syndrome coronavirus 2

The widespread restrictive measures used to control the transmission of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection include but are not limited to social distancing and temporary shutdown of schools, companies and recreational facilities. These dramatic shifts in lifestyle implemented in a short time‐frame have inadvertently exposed a darker social scenery that challenges the well‐being and development of a generation of children and adolescents globally. The pandemic has stretched the capacity of healthcare providers and home caregivers in resource‐rich and resource‐limited economies, leaving many children in circumstances that offer limited physical, infrastructural, emotional and social support. Examples of lifestyle changes include replacement of in‐person schooling with virtual education, loss of social interaction with teachers, friends, and peers, cessation of extra‐curricular activities, and virtual graduation replacing in‐person ceremonies. There is also considerable anxiety among high school, college and university students in their final years about future employment prospects as a result of the global economic downturn. ¹ The consequences of this ‘parallel pandemic’ have been more acutely felt among children and adolescents living in poverty, particularly those from marginalised social groups or minorities.

School closures were one of the initial actions undertaken in several countries to control the spread of the virus. Currently, there are no data on the effect of this appropriate intervention on SARS‐CoV‐2 transmission control; however, it is highly likely that this measure has had an adverse impact on the nutrition, education, safety and mental health of vulnerable children and adolescents, particularly those from impoverished households. ² Several programmes, such as the United States Department of Agriculture (USDA), National School Lunch Program, School Breakfast Program and Child and Adult Care Food Program, that provide food on a daily basis to approximately 35 million children in the United States have now been interrupted. ³ Moreover, the rate of unemployment in the United States has risen significantly from 10.3% to 14.7% in April 2020, becoming the highest unemployment rate since the Bureau of Labor Statistics started registering this rate in 1948. ⁴ As a consequence, several children and adolescents, who are financially dependent on their immediate relatives, may have been forced to reduce their daily food intake.

Another direct consequence of school closure is educational under‐achievement. Several institutions have provided computers and online education on current curricula as a means to compensate for school closure. In the United States, this approach has not been uniform across school districts resulting in significant numbers of students having limited access to educational resources on line. These limitations are apparent in rural areas and among children from impoverished backgrounds in urban settings. Outside the United States, according to the Italian National Institute of Statistics, in the poorest regions of the country, 41% of the households do not count with computers or tablets, ² and only 14.3% of families with at least one child could access distance learning. ² In addition, one in seven children lacked internet access at home. Several parents facing their own socioeconomic stressors during the pandemic often lack the resources or time to support remote learning. ⁵ The SARS‐CoV‐2 pandemic has therefore exposed a lack of global access to virtual education.

Several countries have been in ‘lockdown’ with the purpose of ‘flattening the curve’ for new SARS‐CoV‐2 infections. As a result, children are at home for longer periods of time. Although home should be the safest place for a child, sexual, psychological and physical abuse can occur. Rates of domestic violence and partner abuse have increased globally impacting women and children most often. ⁶ A report from Brazil showed an alarming rise (40%‐50%) in domestic violence, and in one region of Spain, the government reported that calls to the helpline increased by 20% in the first days of confinement. ⁶ Identifying children and adolescents at risk was especially important during clinical visits, but many medical facilities have themselves been closed during lockdown. As measures are relaxed in many countries, asking direct questions on safety at home will be a key strategy to screen patients at risk of or experiencing domestic abuse. ⁶ Other important interventions for families include offering mental health resources, contact or emergency numbers, and counselling. Examples include guidance from Mental Health America (MHA), who have provided or hyperlinked national hotlines on suicide prevention in LGBTQ youth, domestic violence and assistance with food insecurity during the pandemic. ⁷ However, politicians, and lay and social media can also serve as a source of misinformation ⁸ and stigmatisation. Examples include a recent increase in racially motivated hate crimes towards individuals of Asian origin in the United States. ⁹ It is essential to identify misinformation and to carefully select and provide evidence‐based guidance that not only mitigates spread of the virus but limits dissemination of hate.

Psychosocial distress, including depression, can result from social isolation and quarantining. A recent study from China showed that the most common psychosocial and behavioural problems among 320 children and adolescents (168 girls and 142 boys) aged 3 to 18 were inattention, clinginess, distraction and fear of asking questions about the pandemic. ¹⁰ The rates of fear and anxiety were higher in children living in highly endemic areas. ¹⁰ In addition to MHA, the Centers for Disease Control and Prevention (CDC) has provided guidance and resources on these co‐morbidities, in order to help families cope with children and adolescents who exhibit behavioural changes during the pandemic. Strategies on stress management include meditation and continuing to be socially active by distancing using video chats. ¹¹ Given the potential extent of a parallel mental health pandemic, it will be important for medical providers to screen for the psychiatric and psychosocial effects of social distancing and quarantining on families as they resume their lives. The impact of death or disability or long‐term separation of close family members and friends on children also needs to be promptly recognised and managed sensitively.

Although children and adolescents may exhibit milder clinical manifestations of COVID‐19 compared to adults, the burden of this pandemic is not limited to the clinical manifestations of disease. Instead and more significantly, the short‐ and long‐term effects of the ‘parallel pandemic’ in this age group can go overlooked and unaddressed. A proactive approach to screening children and adolescents, and offering appropriate management strategies that address mental health will be key to helping rebuild resilience and emotional intelligence, during their transition to life after lockdown.

CONFLICT OF INTEREST

The authors have no conflict of interest to disclose.