Abstract
To the Editor.
The COVID-19 Pandemic has grown to define our time. Not only is it the pressing issue we face now, it is also the root of the mental health problems that are expected, after the pandemic is over (Loades et al., 2020). Unlike the physical disease, the mental health consequences are often overlooked (Haider et al., 2020).
In March of 2020, the Director General of the World Health Organization (WHO) officially characterized it as a pandemic saying, ‘Pandemic is not a word to use lightly or carelessly. It is a word that, if misused, can cause unreasonable fear or unjustified acceptance that the fight is over, leading to unnecessary suffering and death’. COVID-19, however, is peculiar as this ‘pandemic’ discriminates between the age groups with a better prognosis in the young. COVID-19 manifests mildly in children and adolescents (Ludvigsson, 2020). However, the mental health problems related to isolation have increased in this age group. The isolation and lack of interaction seem to be an important cause of this increase (Ludvigsson, 2020).
Loneliness
Due to the nature of its transmission, social distancing formed the backbone of the preventive measures. The guidelines recommended by various authorities worldwide recommended the closure of schools, colleges and institutions for the safety of the community (Viner et al., 2020). [5] This lack of social interaction leading to the separation of the individual from the circle of support leads to loneliness (Boivin et al., 1995; Bu et al., 2020; Imran et al., 2020). This difference between the required and the acquired attention is potentiated in the younger age group due to its dependence on social cues for personal identity (Danneel et al., 2019). Young people are at an even greater risk to feel lonely in quarantine (Bu et al., 2020).
The correlation of loneliness and mental health problems including Depression, Anxiety, and Stress are well-established. A Rapid Systematic Review concluded that in the context of quarantine during COVID-19, there was a clear association between loneliness and mental health problems in children and adolescents (Imran et al., 2020). Children are more likely to experience depression and anxiety during quarantine (Rehman et al., 2020). Other stressors, in addition to loneliness, further contribute towards the stress and anxiety levels that are seen to be increased (Rehman et al., 2020). Children worry not just about themselves, but their friends and family. The disruption of the school routine along with enforced isolation creates mental stress from all fronts. The word pandemic itself carries with itself a dread. The extent of the stress that COVID-19 has induced can be realized by the fact that a report published by the Childhood Trust in the UK has included post-traumatic stress disorder (PTSD) in the problems being faced by the youth. This is also evident by the high posttraumatic stress scores in quarantined children (Sprang & Silman, 2013). The weight of the isolation and removal from the social circle is fertile soil for loneliness, the long term consequences of which extend well beyond the isolation itself (Brage et al., 1995).
Post-COVID effects of loneliness
Although the root cause of these problems is the social isolation itself, it is suggested that the burden of this pandemic will be carried even after the physical distancing measures have been lifted. This is supported by the observation that the SARS epidemic in 2003 had long-lasting mental health consequences (Esterwood & Saeed, 2020; Ren & Guo, 2020). The effects of loneliness during quarantine will spill over to the post-COVID era. Longitudinal studies reveal how loneliness is associated with later anxiety as well (Danneel et al., 2019). Similarly, social withdrawal during childhood is associated with mental health problems in later years, notably depression (Boivin et al., 1995). The effects of loneliness in children are exaggerated due to their increased dependence on peer interaction for social identity (Danneel et al., 2019; Imran et al., 2020). Eating disorders are also associated with loneliness in an adolescent (Lasgaard et al., 2011). The risk of self-harm and suicide increases with isolation and loneliness as well, and the COVID-19 crisis may lead to an increase in the rates as well (Sher, 2020). All of the problems mentioned above result from loneliness.
Psychological trauma: Short term
The psychological impact of the pandemic was seen to be greater in the younger age group, comprising of students (Wang, Pan, et al., 2020). Psychological trauma from disasters has been frequently associated with negative effects on mental health (Jacobs & Harville, 2015; Steel et al., 2002). Excessive stress in children is related to decrease memory and imagination, narrow cognitive ability, and weakened learning ability. An altered outlook results in increase focus on the negative aspects. To limit the stress, behavioral changes such as inattention, lack of communication, and laziness were seen (Ye, 2020). Clinging and irritability increased in children of all ages (Jiao et al., 2020).
Psychological trauma: Long term
The long term consequences may not manifest until years later. According to one study, children who experience a natural disaster before their fifth birthday have an increased risk of mental health disorder in adulthood (Maclean et al., 2016). COVID-19 does not only cause an episodic exacerbation of mental illness, but the heightened stress of disasters like COVID-19 can actually lead to the development or diagnosis of mental disorders in at risk individuals without a previous diagnosis (Esterwood & Saeed, 2020). This early childhood trauma can lead to the development of stress-related disorders which can include intrusive thoughts, nightmares, avoidance of reminders of the trauma, self-blame, being ‘on edge’, concern for safety, irritability, and concentration problems (Esterwood & Saeed, 2020).
How to deal with the mental health pandemic
Unfortunately, the guidelines to tackle the mental health problems caused by physical distancing are neither as clearly established nor as widely available as the guidelines for distancing itself (Holmes et al., 2020; Moreno et al., 2020). Irritation, increased anxiety and stress levels are already on the rise (Rehman et al., 2020). The figure below depicts some of the interventions that can be used to mitigate the effects of social isolation and home quarantine for a child.
Parenting
WHO (2020) guidelines recommend a number of different strategies that can be used to mitigate these adverse effects on a child’s mental health.
These guidelines are directed towards the caretaker since the caretaker spends the most amount of time with the child during this lockdown so they are the best judge to assess the behavior of the child (WHO, 2020). They should listen to children and give them extra attention, if need be. Children pick up on the parents’ behavior so positive parenting is crucial when children are quarantined at home (Wang, Zhang, et al., 2020).
Social interaction
As many of the adverse effects on mental health are due to the feeling of loneliness, children should be allowed to socialize virtually with their friends and family (Boivin et al., 1995; Bu et al., 2020; WHO, 2020). This can be done via phone, email, facetime, zoom, or Skype etc. Online games can also be relaxing for the children during these trying times (Imran et al., 2020). Moreover, in multiplayer option gamers could socialize with others and create a sense of community. However, this would require parental supervision in order to prevent cyber bullying, and other activities that exposes children to abuse and exploitation.
Establishing a routine
The loss of the school routine can be particularly worrisome for a child, therefore the establishment of a semi-structured routine can help (Imran et al., 2020).
Counseling
Seeking professional help should never be discouraged. Telehealth itself has come a long way during this pandemic (Machado et al., 2020).
Information
Children tend to worry more when kept in the dark. On the other hand, in this age of social media, it is hard to ensure that they only receive the right information (Gonzalez-Padilla & Tortolero-Blanco, 2020). This is why it is essential that the caretaker pays attention to the child, and asks them how they feel about it (WHO, 2020).
What to avoid
When dealing with social media, one needs to be aware of the panic that it induces (Depoux et al., 2020). Worry and agitation can be limited by lessening the time taken to watch the news. Family members should stay together as much as possible. In case children have to be separated from their parents, for example, hospitalization. In case they have to be separated, for example, hospitalization, a constant contact should be ensured to mitigate the feeling of loneliness (WHO, 2020).
Conclusion
The adverse effects of COVID-19 extend far beyond the physical ailment. Social distancing measures have led to an increase in severe mental health problems in children including anxiety, stress and depression during quarantine, expected to continue post-COVID as well. The transition from isolation to interaction that is expected to occur with reopening of schools will present another challenge. Easing into the post-COVID life can make this transition easier (Figure 1).
Helping children cope with stress during the 2019-nCov outbreak and interventions to manage the mental health effects of COVID-19.
