Dr John Vijay Sagar Kommu of NIMHANS examines the factors affecting the mental health of children during the pandemic and the role of caregivers and mental health professionals in helping children navigate this ‘new normal’. He recommends a staggered reopening of schools, focussing on extra-curricular activities, to improve children’s well-being.
Based on your research and your experience, what are the top three ways in which the Covid-19 crisis and associated lockdowns have affected the mental health of children?
The Covid-19 pandemic has affected humanity worldwide, causing disruptions in work, the economy, and social life, and has brought a plethora of mental health issues with it. Children constitute roughly 28% of the world’s population and have been dealing with the pandemic in their own way. It has been estimated that the pandemic will have long-term consequences on their emotional well-being and mental health (Liu et al. 2020, Fergert et al. 2019).
The three major ways in which the pandemic has adversely affected the mental health of children include mobility restrictions and disruption of their daily routine; ‘experiential deprivation’, that is, lack of age-appropriate social, language, and cognitive stimulation; and stress related to the Virus.
Is the impact more pronounced for some groups of children (age, gender, or household income) than others, and why?
Although children of all age groups have been adversely affected, certain groups are certainly more vulnerable. These include female children; children from lower socioeconomic backgrounds such as children of daily-wage workers; children of frontline workers, migrants, or single parents; children with neurodevelopmental disorders and mental illness; children staying in childcare institutions, and those living on the street.
There has been evidence of a shadow pandemic, that is, an increase in domestic abuse of women on account of Covid-19 and lockdowns. Do you think there have been similar implications for children?
During the lockdown, CHILDLINE (1098) reported a 50% increase in children reaching out to them for protection from abuse and violence. Approximately 92,000 calls related to child abuse were received within the first two weeks of the onset of the pandemic itself. Children living in abusive homes have had to bear the brunt of the lockdown, as there is no escape from their perpetrators. Unfortunately, the lockdown and subsequent school closure also imply that children do not have the safe haven of their schools anymore, to escape from difficult home environments even for a brief period.
Increased screen time has been repeatedly cited as a detriment to the mental health of children. However, online classes have made it inevitable for children to use digital devices for a prolonged period and this naturally makes it difficult for parents to restrict access. How much of an impact do you believe this has on children, and how can this be dealt with?
Excessive screen time impacts physical health to a large extent. It reduces the time spent on physical activities and can cause Vitamin D deficiency due to decreased sun exposure. It can lead to eye problems (dry eyes, blurred vision, and increased risk of myopia) and headaches. Third, it negatively impacts the circadian rhythm (sleep-wake cycle) by affecting melatonin1 production, especially if screens are viewed at night. We must also not forget the various behavioural addictions that are rampant in the digital era and have risen during the pandemic.
The World Health Organization (WHO) recommends no screen time for children less than two years of age and limiting screen time to a maximum of one hour for children aged 2-5 years. Unfortunately, they do not make similar recommendations for older children. As per the Ministry of Human Resource Development’s guidelines for digital education, “PRAGYATA”, the daily screen time for online lectures has been limited to one session of 30 minutes for pre-primary children, two sessions of up to 45 minutes each for grades one to eight (that is, a total of 1.5 hours), and four sessions of 30-45 minutes for grades 9to 12 standard (that is, a total of 3 hours).
Following these guidelines will help limit the harmful effects of excessive screen time on children and at the same time ensure that they don’t miss out on academics. Parents should try and set up a routine for children and encourage them to pick up hobbies that do not involve the use of screens, such as art, reading, crafts, and play games with them. The 20-20-20 rule – looking at an object at a distance of 20 feet, for 20 seconds, after every 20 minutes of screen time – can also help minimise eye strain.
Given the restrictions on mobility due to Covid-19, what would you suggest are healthy ways to keep children occupied and physically active?
Family time can now include games that parents may not have had time to play with their children thus far. This is an excellent opportunity to reconnect with the family by playing board games, cards, carrom, and antakshari2. In addition, parents have to ensure that their kids do Yoga and simple physical exercises regularly.
How would you recommend maintaining a healthy balance between keeping children abreast of the situation and ensuring that they understand the importance of following precautions, while also preventing them from developing a constant fear of the Virus?
Parents must educate children about common symptoms of a Covid-19 infection and the importance of precautions such as social distancing, wearing a face mask, and regular sanitisation or washing of hands – using simple age-appropriate language. In addition, parents should encourage children to express their feelings. It is natural to experience some degree of sadness, anxiety, or anger during this stressful time. However, suppose there are signs of persistent negative emotions, changes in behaviour, alterations in sleeping and eating patterns, and impairment in age-appropriate day-to-day functioning. In that case, parents must seek help from qualified mental health professionals for a formal evaluation and management of the child’s problems.
Covid-19 and the associated lockdowns affected adults – with heightened anxiety and distress, both due to health and financial concerns. How might this adversely impact parents’ role as caregivers for children, and what measures could parents/guardians take to mitigate this?
The current scenario has indeed resulted in overwhelming psychological distress among adults. As a result, there is an increased risk of the onset of psychiatric disorders, particularly depression and anxiety, and relapse/aggravation of earlier/pre-existing psychiatric illnesses. In addition, psychological distress has a direct, adverse impact on the day-to-day functioning of adults in their role as parents, while carrying out multiple tasks such as supervision of children’s online classes and household chores – alongside working from home, taking care of physical health of self or family members. Specifically, the caregiving role of parents may be affected as they may find it more stressful on account of these changes.
Parents should stay connected with their friends, relatives, neighbours, and mental health professionals (if needed) who can provide psychological support during these difficult times. They must realise that it is normal for any human being to experience negative emotions during the pandemic. Parents should share their experiences with children and allow the children to do the same. They should be good role models in handling fear, uncertainty, and anxiety related to the pandemic.
How do you think the lack of in-person schooling has affected children? Would reopening schools with some Covid-appropriate protocols in place help alleviate the mental health issues children are facing?
During the first wave of the lockdown, UNESCO (United Nations Educational, Scientific and Cultural Organization) estimated that 90% (1.5 billion) of school-enrolled children were out of the educational system all over the world. This disruption was said to be “unparalleled”, as per the UNESCO Director General Audrey Azoulay.
For children with pre-existing mental health issues, the school routine served as a coping mechanism and anchor. In India, many schools supply midday meals, and hence school closure also impacts the nutritional status of children who depend on these meals. Many schools run programmes and counselling sessions for children with emotional issues or academic difficulties. Thus, school closures have deprived children of resources they relied on to a greater extent.
With the closure of schools, we have been forced to shift to e-learning. However due to lack of access to the internet and digital devices, approximately 70% of children have not attended school since March 2020. Lack of a structured schedule due to school closure has impacted the sleep cycle of all children, more so the adolescents. As they now have the ability to watch pre-recorded lectures at any time, children prefer staying up late at night, being active on various social media platforms and attending ‘Zoom parties’ The lack of physical activity and sports means that the body does not tire as much, and this in turn reduces both the amount and quality of sleep. Additionally, an increase in bodyweight may lead to the development of premature obstructive sleep apnoea, excessive daytime sleepiness, diminished attention, and lower cognitive skills.
Reopening of schools in a staggered manner, ensuring proper Covid-19 safety regulations, is the need of the hour. Covid-19 has introduced a lot of uncertainty in our lives. For many children, the biggest uncertainty is perhaps their return to school. It is extremely important for parents to prepare their children and support their return to school – without in fact knowing when that would happen, and in the face of the possibility that schools will close again at short notice.
As children return to school, many may have experienced traumatic personal loss on account of Covid, and others may have seen or heard of tragic events taking place around them. What particular measures should schools be taking to support children?
For children who have had traumatic experiences such as being separated from their parents or having to quarantine due to extenuating circumstances, losing their parent(s) or any close family members etc., the school can provide counselling through a school-appointed counsellor, after consulting the child’s parent or caregiver. These children will require support from teachers for academic activities. Schools can also encourage the formation of parent support groups and peer support groups. Such traumatic experiences can also lead to children developing symptoms of depression, anxiety, post-traumatic stress disorder (PTSD), and behavioural disorders. If any of the above symptoms persist for over two weeks, a formal consultation with a mental health professional is required, for a detailed evaluation and further interventions.
Evidence has shown that in the Indian context, parents tend to prioritise boys over girls in terms of schooling as well as nutrition. Are you seeing any gender-differentiated impacts in these areas/exacerbation of gaps, in the wake of the Covid-19 crisis, potentially also having different mental health impacts on girls vis-à-vis boys?
The Covid-19 pandemic has adversely impacted both girls and boys. The prevalence of developmental delays, behavioural disorders, substance-use disorders, psychotic disorders, and behavioural addictions like gaming addiction is more common in boys. The prevalence of depression and anxiety disorders are almost equal in both genders. However, eating disorders and suicidal behaviour are more common in girls.
Based on my experience and observations, seeking help from mental health professionals early on is more likely for boys than girls. However, to the best of my knowledge, no published study in the Indian context has explored gender-differentiated impacts in help-seeking, adherence to interventions, and outcomes in girls and boys.
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- Melatonin, often referred to the sleep hormone, is released by the pineal gland at night and has been associated with controlling the sleep-wake cycle.
- Antakshari is a music game played in the Indian subcontinent, which involves those playing singing songs that begin with the Hindustani consonant of the last letter of the song sung by the opponent.
Fegert Jorg M, Benedetto Vitiello, Paul L Plener, Vera Clemens (2020), “Challenges and burden of the Coronavirus 2019 (COVID-19) pandemic for child and adolescent mental health: a narrative review to highlight clinical and research needs in the acute phase and the long return to normality”, Child and adolescent psychiatry and mental health. 14: 20. Available here.
Liu Jia Jia, Yanping Bao, Xiolin Huang, Jie Shi and Lin Lu (2020), “Mental health considerations for children quarantined because of COVID-19”, The Lancet Child & Adolescent Health, 4(5): 347-349.