An ethical analysis of the impacts of the COVID-19 pandemic on the health of children and adolescents

The COVID-19 pandemic has impacted the lives of children and adolescents around the world. Hence, this study aimed to examine how the pandemic has impacted children and adolescents in Brazil through an ethical analysis. An interpretive analysis of Brazilian research on child and adolescent health during the pandemic was conducted. Recognizing this ethical dimension is pivotal to shedding more light on how responses to crisis situations, such as the current situation of the COVID-19 pandemic, can be shaped and where the priorities for action are according to all interested parties, situating the child between these parts of interest. Our analysis highlighted both direct and indirect effects surrounding the decision-making processes for children in the COVID-19 pandemic reality. These decisional processes must sustain the child’s right to participation to ascertain that the action taken is in the child’s best interests. Nevertheless, the Brazilian reality has shown a structural exclusion of children’s voices in decisions affecting them, particularly concerning the effects of the pandemic on their lives. Further studies must be conducted to deepen the knowledge about children’s best interests and their participation in the actions planned during the pandemic.


INTRODUCTION
The COVID-19 pandemic has significantly impacted the lives of children and adolescents around the world. In countries with limited public investments, especially the health and education sectors, social inequalities became even more evident with the pandemic. [1][2][3] Difficulties in access to health services, lack of basic sanitation, gaps in vaccination coverage, precarious housing, and economic hardships are described as situations that preceded COVID-19 and intensified with it as these aspects involve social determinants of health with notable potential for worsening by the humanitarian crisis that the pandemic established. 4 Hence, the COVID-19 pandemic has increased child and youth vulnerability worldwide, albeit it was aggravated in low-and middle-income countries whose health and economic systems critically affected the most impoverished individuals and communities 3,5 compared to economically more prosperous nations. 6 As highlighted by the official document of the United Nations 7 on the crisis of COVID-19 and child care, the situations of restriction and isolation, as well as the lack of health resources to serve the entire population, can be configured everywhere as a humanitarian crisis of children's rights, especially those facing poverty, exclusion, or violence and those affected by humanitarian crises. 7 Therefore, it is a complex reality where children have become invisible victims of the indirect consequences of the pandemic or sometimes even neglected 3,4 in terms of continued access to health care and protection from violence. 6,8 The studies that have analyzed the impacts of the pandemic on children's health have demonstrated the need for further in-depth analysis regarding the ethical implications of these impacts. 1,5 The reason for this is that, in the face of COVID-19, whose natural history has been becoming better known in the course of people falling ill since March 2020, the sanitary control measures applied worldwide have been causing, on the other hand, the silent suffering of children and adolescents. The impacts associated with pandemic precautionary measures (social isolation, wearing masks, staying away from school, and restricting social interactions) have imposed morally problematic consequences that exclude children from important decisions and the lack of access to their fundamental rights. 9 This is due to the vulnerable situation of children who are dependent on adult decisions to preserve their interests and rights. 10 Given this scenario, this article sought to examine how the pandemic impacted children and adolescents in Brazil through an ethical analysis. To this end, an interpretative analysis of relevant Brazilian publications on child and adolescent health during the pandemic was conducted. According to the Brazilian legislation, the ethical referential of the rights of children and adolescents was used as a basis for the reflection presented herein.
Recognizing this ethical dimension is vital to understand how responses to crises (e.g., the COVID-19 pandemic) can be shaped and to identify the priorities for action according to all interested parties, including children. Despite the topic's relevance, the impacts of the current pandemic context on children's lives in Brazil have yet to be analyzed from an ethical perspective. This is quite concerning as it leads to a lack of theoretically grounded claims about the normative dimensions of these impacts and the appropriate ways forward. Therefore, the analysis developed here is an attempt to fill this gap.
This study is included in the theme of social studies on childhood developed by the research group Views On Interdisciplinary Childhood Ethics (VOICE), led by McGill University. In this model, children are understood as social beings who interact with and alter their surrounding social context. 11 VOICE is an interdisciplinary child studies specialization focusing on childhood ethics, and further considerations about this model will be presented in the discussion below.

Social studies on childhood
Social studies on childhood have demonstrated the relevance of understanding children as moral agents, that is, recognizing them as capable of reasoning and interpreting their lived experiences. 12 Children's moral agency can be understood as "children's ability to act deliberately, speak for themselves, and reflect actively on their social worlds, shaping their lives and the lives of others." 11 In this concept, children's ability to communicate may include various forms of interaction other than verbal, such as silence, crying, and that they may be able to represent their moral agency in different settings. 11 Agency, in this view, aims to incorporate the relational aspects intrinsic to children's lives and the environments in which they may be embedded, as these factors guide how they attribute meaning to their experiences. 13 This conceptualization is justified for use in this analysis based on the inherent centrality of Brazilian jurisdiction.

Delineating impacts: the COVID-19 pandemic and children
Since the start of the COVID-19 pandemic in March 2020, children have often been classified as a "lower risk" group due to their clinical reality of less severe complications than adults. 14,15 However, recent studies have shown that although most children with COVID-19 have mild symptoms and a good prognosis, they are just as susceptible to falling ill as adults, and an increased number of children with COVID-19-associated multisystem inflammatory syndrome have been reported. 16 Although these are highly relevant and direct effects caused by the virus, another complex reality covers the indirect effects of the pandemic and related to social issues of inequality and vulnerability of various populations that have their effects accentuated during this time of crisis. 3,4,[6][7][8] From another perspective, the indirect effects of the COVID-19 pandemic raise questions about the long-term impacts on children's well-being and health, especially in the poorest countries and vulnerable situations. 17 For instance, increased malnutrition is expected due to schools closing in most countries where school meals have been a reliable source of daily nutrition, decreased vaccination coverage, and access to health services for women and children. 6,17,18 The Brazilian COVID-19 scenario COVID-19 in children's health: an ethical review Santos RP, Neves ET, Cabral IE, Campbell S, Carnevale F also presents particularities regarding the impacts among children and adolescents, more specifically on mental health.

Mental health in childhood
The preventive measures imposed on children have generated implications for mental health, especially because of barriers to access to health services, social inequality, increased exposure to childhood violence, and children's education regarding COVID-19 and the pandemic. In this sense, studies have reported that the way children deal with the consequences of the pandemic is more associated with age and not precisely with the experience with applying these measures. [19][20][21][22] Furthermore, a paternalistic view on decisions is observed, emphasizing that children "do not have their own voice" and highlighting the "collaborative communication," 19 although without including the child. Nevertheless, regarding the consequences of the emergence of the new disease, there was a sudden change in routine due to the absence of school interaction, greater irritability and aggressiveness, increased use of screens with consequent weight gain, eating disorders, and sleep disorders. [19][20][21][22][23] Access to health services during the pandemic In Brazil, where health resources were already in a state of deprivation, the measures to restrict the movement of people and resources further aggravated the difficulty of access to health services by the population. 6,24,25 The postponement of vaccinations and suspension of routine medical consultations increased vulnerability due to the difficulties in obtaining health care to help meet people's needs. 6,25 This situation is particularly important for children with complex health conditions, since the primary network is a gateway to health services and a source of information and guidance on the specific care these children require at home. 6 One study indicated that some caregivers did not take their children for consultations, exams, and physical therapy for fear of contracting COVID-19. 26 In addition, the drop in vaccination rates increases the risks and social inequalities with greater exposure to other diseases. 26 The distribution of deaths by COVID-19 in people aged 0-14 years in Brazil is unequal, and, depending on the age groups and race/color, a significant variation of the mortality rate has been observed, 27 since inequality is present in numerous aspects of the pandemic. According to data from the COVID-19 Observatory updated in September 2021, 24% of children aged 0-24 months who died from the disease did not have access to intensive care, and 56.8% were of brown and black race/color. 28 In another paper, a retrospective cohort investigation of 4,930 hospitalized children and adolescents diagnosed with COVID-19 found that 2,335 (47.4%) of them belonged to the self-reported brown race/color group. 29 Issues concerning sleep and nutrition disorders during the COVID-19 pandemic were also identified in almost half of the Brazilian children and adolescents analyzed (495 participants) in another study, and the most common sleep problem was excessive daytime sleepiness. 30

Effects of increased social inequality
Studies have demonstrated that sanitary measures and social distancing may not be as effective when social inequality and vulnerability are pre-existing to the pandemic (e.g., basic sanitation and housing problems). Meager access to drinking water, ventilated environments, and financial resources to purchase alcohol-based hand rubs and masks is a condition that worsens the pandemic situation for children who are already poverty-stricken. 31 Still, with regard to inequality, one study developed in Brazil during the COVID-19 pandemic revealed the difficulty in accessing the Internet and mobile phone networks (e.g., smartphones), as well as the lack of knowledge in using them for teleconsultations with families of children with special health needs. 26 The consequences of the isolation and prevention measures on the family, such as increased poverty and hunger resulting from their providers losing their jobs, stand out as sources of psychological suffering for the child. The focus of prevention actions is in the social and programmatic spheres; 25 nevertheless, in the social rights described in the technical notes, the right of children to participate in decisions that affect them has yet to be recognized.

Increased exposure to child violence
Confinement was one of the sanitary measures adopted during the pandemic that brought a significant concern with the exposure of children and adolescents to violence. The increased time spent together with family, the children's irritability due to the abrupt break in routine, and the lack of adequate living conditions were described as factors that could favor increased violence. 25,32 The justification that children present more irritable behaviors demonstrates a paternalistic upbringing in which parents have control over the child's behavior.

Educating children about COVID-19 and the pandemic
Researchers' understanding of how to educate children about COVID-19 and the protective measures taken during the pandemic encapsulate a worldview about children's need for learning. [33][34][35] Children have been understood according to the child development paradigm that "younger children tend to believe that bad people fall ill." Evidence also suggests children's concerns about the relational dimension, although this aspect is little explored. 36 What is more, children's participation in developing materials is not observed, and their views on the problems of the pandemic are not included in decisions. Authors recommend methods such as charts and pictures to educate children about schedules. 35 Research on children's perceptions focuses on understanding based on cognitive process and knowledge about biological conditions of the disease, with little or no voice of the child in this process.

Impacts of the pandemic on children's health in Brazil: an ethical analysis based on children's rights
During the COVID-19 pandemic, the scenarios in low-and middle-income countries, where resources are limited, significantly worsened, threatening children's fundamental rights. 9 The 1989 International Convention on the Rights of the Child includes children's rights in three main categories that will be used in this analysis: the right to participation, the right to prevention and protection against abuse, neglect, discrimination, exploitation, and other harm, and the right to providing assistance to support their basic needs. 37 By and large, the response of low-and middle-income countries to COVID-19 did not recognize the numerous rights of children and adolescents provided for in the International Convention on the Rights of the Child. 38 As defined by Article 12 of the Convention, children have "the right to express [their] views freely in all matters affecting them" and to have their views given "due weight according to their age and maturity." 37 Thus, their participation must be fostered in all situations, regardless of their age or cognitive ability. What is more, their right to participation is understood as a way to ensure that decisions taken consider all dimensions of the child's best interests, which is the fundamental principle on which resolutions involving children must be based. 37 If the right to participation is understood as a primary step for preserving children's rights, the best interest principle has the consequence of excluding them from determinations that affect their lives, and this view can represent a threat to the child's fundamental rights. 39 Decisions made in the context of child exclusion are based on the paternalistic paradigm, meaning a specific group -mostly adults -has structural and legislative privileges in decision-making, while the opinion of the children involved with the outcomes of the action taken is disregarded. 40,41 The International Convention on the Rights of the Child recognizes the right of children to participate in decision-making processes. This international instrument was included in the preamble of Brazilian child protection legislation, which also regulates children's and adolescents' participation in decisions that concern them, recognizing their right to freedom and dignity to express their ideas and opinions. 40 The legislation has incorporated the need to recognize the right of children to be fully informed about health treatments and participate in decision-making processes regarding their health. However, there is a lack of clarity about the extent of their participation in this process and the degree of significance given to their opinions and preferences. 40,41 Although Brazilian legislation recognizes children's rights to participate in decisions affecting them, there are limitations on applying these rights in practice. These shortcomings involve the dominant paternalistic view, which commonly centers decisionmaking on parental authority or responsible adults. 40 As a result, Brazilian children often only play a passive role in decisions involving them, with little recognition extended to their opinions. 40 As for children's rights and the crisis brought on by COVID-19 in 2020, the United Nations Children's Fund (UNICEF) launched an agenda of actions to protect children under vulnerable conditions during the pandemic. According to the document, global coordination to protect the most vulnerable children from the impact of COVID-19 is urgently needed to prevent this health crisis from becoming a child rights crisis. In terms of participation, actions to minimize the social and economic impacts on children and their families include: • Providing peer learning and sharing information with children and adolescents to support their mental health and combat stigma, xenophobia, and discrimination; • Support meaningful child participation in developing and implementing programs that address COVID-19.

Ethical implications of the impacts of the pandemic on children in Brazil based on children's rights
This section will discuss the ethical implications in more detail, including the major impacts reported in the literature reviewed.
1) In the context of the pandemic, decisions made by governments, non-governmental organizations, policy-makers, and parents must consider child participation to preserve children's rights and ensure that their best interests are the focus of the action taken. 9 It is emphasized that understanding best interests in a personalized/individualized way must involve listening directly to the child about what their interests are and how they are particularly significant, as well as considering how various existing policies or practices could impact their interests. This understanding is useful as many adults assume that children cannot participate because they are "immature." In this context, adults will act on behalf of child "protection" based on their own paternalistic view of the child's interests, uninformed about their own lived experiences, aspirations, concerns, and preferences. 10 Nonetheless, children's voices have been overlooked in decisions about pandemic control in Brazil and other low-and middle-income countries. These countries have not respected children's various rights, particularly the right to be included in decisions concerning issues that impact them. In this sense, the increase in child violence reported in Brazilian studies demonstrates how the precautionary measures used to reduce COVID-19 transmission have violated the rights of children and adolescents to be "protected" from all forms of harm.
2) The preventive measures put in place to combat the pandemic have further compromised the guaranteed rights of children to protection from all harm in all aspects of life. 9 Researchers have highlighted that government choices to respond to the pandemic will have future maternal and child health consequences. 9,17 Since the beginning of the pandemic, there have been numerous debates around the balance between establishing movement restrictions and minimizing disruption to businesses and economies, and evidence has shown that the indirect effects of the pandemic are not merely economic. 17 If health care provision is disrupted, many women and children will die. Hence, while public health experts argue for social distancing, there is also a public health case for ensuring access to routine care. 17 In Brazil, where research has already reported the scarcity of resources and increasing inequality, the exclusion of children's voices brings about a morally conflicting situation, placing them in a position of removal from their rights to participate and include their opinions in the decisions that affect them.

3) In general, the rights of children and adolescents to receive
adequate support and information about measures that affect their lives have been compromised in the pandemic, as they continue to lack resources to receive adequate support, education, and recognition from the government, organizations, and the media. 9 Some studies have demonstrated concern for educating children and explaining to them the pandemic context, albeit the information was transmitted unilaterally without the child's active participation in the educational process and without recognizing their ability to understand the reality surrounding them.

4) Social inequality regarding the outcomes of COVID-19 infection
in children has already been described in studies in Brazil. An analysis of an extensive national database of children and adolescents hospitalized with laboratory-confirmed COVID-19 showed that death was associated with ages under two years or between 12-19 years, indigenous ethnicity, living in the poorest macro-regions, and the presence of pre-existing medical conditions. 4 Therefore, health care disparities and social inequalities, exacerbated by intertwined comorbidities, may have synergistically contributed to amplifying the burden of COVID-19 for more socioeconomically disadvantaged and vulnerable individuals. Furthermore, the rates of poor outcomes in patients from Brazil, a middle-income country, were higher than those found in other studies from high-income countries. These results provide evidence of the effects of regional and geographic inequalities on children affected by the pandemic. Death from COVID-19 was associated with age, indigenous ethnicity, poor geopolitical region, and pre-existing medical conditions. Thus, disparities in health care, poverty, and comorbidities may contribute to increasing the burden of COVID-19 in more vulnerable and socioeconomically disadvantaged children and adolescents in Brazil. 4

CONCLUSION, LIMITATIONS, AND RECOMMENDATIONS
The opinions of Brazilian children and adolescents have been systematically neglected in decisions that will affect their lives both directly and indirectly. In a context where various children's rights have not been supported or prioritized in the face of binding choices about resource allocation, the capacities and dignity of children have also not been protected. As a result, this pandemic has exposed the significant injustices that Brazilian children are forced to face, especially in resource-constrained contexts. This work had limitations related to the nature and scope of the studies analyzed as there are still few investigations on the health of children and adolescents in Brazil. In conclusion, in the Brazilian reality, it is vital to highlight the following: → The direct effects of the pandemic on children's health have been aggravated by the social inequality existing in Brazilian childhood; → The indirect effects exacerbate existing social inequality and can continue to impact children's lives for years, even after the COVID-19 pandemic has ended.
Given this above, both direct and indirect effects imply decision-making processes that require one to utilize and sustain the child's right to participation so that the determined action is focused on children's best interests as much as possible. Nevertheless, the Brazilian reality has demonstrated a structural exclusion of children's voices. Hence, we recommend, from this analysis, that further research be conducted in order to shed more light on children's interests and their participation in the actions taken during the pandemic so that practices can be based on scientific evidence and decrease the direct and indirect effects of COVID-19 on the lives of Brazilian children.

FINANCIAL SUPPORT
The lead author received financial support as a research assistant to develop this study. This work was funded by the Social Sciences and Humanities Research Council (SSHRC).