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There are numerous mental health threats associated with the current pandemic and subsequent restrictions. Child and adolescent psychiatrists must ensure continuity of care during all phases of the pandemic. COVID-19-associated mental health risks will disproportionately hit children and adolescents who are already disadvantaged and marginalized. Research is needed to assess the implications of policies enacted to contain the pandemic on mental health of children and adolescents, and to estimate the risk/benefit ratio of measures such as home schooling, in order to be better prepared for future developments.
Fallout 3 Enhanced Children
Coronavirus disease 2019 (COVID-19) is profoundly affecting lives around the globe. Isolation, contact restrictions and economic shutdown impose a complete change to the psychosocial environment of affected countries. The current situation affects children, adolescents and their families in an exceptional way. Kindergartens and schools have been closed, social contacts strongly limited and out-of-home leisure time activities canceled. Parents are asked to support their children with home schooling, while at the same time working from home. External support by other family members and social support systems have fallen away. Beside worries and anxieties related to COVID-19, the economic situation has worsened with high and rising levels of unemployment in all affected countries. This has put a lot of pressure on children, adolescents and their families which could result in distress, mental health problems and violence.
As the pandemic is evolving through phases, this paper evaluates the impact these phases might have on mental health of children and adolescents and the provision of psychiatric services. This paper highlights some key challenges and concerns for treatment and research on child and adolescent psychiatry (CAP) across Europe during the different pandemic phases and offers some recommendations that can be adopted immediately.
Since the pandemic was announced, at the community level, there has been disruption of, or more limited access to basic services, such as kindergarten, schools, and routine medical care [4]. Several countries have seen a re-organization of hospital services, with provisional care (including re-assigning doctors and nurses not usually involved in critical care). There have been closures, partial closures or reduced services of inpatient and day-care facilities, with outpatient contacts reduced in some places to emergency cases only. Some hospitals have been unable to accept new inpatients due to the risk of infection [1]. Questions have arisen on how to deal with the risk of infected patients in closed units infecting staff and other patients. There have been concerns for the possible future lack of adequate resources for mental health services as most resources are directed towards ICU and somatic care [1]. Importantly, even the activity of child protection services and currently existing programs of support or supervision by youth welfare agencies have been disrupted or interrupted [5]. The lack of access to these basic services can be particularly harmful for vulnerable children and/or families.
Moreover, leisure time activities have been limited. In most countries, children have not been allowed to use regular playgrounds, social group activities are prohibited and sports clubs are closed [4]. Social relations have been strongly limited to closest family members. In several countries, contact to peers has been prohibited or severely limited [6]. This can have a negative impact on children and adolescents given the importance of peer contact for well-being [7, 8]. Many countries have experienced a lock-down of schools [9]. As pointed out by a recent review, school closures may not have a major impact on reducing infections and preventing deaths [10]. Hence, possible negative consequences such as loss of education time, restricted access to peers and loss of daily structure need to be taken into account when estimating the advantages and disadvantages of this particular measure. Moreover, in some communities, stigmatization of infected children and families may occur.
At the family level, the pandemic has led to a re-organization of everyday life. All family members have to cope with the stress of quarantine and social distancing. School shutdowns have led to home-schooling and potential postponement of exams. Parents have experienced increased pressure to work from home, to keep jobs and businesses running as well as to take care of schooling children at home at the same time, while caregiver resources including grandparents and the wider family have been restricted. Family connections and support may be disrupted. Fear of losing family members who belong to a risk group can increase. In case of death, the pandemic disrupts the normal bereavement processes of families. Grief and mourning of lost family members, especially in cases where contact with the infected member is restricted or refused, could lead to adjustment problems, post-traumatic stress disorder, depression and even suicide of both, adults and young people [11].
The scarcely available data point towards a detrimental effect of disease-containment measures such as quarantine and isolation on the mental health of children. In a study conducted after the H1N1 and SARS epidemics in Central and North America, criteria for PTSD based on parental reporting were met by 30% of the children who had been isolated or quarantined [34].
In summary, phases one and two of the current COVID-19 pandemic represent a dangerous accumulation of risk factors for mental health problems in children and adolescents of enormous proportions: re-organization of family life, massive stress, fear of death of relatives, especially with relation to grandparents and great-grandparents, economic crisis with simultaneous loss of almost all support systems and opportunities for evasion in everyday life, limited access to health services as well as a lack of social stabilization and control from peer groups, teachers at school, and sport activities.
Together with multiple threats to mental health, the current pandemic could also provide opportunities. When families successfully complete the initial transition phase, the absence of private and business appointments, guests and business trips can bring rest and relaxation into family life. Several external stressors disappear. Mastering the challenges of the COVID-19 crisis together may strengthen the sense of community and cohesion among family members. More time with caregivers can go along with increased social support, which strengthens resilience [39]. In addition, children troubled by school due to bullying or other stressors, can experience the situation of home-schooling as relieving, as a main stressor in their everyday life ceases to exist.
One major challenge after the pandemic will be to deal with its sequelae. One main consequence will be the economic recession and its implications for mental health of children and their families, as discussed above. During the acute phase of the pandemic, stressors such as social distancing, re-organization of family life, school and businesses, fear of COVID-19 infections, and possibly loss of family members/friends are initially in the forefront. Economic problems may be recognized mainly after the acute phase of the pandemic, although their starting point was in an earlier phase. Some parents might have lost their jobs or businesses, while others might have to deal with an accumulated workload or face major re-organization at work. For children and adolescents, the pressure from school to catch-up for time lost during the acute phase of the pandemic may increase. However, there is evidence that rate and direction of change in macroeconomic conditions rather than actual conditions affect harsh parenting [43]. This suggests that the expectation of a negative economic development is a stronger determinant of negative parental behavior than actual recession, which could point towards the conclusion that harsh parenting and violence will have its climax during the acute phase of the pandemic.
Due to interruption of regular medical services, resources in the health care system may not be enough to overcome previous lack of treatment and supervision. Moreover, not only the accumulation of inadequately treated cases, but furthermore the enhanced need for mental health services might be a problem. The increase of mental health problems in children and their families due to recession and quarantine is discussed above and can be expected to further increase in phase three due to emerging recession. Literature suggests that mental health symptoms will outlast the acute phase of the pandemic. In health-care workers, the risk for alcohol abuse or dependency symptoms was still increased 3 years after quarantine [44]. A quarter of quarantined subjects avoided crowded enclosed places and one-fifth avoided public spaces [45].
Additionally, the increased risk of child maltreatment and household dysfunction may not diminish immediately after the pandemic as several triggers such as economic pressure and mental health problems of parents will last for some time. Moreover, sequelae of pandemic-associated increase of maltreatment of children and adolescents may last for a lifetime. Adverse childhood experiences are known to affect the life of survivors across their life span. Long-term effects include increased risk for numerous mental and physical disorders [46], reduced life quality [47], developmental and cognitive impairments [48, 49], social problems [50] and a reduction of up to 20 years in life expectancy [51]. 2ff7e9595c
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