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Social and environmental effects of the COVID-19 pandemic on children

Abstract

Objective:

This study aimed to review the literature, summarizing the existing evidence on the effects of the pandemic on children, adolescents and parents, with an emphasis on the psychological, emotional, and sleep quality consequences.

Source of data:

Empirical studies identified in the following databases: MEDLINE, ISI Web of Knowledge/Web of Science, and preprint servers.

Synthesis of data:

The findings point to a wide range of consequences for children and adolescents resulting from the COVID-19 pandemic, which mainly includes an increase in depressive mood symptoms. There is also an increase in anxiety symptoms, suicidal ideation, as well as potential delays in language and motor development resulting from deprivation of social interaction and the closing of schools. These effects are more severe due to previous neuropsychiatric conditions. For parents, there is an increase in anxiety, depressive and post-traumatic symptoms, which are more accentuated in those who suffered socioeconomic damage due to the pandemic. There was an important increase in situations of violence towards children by parents and caregivers during the pandemic. Also, changes in routine and fear of the pandemic have negatively impacted sleep quality, globally.

Conclusions:

It is noteworthy that most studies published to date used a cross-sectional design and applied online screening questionnaires. The few studies with a longitudinal design suggest that these changes may have been transitory and more prevalent at the beginning of the pandemic.

KEYWORDS
Sleep; Childhood; Adolescence; Mental health; COVID-19

Introduction

At the end of December 2019, a series of pneumonia cases of unknown etiology affected 41 patients in the city of Wuhan, China.11 Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel Coronavirus from patients with pneumonia in China. N Engl J Med. 2019;2020(382):727-33. It was quickly discovered that the cause was contamination by a new type of coronavirus, initially called 2019-nCoV and later updated to SARS-CoV-2. The disease caused by the coronavirus was called COVID-19. Among patients with symptomatic COVID-19, cough, myalgia, fever, and headache are the most commonly reported symptoms. Other features, including diarrhea, sore throat, and loss of smell or taste, have also been described. Based on the rapid increase in the number of infections22 Zhao L, Sznajder K, Cheng D, Wang S, Cui C, Yang X. Coping styles for mediating the effect of resilience on depression among medical students in web-based classes during the COVID-19 pandemic: cross-sectional questionnaire study. J Med Internet Res. 2021;23:e25259. and the possibility of transmission between asymptomatic individuals, the World Health Organization (WHO) declared that the outbreak of COVID-19 was a pandemic. As of July 2021, worldwide epidemiological data indicate more than 190,000,000 cases diagnosed with SARS-CoV-2 and more than 4,100,000 deaths from COVID-19.33 Worldometer. Coronavirus death toll 2021. [Cited 2021 Aug 13]. [Available from: https://www.worldometers.info/coronavirus/coronavirus-death-toll/.
https://www.worldometers.info/coronaviru...

Although vaccines have been developed for the virus, several countries still use preventative guidelines that have been applied to contain the spread of SARS-CoV-2. The main containment strategies are non-pharmacological interventions, such as social distancing, the closing of educational establishments, cancellation of events and social gatherings, hand hygiene, body temperature examination, use of antiseptics and personal protective equipment, travel restrictions, and dissemination of SARS-CoV-2 screening tests.44 Mulugeta T, Tadesse E, Shegute T, Desta TT. COVID-19: socioeconomic impacts and challenges in the working group. Heliyon. 2021;7:e07307. Moreover, several countries declared a state of emergency and imposed a partial quarantine, causing billions of people to go unemployed, or work from home using telecommunication technologies, except to perform tasks considered to be essential. Therefore, in addition to the broad socioeconomic impact, the prolonged social distancing measures introduced insecurity, psychological discomfort, including an overall exacerbation of anxiety, depression, and growing fear.

Particularly in the child population, several changes in children's routines occurred during the COVID-19 pandemic period. They have been instructed to respect rules and habits that are not always understandable to them (e.g., disinfecting their hands, not touching their eyes or nose, and covering their mouth), they are also unable to see the people they would like to be close with, due to the social distancing measures. These changes inroutine can cause significant psychological and emotional distress. In this sense, this study aimed to describe and summarize the existing evidence on the effects of the pandemic on children, adolescents, and their parents, with an emphasis on the psychological, emotional, and sleep quality consequences.

Psychological and emotional consequences arising from COVID 19

Unlike adults, children infected with SARS-CoV-2 have a milder illness, low morbidity, and better prognosis. However, social distancing and quarantine measures can have several consequences for children's mental health. Home confinement is associated with drastic changes in the lifestyle of children and adolescents, mainly due to the decrease in the possibility of social interaction with peers.55 Singh S, Roy D, Sinha K, Parveen S, Sharma G, Joshi G. Impact of COVID-19 and lockdown on mental health of children and adolescents: a narrative review with recommendations. Psychiatry Res. 2020;293:113429.

One of the first studies on the subject was carried out in China, through a web-based survey, which included the participation of 1,784 children and adolescents.A high prevalence of depressive mood symptoms (22%) was observed, followed by a high presence of anxiety symptoms (18%). In this study, the participants had experienced on average 33 days of home confinement.66 Xie X, Xue Q, Zhou Y, Zhu K, Liu Q, Zhang J, et al. Mental health status among children in home confinement during the Coronavirus disease 2019 outbreak in Hubei Province, China. JAMA Pediatr. 2020;174:898–900. Table 1 depicts a summary of the empirical studies cited in this section and in the section on consequences for parents.

Table 1
Characteristics of studies that evaluated the psychological and emotional effects of COVID-19 on children, adolescents and parents.

Subsequently, other studies found that younger children (3 to 6 years) were more likely to manifest symptoms of fear and anxiety about the possibility of family members being infected with SARS-CoV-2 than older children (6 to 18 years).55 Singh S, Roy D, Sinha K, Parveen S, Sharma G, Joshi G. Impact of COVID-19 and lockdown on mental health of children and adolescents: a narrative review with recommendations. Psychiatry Res. 2020;293:113429. However, increased irritability and inattention were observed in children of different age groups. Based on questionnaires answered by the parents, the results show that children feel more insecure, fearful, and isolated in times of pandemic, compared to the pre-pandemic period.77 Viner RM, Russell SJ, Croker H, Packer J, Ward J, Stansfield C, et al. School closure and management practices during coronavirus outbreaks including COVID-19: a rapid systematic review. Lancet Child Adolesc Health. 2020;4:397–404. It has also been shown that children are often experiencing poor appetite, restlessness, inattention, and parents separation anxiety. In children, symptoms of depression and anxiety may present themselves more often as apathy and lack of self-care than verbal expressions of hopelessness. Difficulty in focusing and impaired concentration are also common and may be associated with symptoms of anxiety and depressive mood.88 Esch P, Bocquet V, Pull C, Couffignal S, Lehnert T, Graas M, et al. The downward spiral of mental disorders and educational attainment: a systematic review on early school leaving. BMC Psychiatry. 2014;14:237.

However, most of the evidence in this regard is concentrated in studies with adolescent samples. For instance, a recent study conducted with 1,339 adolescents showed a 28% increase in depressive symptomatology in the first 6 months of the COVID-19 pandemic.99 Barendse M, Flannery J, Cavanagh C, Aristizabal M, Becker SP, Berger E, et al. Longitudinal change in adolescent depression and anxiety symptoms from before to during the COVID-19 pandemic: a collaborative of 12 samples from 3 countries.(2021, February 3) PsyArXiv [Preprint]. Available from: https://doi.org/10.31234/osf.io/hn7us
https://doi.org/10.31234/osf.io/hn7us...
Although these symptoms are not necessarily associated with a neuropsychiatric condition that emerged during the pandemic, these manifestations are warning signs for parents and guardians. These types of nonspecific yet severe presentations often benefit from an early diagnosis and referral to mental health services.

The estimates mentioned so far are derived from studies conducted through an online survey. A recent study conducted a screening for depression symptoms in pediatric primary care.1010 Mayne SL, Hannan C, Davis M, Young JF, Kelly MK, Powell M, et al. COVID-19 and adolescent depression and suicide risk screening outcomes. Pediatrics. 2021:e2021051507. Epub ahead of print. The results indicated that the percentage of adolescents with depressive symptoms increased from 5.0% to 6.2%, with a greater increase among the femalegender. Positive suicide risk screenings increased from 6.1% to 7.1%, with a 34% relative increase in the odds of reporting recent suicidal thoughts among adolescent girls. In this sense, children and adolescents at risk of suicide need immediate referral and follow-up. During the pandemic, the most common manifestations associated with suicidal behavior in adolescents were related to the pre-existence of mental disorders, as well as an exacerbated feeling of loneliness, and psychological suffering associated with online schooling.1111 Manzar MD, Albougami A, Usman N, Mamun MA. Suicide among adolescents and youths during the COVID-19 pandemic lockdowns: a press media reports-based exploratory study. J Child Adolesc Psychiatr Nurs. 2021;34:139–46. Also noteworthy is the psychological suffering related to the dependence on digital media, and a positive test for SARS-CoV-2.

Particularly in relation to children and adolescents affected with neurodevelopmental disorders and other psychiatric conditions prior to the pandemic, there is a high risk of psychological and emotional manifestations in the pandemic context. For instance, in children with Cerebral Palsy, impairment in epileptic seizurecontrol, worsening of spasticity, and motor control have been observed.1212 Ben-Pazi H, Beni-Adani L, Lamdan R. Accelerating telemedicine for cerebral palsy during the COVID-19 pandemic and beyond. Front Neurol. 2020;11:746. The Autism Spectrum Disorder (ASD) is also highlighted due to the following factors: 1) Individuals with ASD experience greater social isolation and distress in situations of uncertainty compared to their typical peers; 2) Recent evidence indicate high levels of post-traumatic stress symptoms associated with social stressors in children diagnosed with ASD, indicating that this population is at high risk for developing posttraumatic stress disorder in the post-pandemic period1313 Taylor JL, Gotham KO. Cumulative life events, traumatic experiences, and psychiatric symptomatology in transition-aged youth with autism spectrum disorder. J Neurodev Disord. 2016;8:28.; 3) Any type of change in daily activities, such as changes in activity schedules and restricted access to schools, due to the quarantine periods, can cause great discomfort and consequent behavioral change; 4) These children usually undergo clinical follow-up for several hours during the week with a multidisciplinary team; however, due to contagion containment measures, families and children with ASD are facing several restrictions regarding the possibility of continued clinical care; and, 5) The sum of these factors resulted in the recent assessment of the Secretary General of the United Nations, António Guterres, who verified that the consequences of the COVID-19 pandemic for the lives of individuals with ASD is disproportionately greater and needs immediate attention and efforts at the public health level.1414 Guterres A. COVID-19 should not herald rollback in rights for people with autism: UN chief. In: Twitter, editor. 2020.

In this sense, an extremely relevant aspect refers to social isolation. Although many families have been confined during the pandemic period, loneliness remains a significant problem for children and adolescents.1515 Bartek N, Peck JL, Garzon D, VanCleve S. Addressing the clinical impact of COVID-19 on pediatric mental health. J Pediatr Health Care. 2021;35:377–86. A recent systematic review found that 63 of the 83 included studies documented the negative impact of loneliness on the mental health of previously healthy children and adolescents.1616 Loades ME, Chatburn E, Higson-Sweeney N, Reynolds S, Shafran R, Brigden A, et al. Rapid systematic review: the impact of social isolation and loneliness on the mental health of children and adolescents in the context of COVID-19. J Am Acad Child Adolesc Psychiatry. 2020;59. 1218-39.e3. Children affected by loneliness are more likely to have symptoms of anxiety and depression that persist in post-pandemic conditions.

Pre-existing family dysfunctions, such as frequent conflicts and marital violence, can increase the negative impact on the aforementioned manifestations. For instance, Green et al. conducted an online investigation of 462 Dutch adolescents in May 2020, with a follow-up in November 2020.1717 Green KH, van de Groep S, Sweijen SW, Becht AI, Buijzen M, de Leeuw RN, et al. Mood and emotional reactivity of adolescents during the COVID-19 pandemic: short-term and long-term effects and the impact of social and socioeconomic stressors. Sci Rep. 2021;11:11563. They found that the severity of depressive mood symptoms increased between May 2020 and November 2020, especially for younger adolescents. There were positive associations between the intensity of negative emotions with exposure to family stressor factors.

Also, a very important aspect that should be considered is related to the interruption of classroom teaching during the COVID-19 pandemic. For example, Zhang et al., using a longitudinal design,observed that the closing of schools significantly increased depressive symptoms and suicidal ideation in children and adolescents.1818 Zhang L, Zhang D, Fang J, Wan Y, Tao F, Sun Y. Assessment of mental health of Chinese primary school students before and after school closing and opening during the COVID-19 pandemic. JAMA Netw Open. 2020;3:e2021482. The home confinement of children and adolescents is associated with uncertainty and anxiety, which can be attributed to interruptions in their schooling, physical activities, and socialization opportunities.55 Singh S, Roy D, Sinha K, Parveen S, Sharma G, Joshi G. Impact of COVID-19 and lockdown on mental health of children and adolescents: a narrative review with recommendations. Psychiatry Res. 2020;293:113429. The absence of a structured school environment for a long period results in routine disruption, boredom, and lack of innovative ideas for engaging in several academic and extracurricular activities. Some children may express lower levels of affection due to not being able to play outdoors, not meeting friends, and not getting involved in face-to-face school activities. These children can also become more dependent, seeking frequent parental attention due to the long-term change in the routine. It is presumed that children may resist going to school after the quarantine ends and may face difficulties in establishing relationships with their teachers after the reopening of schools. Consequently, the movement restriction imposed on them can have a longterm negative effect on theiremotional, cognitive development,and overall psychological well-being.55 Singh S, Roy D, Sinha K, Parveen S, Sharma G, Joshi G. Impact of COVID-19 and lockdown on mental health of children and adolescents: a narrative review with recommendations. Psychiatry Res. 2020;293:113429.

Children with hearing loss can also be disproportionately affected by virtual education when compared to their normal-hearing peers.1919 Charney SA, Camarata SM, Chern A. Potential impact of the COVID-19 pandemic on communication and language skills in children. Otolaryngol Head Neck Surg. 2021;165:1–2. Hearing-impaired individuals are particularly affected by what has been termed "zoom fatigue", which is due to increased auditory effort resulting from difficulties in interpreting non-verbal cues (e.g., inability to read lips due to pixelated video), low audio quality, and audio-visual dyssynchrony. This phenomenon is also associated with impairments and delays in language development for typical children.

Implications for parents and caregivers

A child's illness is recognized as one of the most destabilizing events for parents, having a significant impact on their mental health. There is an increased risk for the development of a wide range of psychopathological sequelae, such as depression, anxiety, and post-traumatic stress disorder. Although COVID-19 in children is mostly asymptomatic orshows milder symptoms than those typically seen in adults, the mere suspicion of SARS-CoV-2 infection in children can be a destabilizing event for a parent.2020 Corsi M, Orsini A, Pedrinelli V, Santangelo A, Bertelloni CA, Carli N, et al. PTSD in parents of children with severe diseases: a systematic review to face Covid-19 impact. Ital J Pediatr. 2021;47:8.

In this sense, Orsini et al. demonstrated that parents whose children tested positive for SARS-CoV-2 were more likely to develop post-traumatic, anxiety, and depressive symptoms.2121 Orsini A, Corsi M, Pedrinelli V, Santangelo A, Bertelloni C, Dell'Oste V, et al. Post-traumatic stress, anxiety, and depressive symptoms in caregivers of children tested for COVID-19 in the acute phase of the Italian outbreak. J Psychiatr Res. 2021;135:256–63. Similar results emerged for parents who were quarantined, as opposed to those who did not. Moreover, parents who suffered some type of economic loss as a result of the pandemic had a higher prevalence of anxiety and depressive symptoms, while post-traumatic symptoms were more common among parents who went unemployed during the pandemic period. Similarly, Carroll et al. found that in a sample of 254 families,2222 Carroll N, Sadowski A, Laila A, Hruska V, Nixon M, Ma DW, et al. The impact of COVID-19 on health behavior, stress, financial and food security among middle to high income Canadian families with young children. Nutrients. 2020:122352. more than half reported that their eating routines changed in the COVID-19 pandemic, as well as screen time increased for 74% of mothers, 61% of fathers, and 87% of the children. Additionally, physical activity decreased for 59% of mothers, 52% of fathers, and 52% of children. The main factors influencing family stress include balancing work and parenting, remote home education, and financial instability. These findings indicate that several socio-environmental factors can influence the vulnerability of parents and caregivers to the emergence of psychological and emotional manifestations associated with the COVID-19 pandemic.

It is important to highlight that recent evidence points to reversibility of the negative effects of the pandemic on children and parents, after the relaxation of social distancing measures and return to activities. Bailey et al. demonstrated in the United Kingdom that well-being (quality of life and measures of psychological distress) in families with children werefound to be at similar levels in the pre-and post-pandemic period.2323 Bailey T, Hastings RP, Totsika V. COVID-19 impact on psychological outcomes of parents, siblings and children with intellectual disability: longitudinal before and during lockdown design. J Intellect Disabil Res. 2021;65:397–404. However, the cognitive effects on parents resulting from COVID-19 seem to persist even after the clinical recovery, including in asymptomatic cases.2424 Hampshire A, Trender W, Chamberlain SR, Jolly AE, Grant JE, Patrick F, et al. Cognitive deficits in people who have recovered from COVID-19. EClinicalMedicine. 2021:101044.

Still, there is an important warning regarding the increase in situations of violence towards children by parents and caregivers during the pandemic. Cappa and Jijon conducted a literature review on the topic,2525 Cappa C, Jijon I. COVID-19 and violence against children: a review of early studies. Child Abuse Negl. 2021;116:105053. raising the following points: 1) Studies found a decrease in police reports and referrals to child protection services, 2) mixed results were found regarding the number of calls to the police or domestic violence helplines, and 3) studies have shown an increase in child abuse-related injuries treated in hospitals and other health services. In this sense, emerging results indicate an increase in situations and frequency of family violence, which may be associated with several negative outcomes for the development of children exposed to such events.

Sleep and COVID 19

Sleep is an essential biological process for life and overall health. It plays an important role in the regulation of brain functions and in body physiology, such as metabolism and the immune, hormonal and cardiovascular system function.2626 Aldabal L, Bahammam AS. Metabolic, endocrine, and immune consequences of sleep deprivation. Open Respir Med J. 2011;5:31–43. Good sleep quality is mainly characterized by a sufficient duration of sleep, good quality and regularity, and absence of sleep disturbances.

Good quality sleep is essential for child development. Studies have suggested that sleep deprivation can compromise the physical and mental health of children and interfere with growth and development.2727 Alimoradi Z, Broström A, Tsang HWH, Griffiths MD, Haghayegh S, Ohayon MM, et al. Sleep problems during COVID-19 pandemic and its' association to psychological distress: a systematic review and meta-analysis. EClinicalMedicine. 2021;36:100916. The wide variety of systems affected by sleep deprivation demonstrates the important role that sleep plays in controlling the adequate physiological function of both the central nervous system and peripheral signaling, which include total body function.2828 Jahrami H, BaHammam AS, AlGahtani H, Ebrahim A, Faris M, AlEid K, et al. The examination of sleep quality for frontline healthcare workers during the outbreak of COVID-19. Sleep Breath. 2021;25:503–11.

During the pandemic period, mobility restriction and home isolation measures adopted by several countries significantly changed familyroutines. People who go through a quarantine often report that itis an unpleasant experience. Being apart from loved ones, loss of freedom of movement, uncertainty, and fear regarding the disease usually bring psychological consequences, such as mood changes and anxiety symptoms.2929 Rubin GJ, Wessely S. The psychological effects of quarantining a city. BMJ. 2020;368:m313.

Habit/routine changes, fear, depression, and anxiety are potential risk factors for sleep quality alterations. In clinical practice, complaints of sleep problems significantly increased during the pandemic. Several studies, carried out in all regions of the world, have evaluated the relationship between social isolation/pandemic and sleep disorders in children and adolescents. The majority of these studieshad a cross-sectional design and used questionnaires sent via the internet (web-based survey) as the research instrument. Table 2 summarizes these findings.

Table 2
Characteristics of studies that evaluated the consequences on sleep quality resulting from COVID-19 in children and adolescents.

Among the studies carried out in European countries during the pandemic, those carried out in Italy stand out. Bruni et al. evaluated 4,314 children and adolescents (aged 0 to18 years), divided into four groups by age group, through a digital platform using a previously validated sleep scale and demographic data.3030 Bruni O, Malorgio E, Doria M, Finotti E, Spruyt K, Melegari MG, et al. Changes in sleep patterns and disturbances in children and adolescents in Italy during the Covid-19 outbreak. Sleep Med. 2021. S1389-9457(21)00094-0. They observed a significant delay in both going to sleep and waking up times in all groups, in addition to an increase in screen time. Sleep disturbances increased in all groups except for adolescents, with younger children showing a higher prevalence of difficulty initiating sleep, anxiety at bedtime and nocturnal awakenings. Celini et al. evaluated 299 dyads of mothers/children,3131 Cellini N, Canale N, Mioni G, Costa S. Changes in sleep pattern, sense of time and digital media use during COVID-19 lockdown in Italy. J Sleep Res. 2020;29:e13074. the latter aged between 6 and 10 years. They observed a delay in bedtime in the child population and an increase in emotional and behavioral problems, in addition to hyperactivity, with these changes being related to maternal psychological difficulties. Mothers also showed worsening of sleep quality depending on their working conditions (home vs. external). Those who maintained their professional activities that required work outside the home had fewer sleep alterations.

The study by Androutsos et al.3232 Androutsos O, Perperidi M, Georgiou C, Chouliaras G. Lifestyle changes and determinants of children's and adolescents' body weight increase during the first COVID-19 lockdown in Greece: the COV-EAT Study. Nutrients. 2021;13:930. carried out in Greece also evaluated children and adolescents. During the period of social isolation (lockdown), increased screen time, increased sleep duration, reduced physical activity, and increased body weight were observed. Alonso-Martinez et al.3333 Alonso-Martínez AM, Ramírez-Vélez R, García-Alonso Y, Izquíerdo M, García-Hermoso A. Physical Activity, Sedentary Behavior, Sleep and Self-Regulation in Spanish Preschoolers during the COVID-19 Lockdown. Int J Environ Res Public Health. 2021;18:693. https://doi.org/10.3390/ijerph18020693. PMID: 33467399; PMCID: PMC7830291.
https://doi.org/10.3390/ijerph18020693...
evaluated preschool-age children in Spain. They observed a reduction in total physical activity, sleep efficiency, increased sedentary lifestyle, and internalizing and externalizing symptoms. Children who maintained their regular physical activity levels had fewer internalizing symptoms than their sedentary peers.

The study by Markovic et al. has a longitudinal design with two follow-up assessments,3434 Markovic A, Mühlematter C, Beaugrand M, Camos V, Kurth S. Severe effects of the COVID-19 confinement on young children's sleep: a longitudinal study identifying risk and protective factors. J Sleep Res. 2021: e13314. all carried out in 2020 and online. A total of 452 infants (0 to 35 months) and 412 preschoolers from different European countries were included. An abrupt decrease in sleep quality, albeit transient, was observed in all groups. The caregivers' stress level was a significant risk factor for poor sleep quality in both groups during all assessments.

Studies carried out in Middle Eastern countries also showed significant changes in sleep during the pandemic. In Tunisia, Abid et al. evaluated 100 children (aged 8.66 ± 3.3 years) through an online study, using the Pittsburgh Sleep Quality Index.3535 Abid R, Ammar A, Maaloul R, Souissi N, Hammouda O. Effect of COVID-19-related home confinement on sleep quality, screen time and physical activity in Tunisian boys and girls: a survey. Int J Environ Res Public Health. 2021;18:3065. They observed that during the confinement period, there was a worsening in all indexes, especially in girls, who showed longer screen time and worse sleep quality. There was a significant correlation between longer screen time and worse scoresonthe sleep scale.

The study by Ranjbar et al.3636 Ranjbar K, Hosseinpour H, Shahriarirad R, Ghaem H, Jafari K, Rahimi T, et al. Students' attitude and sleep pattern during school closure following COVID-19 pandemic quarantine: a web-based survey in south of Iran. Environ Health Prev Med. 2021;26:33. had a sample of 20,697 children with a mean age of 13.7 years, of which the majority (69.3%) was female, living in urban areas and attending public schools. Increased total sleep duration and screen use were observed. In the study by Ghanamah & Eghbaria-Ghanamah3737 Ghanamah R, Eghbaria-Ghanamah H. Impact of COVID-19 pandemic on behavioral and emotional aspects and daily routines of Arab Israeli children. Int J Environ Res Public Health. 2021;18:2946. also carried out online during the pandemic, with children of Arab origin living in Israel, it was observed that half of the sample demanded to sleep with their parents and showed fears that had not been previously reported. Most children also had increased complaints of irritability, mood swings, increased use of screens, reduced physical activity, and sleep problems (sleeping longer, among others).

In Asia, three studies are highlighted, two conducted in China and another in Singapore, with the Chinese studies,3838 Zhou SJ, Wang LL, Yang R, Yang XJ, Zhang LG, Guo ZC, et al. Sleep problems among Chinese adolescents and young adults during the coronavirus-2019 pandemic. Sleep Med. 2020;74:39–47.,3939 Liu Z, Tang H, Jin Q, Wang G, Yang Z, Chen H, et al. Sleep of preschoolers during the coronavirus disease 2019 (COVID-19) outbreak. J Sleep Res. 2021;30:e13142. having large samples. The study by Zhou et al., which included 11,835 adolescents and young adults, showed a prevalence of insomnia of 23%, with female gender and living in urban areas being considered risk factors. Depression and anxiety were also risk factors for insomnia. The study by Liu et al. included children (n = 1619) aged 4 to 6 years evaluated during the pandemic. When the sample was compared with data collected in 2018, an increase in sleep problems (going to sleep and waking up later) was observed. Good sleep hygiene practices were positive in reducing the problems.

Lim et al. questioned the parents of 593 children/adolescents from Singapore, aged 3 to 16 years before and during school closure in the national lockdown period.4040 Lim MT, Ramamurthy MB, Aishworiya R, Rajgor DD, Tran AP, Hiriyur P, et al. School closure during the coronavirus disease 2019 (COVID-19) pandemic - Impact on children's sleep. Sleep Med. 2021;78:108–14. An increase in sleep time was observed, with going to sleep and waking up later being more evident in high school students.

In two studies carried out in North America, the Canadian one through telephone contact, the parent-child relationships were evaluated in 144 families with children aged 9 to 12 years during the pandemic. It was observed that the parents' fear of COVID was associated with more fear for the children, and changes in sleep habits were associated with greater concerns about COVID-19.4141 Suffren S, Dubois-Comtois K, Lemelin JP, St-Laurent D, Milot T. Relations between child and parent fears and changes in family functioning related to COVID-19. Int J Environ Res Public Health. 2021;18:1786. In the United States study, the mothers of 572 infants were interviewed, comparing those in home confinement with those who were working regularly. The evaluation took place atfour moments using videosonography. More sleep problems were observed at baseline in infants whose mothers were confined at home.4242 Kahn M, Barnett N, Glazer A, Gradisar M. Infant sleep during COVID-19: Longitudinal analysis of infants of US mothers in home confinement versus working as usual. Sleep Health. 2021;7:19–23.

In South America, the authors of the present study highlight two studies, one carried out in Chile and the other in Brazil. In the Chilean study involving 3,157 parents of children aged 1 to 5 years, screen time, sleep habits, and physical activity were evaluated. In the initial period of the pandemic, there was a reduction in the time of physical activity, an increase in the recreational use of screens and in sleep duration, as well as aworsening in the quality of sleep.4343 Aguilar-Farias N, Toledo-Vargas M, Miranda-Marquez S, Cortinez-O'Ryan A, Cristi-Montero C, Rodriguez-Rodriguez F, et al. Sociodemographic predictors of changes in physical activity, screen time, and sleep among toddlers and preschoolers in Chile during the COVID-19 pandemic. Int J Environ Res Public Health. 2020;18:176. In the study carried out in Brazil, 577 families with children aged 0 to 17 years were evaluated, and respondents were directed to online questionnaires according to the age group. Sleep alterations were observed in 69.8% of adults, 58.6% of the children aged 0 to 3 years, 33.9% in those aged 4 to12 years, and 56.6% of the adolescents. The female gender and having children with sleep problems were predictors of sleep disorders in parents. The subjective perception of sleep worsening showed complaints in the emotional domain (anxiety and fear) in parents and changes in sleep routine (going to sleep later) in all groups of children/adolescents.4444 Wearick-Silva LE, Richter S, Viola TW, Nunes ML. COVID-19-Sleep Research Group. Sleep quality among parents and their children during COVID-19 pandemic in a Southern - Brazilian sample. J Pediatr (Rio J). 2021. in press.

Regarding the comorbidities in the emotional/behavioral domain, during the pandemic, Bruni et al. evaluated 992 Italian children and adolescents with Attention Deficit Hyperactivity Disorder (ADHD).4545 Bruni O, Giallonardo M, Sacco R, Ferri R, Melegari MG. The impact of lockdown on sleep patterns of children and adolescents with ADHD. J Clin Sleep Med. 2021. Epub ahead of print. They observed that the social isolation period had a negative impact on sleep organization, decreasing or increasing total sleep time. A significant association between increased screen time and delay in the onset of sleep, as well as shorter sleep duration, was also observed. Panda et al. performed a systematic review including 15 studies and a total assessment of 22,996 children/adolescents.4646 Panda PK, Gupta J, Chowdhury SR, Kumar R, Meena AK, Madaan P, et al. Psychological and behavioral impact of lockdown and quarantine measures for COVID-19 pandemic on children, adolescents and caregivers: a systematic review and meta-analysis. J Trop Pediatr. 2021;67:fmaa122. They observed high percentages of anxiety, depression, irritability, and inattention (respectively, 34.5%, 41.7%, 42.3%, and 30.8%). The behavioral/emotional state of almost 80% of the children in the sample was altered during the pandemic, with fear of COVID (22.5%), boredom (35.2%), and sleep disorders (21.3%) being the main factors. Children with prior neurobehavioral disorders, such asASD and ADHD were more likely to experience symptom worsening.

Conclusion

As demonstrated, there is a wide range of consequences for children and adolescents resulting from the COVID-19 pandemic, which include, above all, an increase in depressive mood symptoms resulting from social interaction deprivation and the closing of schools. Moreover, some studies reported an increase in anxiety symptoms, suicidal ideation, as well as potential delays in language and motor development.

There are also important consequences for the mental health of parents and caregivers. The recommendations to ensure the mental well-being of children and adolescents during and after the pandemic are being discussed, and include a collaborative network between parents, teachers, pediatricians, psychologists, psychiatrists, neurologists, other health professionals, and public health policy managers.55 Singh S, Roy D, Sinha K, Parveen S, Sharma G, Joshi G. Impact of COVID-19 and lockdown on mental health of children and adolescents: a narrative review with recommendations. Psychiatry Res. 2020;293:113429. The role of parents and family members is fundamental in this regard, since in times of great stress and uncertainty, a safe and organized family environment regarding schedules and activities is a strong protective factor. There is evidence showing that parental stress coping strategies affect children's mental health after disaster situations.55 Singh S, Roy D, Sinha K, Parveen S, Sharma G, Joshi G. Impact of COVID-19 and lockdown on mental health of children and adolescents: a narrative review with recommendations. Psychiatry Res. 2020;293:113429.

Regarding the impact of the pandemic itself and the consequent social isolation on sleep quality, in the pediatric age group (including from infants to adolescents), it is clear that routine changes and fear of the pandemic negatively impacted sleep quality, in a globalized way. However, it is noteworthy that most studies published to date used a cross-sectional design and applied online screening questionnaires. The few longitudinal studies suggest that these changes may have been transitory and more prevalent at the beginning of the pandemic, that is, they resulted from the sudden imposition of changes in habits and routines.

Acknowledgments

MLN is a CNPq PQ 1D Fellow (306338/2017-3).

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Publication Dates

  • Publication in this collection
    20 Apr 2022
  • Date of issue
    Mar-Apr 2022

History

  • Received
    13 Aug 2021
  • Accepted
    16 Aug 2021
  • Published
    20 Sept 2021
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