Yasmin Haque, UNICEF Representative in India, outlines the evidence on the severe impact of the pandemic on the mental health of children and adolescents – particularly girls, and the measures being taken by UNICEF and its partners to provide support.
Based on your research and 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 brings with it increased psychological distress for children, adolescents, and young people due to the fear of losing a loved one and getting infected themselves, economic distress of family members, increased incidences of gender-based violence (GBV), disruption of their routine, stress and loss of learning, recreation and social interactions with friends, and school closed for over 15 months.
A UNICEF (United Nations Children's Fund) U-Report poll of 16,527 young people (31% girls, 67% boys, and 2% others) in South Asia, about their feelings on Covid-19, highlighted that the pandemic has been experienced differently by girls and boys. Girls reported that they had less access to internet than boys. Girls also felt more restricted to their homes (13%) than boys (5%), and adolescent boys felt more economic stress (44%) than girls (36%) possibly due to their gendered needs and expectations from them to provide for their family. Girls being more restricted to homes had to contribute more to housework with little or no opportunities for economically productive work. One in five young people who participated reported the need to focus on psychosocial care and access to professional mental healthcare for young people. Those with pre-existing mental illness, or those who are exposed to violence and abuse face greater risk.
Covid-19 lockdowns and mobility restrictions also meant lack of access to child protection and mental health services. Even before the pandemic, it is estimated that at least 50 million children and adolescents are affected by mental health issues, and 80-90% of them never seek treatment (Hossain and Purohit 2019). According to WHO (World Health Organization), half of all mental health conditions start by age 14, but most cases are undetected and untreated. Another indication of the mental health burden among adolescents and young people comes from high rates of suicide in this age cohort. A Lancet Report (Patel et al. 2012) found that suicides were the second leading cause of death in the age group of 15-29 years in India. Every hour, one student commits suicide in the country, with about 28 such suicides reported every day, according to data compiled by the National Crime Records Bureau (NCRB) (NCRB, 2018, NCRB, 2019).
Is the impact more pronounced for some groups of children (age, gender, or household income) than others, and why?
We have some evidence to say that girls and boys have been impacted differently, not only in terms of access to online platforms and education resources, but also in sharing the burden of household work (UNICEF, 2020a). While we do not have concrete data and evidence on how mental health and overall psychological well-being have been impacted differently, it can be safely deduced that girls have had a tougher time because of increased incidences of GBV and burden of care.
The pandemic has also disproportionately impacted the most marginalised groups, including families and communities from minority groups, Scheduled Castes and Tribes (UNICEF, 2020b). Covid-19 also severely impacted migrant workers and their families. With almost 90% of India’s workforce being informal, around 400 million workers are at risk of falling deeper into poverty during the crisis. A rapid assessment of the situation of migrant workers undertaken by UNICEF in the states of Uttar Pradesh and Bihar, revealed that over 70% of migrant workers faced challenges in accessing the government’s social protection schemes and other Covid-19-specific benefit packages due to lack of documentation; 31% of migrant families experienced stigma or discrimination after returning to their native places (UNICEF, 2020b). All these factors added to the psychological distress of the adults, and had an even greater impact on children and adolescents.
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?
Children are impacted directly and indirectly by domestic violence, both as witnesses and victims. While we do not have concrete data, it is apparent that risks of all forms of violence against children, as well as other harmful practices like child marriage and child labour, have increased manifold since the pandemic. During the initial weeks of the national lockdown (March 2020), CHILDLINE reported 50% increase in calls of children in distress. This is an indication of children facing difficult circumstances, in the form of violence, abuse and neglect.
Covid-19 has exposed and exacerbated gender inequalities – nowhere more evident than in the increased risks of GBV against women1.
The National Commission for Women (NCW) noted a more than two-fold surge in recorded complaints of violence against women and girls since the imposition of lockdown in the country.
These incidences are bound to have serious mental health consequences for both women and children – increasing stress and anxiety, and causing other serious mental health problems. For most, these symptoms are mild and transitory, but some may develop severe and long-term mental health issues that require additional mental healthcare and support.
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 can has on children, and how can this be dealt with?
The Covid‑19 crisis has fostered widespread digitalisation. However, greater use of digital tools has its downsides – the quality of home-schooling and social contacts may be lower than through school or contact in person. Increased digitalisation can also magnify risks such as sexual exploitation and cyber-bullying, if internet use is increasingly unsupervised. UNICEF U-Report poll (2019) shows that one in three children in India reported being bullied online. Of these, more than half the respondents were not aware of services to report online violence. According to NCMEC Cybertip reports India accounts for nearly 12% of the global child sexual abuse material in circulation.
Moreover, increased digitalisation is likely to widen inequalities between children, as the poorest children are least likely to have tools to access online education and a quiet place in their home to concentrate on their studies.
Given the restrictions on mobility due to Covid-19, what would you suggest are healthy ways to keep children occupied and physically active?
It is very important to create a space within the family and community where children can be positively engaged in activities that promote social and emotional well-being. UNICEF has worked with partners including CHILDLINE, other civil society organisations, and frontline government functionaries, to develop simple age-specific tools for psychosocial education that enable parents and caregivers to understand the mental health needs of children, and undertake easy activities to reduce their stress and anxiety. This includes interactive activities, exercises, and healthy coping mechanisms that help both parents/caregivers and children. We have used digital platforms as well as direct interaction to orient parents, caregivers, children, and adolescents, reaching over 440,000 individuals across 17 states.
However, in a situation like the current pandemic, only positive engagement and physical activities are not enough to address the grief, anxiety, and fear faced by children. The second wave of Covid-19 was more devastating for India, as many children lost either one or both parents and other loved ones. UNICEF worked with NIMHANS (National Institute of Mental Health and Neuro Sciences) and other partners to provide grief counselling as an immediate response. Messages and materials were developed for immediate caregivers on how to support children in processing grief. At the same time, UNICEF worked with state governments to implement special social protection measures, and promote family-based alternative care2.
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?
There are age-specific simple tools and materials developed by UNICEF, which help parents and caregivers in communicating the importance of observing Covid-19-appropriate behaviour to children. It is important to promote an environment where children feel safe, and one that prevents stigmatisation. UNICEF proposes a three-fold strategy for communicating with children: (i) Listen: Give children opportunities to talk about what they are feeling. Encourage them to share their concerns and ask questions. (ii) Comfort: Use simple tools to comfort and calm children, for example, telling stories, singing with them, and playing games. Praise them frequently for their strengths, such as showing courage, compassion, and helpfulness. (iii) Reassure children that you are well-prepared to keep them safe. Provide them with correct information through valid sources in a language that they understand.
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?
It is expected that a prolonged economic downturn due to Covid-19 containment measures will lead to a substantial increase in unemployment and decline in earnings3.
Children from marginalised families are likely to be disproportionally disadvantaged by school closures, and face lower access to good nutrition, sanitation, space to play or study, and resources to engage in online schooling. They are also most likely to be at greater risk of child labour, and other protection risks such as a considerable rise in mistreatment by the exacerbation of some known contributing factors such as overcrowded housing, social isolation, intimate partner violence, parental substance abuse and child abuse (Foster and Gehrke 2021).
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?
Apart from Covid-19 appropriate protocols, parents and teachers need support in addressing some of the expected challenges such as loss of routine and learning gap. Teachers would also need special support in observing children’s mental well-being and refer children who need support. UNICEF is working closely with many state governments to provide this support to teachers. Age-appropriate and child-centric communication materials can enable children to both follow and become champions of Covid-10-appropriate behaviour for the ‘new normal’, and also help reduce their stress.
With regard to trauma, what particular measures should schools be taking to support children?
It is important that both parents and teachers are provided with the skills to recognise and understand the symptoms of traumatic experience in children and their overall well-being. We need to train teachers to assist children in re-aligning with the school routine and learning objectives in a sensitive and age-appropriate manner. At the same time, it is important to strengthen the referral system for child protection and mental health services so that those who need these may be able to access smoothly5,
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 versus boys?
Before Covid-19, India already had 30 million out-of-school children, out of which 40% were adolescent girls. Evidence also indicates that girls from marginalised communities are more likely to drop out of schools. Additionally, remote learning poses the risk of aggravating gender gaps, given the limited access of girls and women to smart phones and internet6, coupled with increasing burden of household chores and care work. Further, the increases in economic hardships due to Covid-19 puts girls at a higher risk of GBV and child marriage (Cousins 2020).
Micronutrient supplements and deworming which children receive at school are essential to tackle anaemia. All these provisions (meals, health and nutrition services (Chakrabarti et al. 2021), and physical activities and education) have collapsed due to Covid-19. UNICEF’s internal rapid assessments have also validated that the disruption of essential services especially food provisions have had a greater impact on women and girls.
Additionally, the closure of schools along with disruption of essential services, have restricted spaces – especially for girls – to engage with their peers and this can have a severe impact on their mental well-being. A UNICEF U-Report poll and interactions with young people have indicated that girls have fewer safe spaces to manage their mental health needs and access relevant services.
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- The National Family Health Survey-4 (2015-16) indicates that at the national level, 28.8% of ever-married women have experienced spousal violence; 27% of women have experienced physical violence since the age 15 – with physical violence among women being more common in rural than urban areas.
- These include sponsorship, foster care, kinship care, sponsor care, group foster care, and aftercare as part of national flagship programme - Mission Vatsalya
- According to the ILO, the lockdowns in India have adversely impacted the livelihoods of a large proportion of the country's nearly 400 million workers in the informal sector. Job losses are expected for 122 million people in India, causing the unemployment rate to rise to 27% and this will have an adverse effect on children and their lives.
- A rapid assessment conducted by UNICEF and Population Council in the state of Bihar found that 1.8 million migrants returned to the state after Covid-19 lockdown in 2020, of which more than 80% were casual labourers. About half of the migrant labour households lost their entire income. Job losses were relatively higher among the most marginalised population including Scheduled Castes and Scheduled Tribes. About one-fifth of them reported that their primary source of income was from government Covid-19-related assistance, which was not sufficient.
- To address this, there are counsellors and caseworkers available within child care institutions and at district level with child protection unit and child welfare committees. Children who need special attention are referred to district and sub-district medical facilities with mental health services. Nonetheless, these systems need to be strengthened.
- There already exists a 50% gender gap in mobile internet users in India where 21% of women and 42% of men use mobile internet facilities, which is further exacerbated in the pandemic.
- Cousins, Sophie (2020), “2·5 million more child marriages due to COVID-19 pandemic”, The Lancet, 396(10257): 1059.
- Chakrabarti, S, H Alderman, D Gilligan, P Menon and S Scott (2021), ‘The power of school feeding programmes to improve nutrition’, Ideas for India, 4 August.
- Foster, A and E Gehrke (2021), ‘Start what you finish! Risk and schooling investments’, Ideas for India, 19 July.
- Hossain, Md Mahbub and Neetu Purohit, “Improving child and adolescent mental health in India: Status, services, policies, and way forward”, Indian Journal of Psychiatry, 61(4): 415-419. Available here.
- NCRB (2018), ‘Crime in India 2018 (Volume-I)’, Report.
- NCRB (2019), ‘Crime in India 2019 (Volume-II)’, Report.
- Patel, Vikram et al. (2012), “Suicide mortality in India: a nationally representative survey”, The Lancet, 379(9834): 2343-2351.
- UNICEF (2020a), ‘Community Rapid Assessment on COVID-19: Behavioural Findings and Insights from Round 1 in Kenya, Madagascar and South Sudan’, Report.
- UNICEF (2020b), ‘Assess Impact of COVID Pandemic On Socio-economic Condition of Vulnerable Population’, Report.