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      COVID-19 and child and adolescent psychiatry: an unexpected blessing for part of our population?

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          Abstract

          The COVID-19 pandemic has left children and adolescents largely unaffected in terms of infectious morbidity and mortality [1]. A greater challenge for this age group is expected in dealing with lockdown and quarantine measures that may push children into crises and destabilize families [2, 3]. Especially, when quarantine measures are strict and in the presence of preexisting psychological or psychiatric vulnerabilities [4–6], a variety of negative outcomes are to be expected [7]. The COVID-19 outbreak has brought new challenges for child psychiatry and mental health services that must be addressed, including national guidelines covering interventions for major public health crises affecting children [8]. These threats and challenges have been rightfully addressed in several commentaries and are currently being studied across the globe [2]. Notwithstanding the importance of stressing the need for harm reduction in vulnerable children these days, here, we would like to draw attention to the flipside of the same coin. Clinical experience over the last weeks, as well as popular press coverage, shows that the sudden lockdown-induced changes for some children and families reduce daily stress, and sensory exposures and changes family routines. These changes seem to actually reduce child and adolescent mental illness symptoms and even improve well-being. Some kids seem to experience alleviation of social and sensory pressure and enjoy the more intensive family life. In this context, the crisis may provide a unique window of opportunity to test long-standing hypotheses on modern life stressors and mental health problems or psychiatric pathogenesis and well-being in developing children and adolescents [9, 10]. At no point in recent history, we have been given a similar chance to evaluate the effects of such a drastic environmental change; not only for the worse, but also for some for the good. For instance, in The Netherlands and many other European countries, schools, companies, offices, social and sports clubs were all closed at once, but walks in the park and other outdoor activities were allowed under certain restriction. Nuclear family life was forcefully reinvented in many homes in sharp paradox with their usual busy normal routines of balancing work and family. Many parents became homebound schoolteachers whilst trying to keep their own professional lives going through online interactions. In the clinic, this led to mixed reports of being tied up in their houses whilst also being able to pay unprecedented amount of time and attention to each other. Indeed, another frequent noted observation was that certain patients and families seemed to thrive on the novel situation and context. Therefore, we argue that the research agendas currently laid out to register and understand the negative effects of COVID-19 on child and adolescent (mental) health should also include the perspective of children and families who are benefitting from the societal changes. Taking these heterogenous experiences in mind, we advocate an open scientific mind to COVID-19 studies by including ‘positive’ hypotheses and questions in addition to those testing negative expectations. We suggest that a diverse range of potential effects of the crisis, such as reduction of stress, improved sleep and relaxation, loss of social pressure, more time to think and improved affect. We caution against recruitment bias strategies when merely focusing on increased morbidity and problems. A wider approach will open up opportunities to go beyond studies on mental illness and mental health, by also including mental well-being. We should not only aim to help those who suffer, but also support well-being, which is a prerequisite for optimal psychological, social, and physical development. Research designs should, therefore, incorporate dimensional symptom evaluations and include multi-directional screenings of potential negative, but also positive influences. Hypotheses on both positive and negative responses of children and families to this crisis should be developed to understand the full breadth of impact on modern daily life routines and environments in future post COVID-19 times. In all, the COVID-19 crisis confronts us with many novel realities and changes and has many insightful messages. For the field of child and adolescent psychiatry, and child development in general, these may be also related to learning how our social and economic environment interacts with child mental health and well-being. Comprehensive analysis of psychiatric morbidity in children and adolescents between the pre and post crisis times, in combination with carefully matched population-based control samples, offers an unprecedented window of opportunity to gauge how our current day society impacts well-being; for bad and for good.

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          Most cited references8

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          The Mental Health Consequences of COVID-19 and Physical Distancing: The Need for Prevention and Early Intervention

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            Mental health considerations for children quarantined because of COVID-19

            To control the transmission of coronavirus disease 2019 (COVID-19), the Chinese Government has implemented strict domestic quarantine policies. As of March 24, 2020, more than 80 000 individuals with COVID-19, and 690 000 individuals who have come into close contact with individuals with COVID-19 have been registered and quarantined, including a large number of children. 1 This quick action has effectively slowed the spread of new cases of infection on both the Chinese mainland and the rest of the world. However, researchers have realised that such measures might have adverse psychological effects on children who are quarantined. For children who are quarantined at home with their parents or relatives, the stress caused by such a sharp change in their environment might be eased to some degree. 2 However, children who are separated from their caregivers require special attention, including children infected with or suspected of being infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), who are quarantined in local hospitals or collective medical observation centres; and children whose caregivers are infected with SARS-CoV-2 or who have died from the disease and are thus under the care of social charity groups. These children might be more susceptible to mental health problems because of their higher risk of infection, and the grief and fear caused by parental loss or separation. Companionship is essential for children's normal psychological development and wellbeing. 3 Separation from caregivers pushes children into a state of crisis and might increase the risk of psychiatric disorders. 4 Sprang and colleagues 5 reported that children who were isolated or quarantined during pandemic diseases were more likely to develop acute stress disorder, adjustment disorder, and grief. 30% of the children who were isolated or quarantined met the clinical criteria for post-traumatic stress disorder. 5 Furthermore, separation from parents or parental loss during childhood also has long-term adverse effects on mental health, including a higher risk of developing mood disorders and psychosis, and death by suicide in adulthood.6, 7 The age of the initial separation is known to be relevant to psychological development. The parent–child separation initiated in the first few years after birth might disrupt the ongoing attachment processes, which might be associated with poorer mental health outcomes. 8 The Chinese Government has implemented a series of strategies to prevent the potential mental health problems that might arise among children who are quarantined during the COVID-19 pandemic. For example, in many Chinese tier 1 cities —typically the largest and wealthiest—like Shanghai, Guangzhou, and Hangzhou, nurses are guaranteed to be available 24 h per day in the children's isolation ward. Nutritionists are invited to give professional guidance for children's diets according to their medical conditions and normal developmental requirements. To reduce fear and other psychological discomfort, children who are quarantined can communicate with their parents via mobile devices at any time. Many citizens from the local community or district volunteers act as temporary mothers to care for recovered children after their discharge, when their caregivers are not available because of infection, quarantine, or death. In response to the notice on improving rescue and protection for children without effective guardianship issued by the Ministry of Civil Affairs, many cities like Zhengzhou opened free psychological counselling hotlines, which were available 24 h per day. 9 Most recently, the National Health Commission of China issued guidelines and listed specific intervention strategies for children who are quarantined in collective medical observation centres. For example, these measures seek to increase children's communication time with their parents; increase children's access to disease information via comic books and videos; guide children to establish a regular activity schedule; provide night lights and small gifts; and provide timely referrals to psychiatrists when children feel mental discomfort, such as worry, anxiety, difficulty sleeping, and loss of appetite. 10 Although great efforts have been made across China, the emerging psychological interventions are unlikely to be provided nationwide because most local support for unaccompanied children focuses only on meeting children's basic daily needs. We propose that paediatric health-care workers should receive formal training to facilitate the early identification of children's mental health problems by learning to discern children's normal and abnormal behaviours, recognise red flags indicating further intervention or referral are needed, and standardise the use of rapid screening tools for mental health. Furthermore, mental health professionals should establish evidence-based guidelines and easy operational strategies to cope with COVID-19 pandemic-related mental health problems in children. We also believe that children's access to mental health services can be improved through collaborative networks that are established nationwide and consist of psychiatrists, psychotherapists, researchers, and community volunteers. Additionally, the post-pandemic surveillance of mental disorders among these children should be considered. Since the global transmission of COVID-19 began, the total number of cases in countries other than China have already exceeded that in China. Following WHO's recommendation, an increasing number of countries have learned from China's experience with regard to quarantine policies. We suggest that the specific response to the mental distress of children who are quarantined should also be considered when designing psychological intervention strategies in response to COVID-19. © 2020 estherpoon/iStock 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.
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              Mental health effects of school closures during COVID-19

              Joyce Lee (2020)
              The coronavirus disease 2019 (COVID-19) pandemic—and the social distancing measures that many countries have implemented—have caused disruptions to daily routines. As of April 8, 2020, schools have been suspended nationwide in 188 countries, according to UNESCO. Over 90% of enrolled learners (1·5 million young people) worldwide are now out of education. The UNESCO Director-General Audrey Azoulay warned that “the global scale and speed of the current educational disruption is unparalleled”. For children and adolescents with mental health needs, such closures mean a lack of access to the resources they usually have through schools. In a survey by the mental health charity YoungMinds, which included 2111 participants up to age 25 years with a mental illness history in the UK, 83% said the pandemic had made their conditions worse. 26% said they were unable to access mental health support; peer support groups and face-to-face services have been cancelled, and support by phone or online can be challenging for some young people. School routines are important coping mechanisms for young people with mental health issues. When schools are closed, they lose an anchor in life and their symptoms could relapse. “Going to school had been a struggle for [some children with depression] prior to the pandemic, but at least they had school routines to stick with”, said Zanonia Chiu, a registered clinical psychologist working with children and adolescents in Hong Kong, where schools have been closed since Feb 3. “Now that schools are closed, some lock themselves up inside their rooms for weeks, refusing to take showers, eat, or leave their beds.” For some children with depression, there will be considerable difficulties adjusting back to normal life when school resumes. Children with special education needs, such as those with autism spectrum disorder, are also at risk. They can become frustrated and short-tempered when their daily routines are disrupted, said psychiatrist Chi-Hung Au (University of Hong Kong, Hong Kong, China). He advised parents to create a schedule for their children to reduce anxiety induced by uncertainty. With speech therapy sessions and social skills groups suspended, he cautions that stopping therapy can stall progress, and children with special needs might miss their chance to develop essential skills. He points out that creative ways, such as online speech and social skills training, are needed to make up for the loss. Many countries are postponing or cancelling university entrance exams. In Hong Kong, the authorities made a last-minute decision on March 21 to push back the Diploma of Secondary Education (DSE) exams, which were scheduled to start on March 27, by a month to April 24. According to a poll by the student counselling group Hok Yau Club in March, 2020, over 20% of the 757 candidates surveyed said their stress levels were at a maximum 10 out of 10, even before the postponement was announced. 17-year-old DSE candidate Yoyo Fung has been experiencing loss of appetite and sleep problems, and said she found the uncertainties of whether the exams could be delayed further stressful. “I have a huge wave of fear that I might contract the virus and thus cannot make it to the exams. Staying healthy has become another stressor”, she said. Meanwhile, college and university students are stressed about dormitory evacuation and cancellation of anticipated events such as exchange studies and graduation ceremonies. Some lost their part-time jobs as local businesses closed. Students in their final years are anxious about the job market they are going to enter soon. “College students […] are more vulnerable than we think, especially with the current academic and financial burden”, said Chiu. Social distancing measures can result in social isolation in an abusive home, with abuse likely exacerbated during this time of economic uncertainty and stress. Jianli County in Hubei province, China, has seen reports of domestic violence to the police more than triple during the lockdown in February, from 47 last year to 162 this year. Increased rates of child abuse, neglect, and exploitation have also been reported during previous public health emergencies, such as the Ebola outbreak in west Africa from 2014 to 2016. However, not much is known about the long-term mental health effects of large-scale disease outbreaks on children and adolescents. While there is some research on the psychological impact of severe acute respiratory syndrome (SARS) on patients and health-care workers, not much is known about the effects on ordinary citizens. Evidence is especially scarce in children and adolescents. “This is an important gap for research”, Au said. COVID-19 is much more widespread than SARS and other epidemics on a global scale. As the pandemic continues, it is important to support children and adolescents facing bereavement and issues related to parental unemployment or loss of household income. There is also a need to monitor young people's mental health status over the long term, and to study how prolonged school closures, strict social distancing measures, and the pandemic itself affect the wellbeing of children and adolescents. © 2020 kiankhoon/iStock 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.
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                Author and article information

                Contributors
                h.bruining@amsterdamumc.nl
                Journal
                Eur Child Adolesc Psychiatry
                Eur Child Adolesc Psychiatry
                European Child & Adolescent Psychiatry
                Springer Berlin Heidelberg (Berlin/Heidelberg )
                1018-8827
                1435-165X
                4 July 2020
                4 July 2020
                : 1-2
                Affiliations
                [1 ]GRID grid.7177.6, ISNI 0000000084992262, Department of Child and Adolescent Psychiatry, , Amsterdam UMC, University of Amsterdam, ; Meibergdreef 5, 1105 AZ Amsterdam, The Netherlands
                [2 ]GRID grid.12380.38, ISNI 0000 0004 1754 9227, Department of Biological Psychology, , Vrije Universiteit Amsterdam, ; Amsterdam, The Netherlands
                [3 ]GRID grid.16872.3a, ISNI 0000 0004 0435 165X, Amsterdam Public Health Research Institute, , Amsterdam UMC, ; Amsterdam, The Netherlands
                Article
                1578
                10.1007/s00787-020-01578-5
                7335225
                32623697
                16650bdd-80b2-4751-ad4b-be7b9b88bc74
                © The Author(s) 2020

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

                History
                : 14 May 2020
                : 13 June 2020
                Categories
                Letter to the Editor

                Clinical Psychology & Psychiatry
                Clinical Psychology & Psychiatry

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