Risks to children and young people during covid-19 pandemic

Dear Editor,

As frontline paediatricians advocating for the rights and safeguarding of children, we applaud Dr Green’s editorial (1) and call upon the government to shift the focus to children and the collateral damage they have suffered as a result of the pandemic in terms of their health and well-being.

Information regarding the pandemic has not been communicated in a child and youth friendly manner. New Zealand and Norway have both held press conferences for children only, whereas our government has never done this since the pandemic broke (2,3).

As a collective we share concerns around the vulnerability of our children and young people. We worry for the children at home, hidden from society and some living with the perpetrator of their abuse. Their voices and cries cannot be heard.

Calls to Childline have dramatically increased (4) and domestic violence arrests are up by 25% (5) but by contrast, our child protection referrals are down. Teachers, social workers, health visitors, community midwives – all partners in safeguarding - have had their interaction with children and young people reduced.

As paediatricians on the frontline, we have seen an overall decline in attendances to the emergency department (ED) but witnessed families and young people coming to ED for issues that would have been absorbed by community and safeguarding teams: babies exhibiting poor weight gain who may have been picked up via our community services pre-Covid-19; distressed mothers bringing their constantly crying babies who may have avoided medical attention with the presence of extended family to support; parents presenting late with their septic babies, fearful to come to hospital due to the virus.

We worry for the mental health of young people who we are seeing attending ED in crisis with nowhere to turn. Their triggers are varied (6) but isolation has certainly played a part (7). Having previously been warned of the dangers of spending too much time in cyberspace, children and young people are now spending a vast amount of time online for education and socialisation and the risks are very real (8). Meanwhile their lives are on hold, impacting both emotional resilience and mental wellbeing.

Protecting children is everyone’s responsibility and never have those words been more meaningful. We must all act now to give children a voice: not just the professionals to whom this role would ordinarily be given, but their local communities. By empowering neighbours, delivery drivers, supermarket workers and those who now may be the only ones seeing our young, through education, they may speak up and report any concerns to the NSPCC or Children’s social care.

We call upon Government to direct resources to enable community workers from health, education and social care to visit homes and connect with children at risk. We also need a strategy to safely bring all children back to school.

We call upon Government to move quickly and decisively to try and repair the harm suffered by young, vulnerable people during this pandemic. Failure to do so will come at a price too high.

Where is the voice of the child in weighing the cost of this pandemic? These children need a voice.

Reference:
1. Green P. Risks to children and young people during covid-19 pandemic BMJ 2020; 369 :m1669. https://www.bmj.com/content/369/bmj.m1669?fbclid=IwAR0ouFiLolxwtE5m1h-3R...
2. Young, E. 'It’s okay to be scared’: Norway PM holds children-only COVID-19 press conference’. SBS News. 2020 March 17.. https://www.sbs.com.au/news/it-s-okay-to-be-scared-norway-pm-holds-child...
3. Ainge Roy, E. Jacinda Ardern holds special coronavirus press conference for children, The Guardian. 2020 March 19. https://www.theguardian.com/world/2020/mar/19/jacinda-ardern-holds-speci...
4. Morgan, T. Coronavirus: Child abuse calls to NSPCC up 20% since lockdown. BBC News. 2020 April 30. https://www.bbc.co.uk/news/uk-wales-52473453?intlink_from_url=https://ww...
5. Kelly, J & Morgan, T. Coronavirus: Domestic abuse calls up 25% since lockdown, charity says. BBC News. 2020 April 6. https://www.bbc.co.uk/news/uk-52157620
6. Gombert-Waldron, K. Children and stress, what’s worrying them most, Children’s Commissioner. 2020 May 20. https://www.childrenscommissioner.gov.uk/2020/05/20/children-and-stress-...
7. Young Minds. Coronavirus having major impact on young people with mental health needs – new survey. 2020 March 30. https://youngminds.org.uk/about-us/media-centre/press-releases/coronavir...
8. Girlguiding. Girlguiding research briefing: Early findings on the impact of Covid-19 on girls and young women. 2020 May. https://www.girlguiding.org.uk/globalassets/docs-and-resources/research-...

Dear Editor

The COVID-19 crisis so far seems to be less intruding for children’s physical condition and it affects older people disproportionately. Much effort must be spent to control COVID-19 in this older age group and improve their living conditions, including quality of care. But this first impression is misleading. Once mortality and morbidity caused by COVID-19 are controlled in Western countries, the current state of primary health care for children also requires a forward view to improve the primary health care of the youngest generation.

Despite the expected economic shortfalls foreseen in the coming years, we must guarantee prolongation of effective primary health care systems available for children and adolescents. But we also need to thrive for the improvements recommended in the EU financed Models of Child Health Care Appraised (MOCHA) research project, www.childhealthservicemodels.eu [1].

So far, the mechanism of viral resistance for COVID-19 in children and young people is unknown. We probably do not need to be concerned about direct effects on their physical health, however, we do need to be concerned about their social and psychological condition caused by the COVID-19 crisis. It can be expected that children and especially those from disadvantaged families, will bear the health consequences of the crisis the world has fallen in.

Children from low income and migrant populations witness a disproportionate high morbidity and mortality among family members afflicted by COVID-19 [2]. They will also disprortionately experience the health consequences of the economic crisis and associated austerity, already significant [3]. Moreover, there are signs the lockdown affects the mental health of children and adolescents. The number of children who are victim of abuse, or witness of abuse and domestic violence, is expected to rise. The confinement through measures such as staying at home, not seeing friends and avoiding physical contact will also cause stress in children and adolescents.

There are also early signs that vaccination rates are dropping, and a parallel likelihood that children are not being presented early enough for lesser health problems or developmental delays – either because services are currently restricted, or because of concern at taking children to heavily protected settings [4]. The combination of focussing service redesign onto adult services, and the growing backlog of preventive and early diagnosis needs, bring a new double jeopardy to health services for children.

Yet the pre-pandemic baseline is itself deficient. We bring to readers’ attention a selection of the worrying issues the MOCHA research project brought to light. They need attention from primary care professionals and policy makers, especially in current circumstances with low budgets, making it even more desperate to bring about child health care systems’ change.

1. The immunization rate of children already gradually dropped in many European countries last years. The current children’s underuse of primary care due to COVID-19 will further influence this decline in the current cohorts ready to be immunized. This backlog has to be repaired as soon as possible putting primary care facilities for an enormous task to continue its immunization program. Hopefully vaccine hesitant parents have now become more aware of the viral threat and need for immunization of their child. COVID-19 underlines the need for EU countries to work together to align immunization programs and communicate about the importance of immunization. We have seen the impact of ‘fake news’ on the immunization rates, which we will have to continue to countervail. A uniform message should be brought to the public, based on science and supported by (social) media expertise: vaccination is the main tool and the safest way to prevent communicable diseases. At the same time, delivery systems should be better tuned to the needs of busy parents with employment as well as varied caring commitments, and to their concerns about indivuidual health issues [5,6].

2. Primary health care systems should secure a free access to mental health care for young people having experienced abuse or COVID-19 stress. They as ever should have access to child friendly units that can provide comprehensive care in a neutral empathetic climate and secure confidentiality when requested[7]. It is currently unclear in which contexts and settings confidential access should be guaranteed to adolescents. Discussions and agreement in the EU on access with and without parental consent is needed.

3. Professionals in primary care and school health services should be trained in mental health consequences of COVID-19. They should be skilled to identify adolescents who need psychological support or treatment, and to respond or refer adequately [8].

4. The MOCHA research project concluded that availability of data on health indicators for children and adolescents is poor and data are often incomparable between EU countries. Improved data collection and registration systems are needed that provide health care professionals at all levels with information and feedback. Such data systems are essential to monitor and compare the health and social consequences of the COVID-19 crisis for young people (Rigby et al, 2020). They also enable the evaluation of measures taken to control COVID-19 in EU-countries and anticipate future developments.

Primary health care systems’ improvements and data availability are unconditional to achieving a demonstrable healthy population of well-developed and happy children and adolescents, especially in low-income groups. This must be evident from figures on immunization rates, children’s psychosocial health and quality of care. We are aware of the enormous challenges our economic and health care systems face but claim attention to the care for the youngest generation – the adverse legacy of the Covid-19 pandemic will be further deepened if the health of the emergent next generation is also compromised. Therefore we must not forget to invest in the care for this future generation who can contribute to avoid such crisis as we are in now.

Paul L. Kocken PhD, research on behaviour change and policy at Erasmus School of Social and Behavioural Sciences, Erasmus University Rotterdam, the Netherland, kocken@essb.eur.nl

Danielle E.M.C. Jansen PhD, chair section Child and Adolescent Public Health, EUPHA, Research on organization of care for children and adolescents at Department of Health Sciences, University Medical Center Groningen, the Netherlands, d.e.m.c.jansen@umcg.nl

Daniela Luzi, research on models based on clinical standards and quality indicators at National Research Council Institute for Research on Population and Social Policies IRPPS, Italy, d.luzi@irpps.cnr.it

Prof dr Michael Rigby, Emeritus Professor of Health Information Strategy at the School of Social, Political and Global Studies and School of Primary, Community and Social Care, Keele University, United Kingdom, Visiting Professor, Section of Paediatrics, Imperial College London, for the duration of the MOCHA project, m.j.rigby@keele.ac.uk

References:
1. Blair M, Rigby M, Alexander D (eds). Issues and Opportunities in Primary Health Care for Children in Europe: The Final Summarised Results of the Models of Child Health Appraised (MOCHA) Project. Emerald, Bingley, 2019. doi/book/10.1108/9781789733518. Open Access at https://www.emerald.com/insight/content/doi/10.1108/978-1-78973-351-8201...
2. ICNARC report on COVID-19 in critical care. Intensive Care National Audit & Research Center, London, 2020. https://www.icnarc.org/Our-Audit/Audits/Cmp/Reports (accessed May 15 2020)
3. Rigby MJ. Potentially over 3 million children in EU Europe believed not to be receiving needed medical and dental treatment—and parents' reasons why. Child Care Health Dev 2020;1–7. https://doi.org/10.1111/cch. 12757
4. Lazzerini M, Barbi E, Apicella A, Marchetti F, Cardinale F, Trobia G. Lancet Child Adolesc Health 2020, https://doi.org/10.1016/S2352-4642(20)30108-5
5. Expert Panel on Effective Ways of Investing in Health. Programmes and Health Systems in The European Union; Brussels, 2018 (available at https://ec.europa.eu/health/expert_panel/sites/expertpanel/files/020_vac...)
6. Bedford H, Attwell K, Danchin M, Marshall H, Corben P, Leask J. Vaccine hesitancy, refusal and access barriers: The need for clarity in terminology; Vaccine 2018;36:6556–6558. https://doi.org/10.1016/j.vaccine.2017.08.004
7. Michaud PA, Visser V, Vervoort JPM, Kocken PL, Reijneveld SA, Jansen DEMC. Availability and accessibility of mental health services for adolescents: national recommendations and services in E.U. European Journal of Public Health, accepted
8. Rigby MJ, Deshpande S, Blair M. Child health research and planning in Europe disadvantaged by major gaps and disparities in published statistics; European Journal of Public Health, 2020, doi: https://doi.org/10.1093/eurpub/ckaa052

Dear Editor,

It was with great interest that I read the timely editorial by Peter Green on the heightened risk of child abuse and neglect during the COVID-19 pandemic (1), particularly in areas where a lockdown or curfew has been imposed. There is already enough evidence to suggest that this is the case in several countries, and that it is accompanied by a heightened risk of spousal abuse, which can further compromise the care and well-being of children (2).

Successful approaches to the prevention and management of this grave problem depend crucially on the use of an appropriate theoretical framework that would permit both a realistic appraisal of risk and the development of effective protective and therapeutic strategies. In this case, the perspective of John Bowlby, founder of attachment theory, on the topic of violence in the family is worth recalling (3). Seen from this viewpoint, perpetrators of violence against their own children have often themselves been exposed to threats of violence and abandonment, if not actual violence itself, during childhood. These vulnerabilities lead to an insecure attachment style, characterized by mistrust, anger, anxiety, and difficulty in generating helpful responses when their own child is distressed.

This attachment system can be activated by external threats or environmental dangers (4), which would include not only the COVID-19 pandemic but the privations and restrictions necessitated in order to contain it (5). This leads to maladaptive emotional responses, such as anxiety and anger, the effects of which are exacerbated by social isolation and a lack of support (3), as well as by socioeconomic deprivation (6).

Furthermore, perceived threats or dangers - such as a disease outbreak, quarantine or lockdown - can also activate the child's own innate attachment response, leading to behaviours such as increased clinging to parents and irritability. Such behaviours have already been documented in young children (aged 3-6 years) during the COVID-19 lockdown (7). The result is a vicious circle, in which an anxious child's increased demand for attention evokes an angry and violent response from a vulnerable parent, which in turn evokes further "undesirable" behaviours from the parent's point of view - thus perpetuating the cycle of violence.

Following this model, an effective response to the problem of child abuse and neglect during the COVID-19 outbreak requires a multifaceted approach. First, environmental factors that evoke insecure attachment responses should be controlled or minimized where possible. This would require the identification and provision of material and psychological assistance to vulnerable families; ensuring the continuity of social bonds and contacts in communities without compromising infection control; the dissemination of accurate information to minimize paranoia and panic at the broader social level; and, finally, communicating effectively with children who may have an inaccurate understanding of the sudden changes taking place around them (8). Second, more direct intervention in specific cases could include volunteer-based befriending and parent training programmes, under the supervision of a medical or social work professional (2). These may be delivered using remote communication if direct contact is imprudent, and will need to be adapted to the parenting practices and patterns of specific cultures (9).

It is hoped that such knowledge of such a perspective will be helpful to therapists as well as to those involved in planning and implementing health and social policies during this crisis, in order to protect the well-being of children, particularly their psychological health (2, 4).

References
1. Green P. Risks to children and young people during covid-19 pandemic. BMJ [Internet]. 2020;369. Available from: https://www.bmj.com/content/369/bmj.m1669
2. Usher K, Bhullar N, Durkin J, Gyamfi N, Jackson. Family violence and COVID-19: increased vulnerability and reduced options for support. Int J Ment Health Nurs 2020 Apr 20. [Online ahead of print.] https://doi.org/10.1111/inm.12735.
3. Bowlby J. Violence in the family. In: Bowlby J, A Secure Base: Parent-Child Attachment and Healthy Human Development. London; Routledge, 1988.
4. Bowlby J. Attachment and loss. Vol. 1: attachment. London; Hogarth Press, 1969
5. van Gelder N, Peterman A, Potts A et al. COVID-19: reducing the risk of infection might increase the risk of intimate partner violence. EClinicalMedicine 2020 Apr 2. [Online ahead of print.] https://doi.org/10.1016/j.eclinm.2020.100348
6. Stansfeld S, Head J, Bartley M, Fonagy P. Social position, early deprivation and the development of attachment. Soc Psychiatry Psychiatr Epidemiol 2008; 43: 516-26. https://doi.org/10.1007/s00127-008-0330-4
7. Jiao WY, Wang LN, Liu J et al. Behavioral and emotional disorders in children during the COVID-19 epidemic. J Pediatr 2020 Mar 13. [Online ahead of print.] https://doi.org/10.1016/j.jpeds.2020.03.013
8. Dalton L, Rapa E, Stein A. Protecting the psychological health of children through effective communication about COVID-19. Lancet Child Adolesc 2020; 4: 346-347. https://doi.org/10.1016/S2352-4642(20)30097-3.
9. Keller H: Universality claim of attachment theory: children’s socioemotional development across cultures. PNAS 2018; 115: 11414-11419. https://doi.org/10.1073/pnas.1720325115