EVIDENCE ON THE IMPACTS OF COVID-19 PANDEMIC ON VIOLENCE AGAINST CHILDREN: SCOPING REVIEW

Parnamirim, Rio Grande do Norte, Brasil. ABSTRACT Objective: to map existing evidence in the literature on the impacts of the Covid-19 pandemic on child violence. Method: scope review carried out according to the recommendations of the Joanna Briggs Institute and the international guide PRISMA-ScR in the Databases PubMed, CINAHL, Web of Science and LILACS in October 2020. Inclusion criteria were: studies available in full text, online, in the Portuguese, English or Spanish language, published in 2020 and addressing violence against children in the context of the pandemic. The data were submitted to descriptive analysis. Results: 216 articles were found, of which 26 were kept for review. The results were presented in the form of a table and, for their discussion, were summarized in the following axes: Closing schools, increasing risks and reducing reports of violence; Economic changes, parental stress and increased violence against children; Health professionals, protection services and negligence violence against children. Conclusion: the Covid-19 pandemic has had numerous impacts on violence against children. The summary of the findings of this review may contribute to the dissemination of the theme and stimulate actions that favor the identification, notification and monitoring of cases of violence against children as an important part of


INTRODUCTION
The World Health Organization (WHO) defines violence as the intentional use of physical force or power, either by threat or in a real way used against oneself, against another person or against a group or community, which enables or results in injury, psychological damage, death, disability or development deprivation. The types of violence are: collective violence, which concerns acts that occur in the social, political and economic spheres; self-inflicted violence, which may present as suicidal or self-abuse (self-harm); and interpersonal violence, subdivided into family violence (domestic) and community violence 1 .
Domestic violence is that committed mainly at home by family members and/or intimate partners 1 . It is important to mention that children living in environments in which domestic violence is a reality are more likely to reproduce violent behaviors in the future [2][3][4] .
The world is currently experiencing the Covid-19 pandemic 5-6 and numerous measures have been taken so that the virus can be contained, among these, social distancing and isolation, which although important, has consequences mainly for the family relationship, since domestic interaction has become more prolonged and continuous 7 .
In view of this, there is a paradox in the Covid-19 pandemic: on the one hand, staying at home is one of the most efficient means for containing the disease; on the other hand, the family environment, which should be a safe and welcoming place, is considered a great facilitator of violent acts 8 .
Violence that occurs in the domestic environment is the one with the highest number of reports of child violence 9 . The child's permanence in this hostile and violent environment makes it more difficult to report 10 , since they are in the presence of its aggressor(s) and/or potential aggressors 7 .
The pandemic has had negative impacts on the mental, physical and mental development of children who, although less biologically affected by Covid-19, are predisposed to the emergence and/ or increase of the vulnerabilities of their rights and greater exposure to their violation 7 .
In March 2020, reports of sexual violence against children in Brazil increased by 85% compared to the same period in the previous year. In April 2020, there were 19,663 complaints, approximately 10% less than the previous month. Despite the high number, this decrease is associated with the suspension of classes, exposure to continuous contact with aggressors and distancing from protective adults 11,12 .
During the pandemic, there was an increase in child abuse in Brazil and worldwide [13][14][15] , which intensified the urgency of discussing the confrontation of this problem, since behind the health crisis brought by the pandemic, another obstacle grows: the violation of the rights of children and adolescents 11,15 .
Based on the above, the importance of this research for the production of knowledge and for the dissemination of information regarding the impacts that the pandemic has caused on child violence is justified. The methodological option adopted -scoping review 16 -gathers existing evidence on the theme in a clear and direct way, so that health professionals can have an expanded perception of existing problems and a greater clarity when planning, implementing and making decisions.
Therefore, the aim of this research is to map existing evidence in the literature on the impacts of the Covid-19 pandemic on child violence.

METHOD
This is a scoping review, developed from the recommendations of the Joanna Briggs Institute (JBI) 16 and preferred reporting items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) 17 . This choice is anchored in its potential to identify and analyze knowledge 4/14 gaps, clarify the main concepts/definitions, as well as the main characteristics or factors related to a concept 16 .
The title of the review was recorded in Open Science (https://osf.io/dashboard), in the profile of one of the authors. In order to formulate the research question, the mnemonic PCC was used, in which the (P) concerns the "population", (C) the "context" and (C) the "concept". 16 The following elements were defined: P (children); C (pandemic) and C (child violence). Based on this, the following question was elaborated: what evidence is there in the literature on the impacts of the Covid-19 pandemic on child violence?
It is emphasized that, for the MESH vocabulary 18 , the descriptor "child" refers to the person from 6 to 12 years of age. The term child violence is an alternative term for the descriptor "Child Abuse", adopted in the search. The pandemic is defined in this vocabulary as an epidemic of infectious disease that has spread to several countries, often in more than one continent and which generally affects a large number of people.
In order to be included in the review, the studies should be available in full text, online, in the Portuguese, English or Spanish language, published in 2020 and addressing, in their title and/or summary, child violence in the context of the pandemic. Studies which when read in full, did not have evidence related to the theme were excluded. Repeated articles were also excluded and considered only the first time.
The construction of search strategies was performed from combinations of descriptors combined by the Boolean operators "AND" and "OR". Each strategy was adapted to the respective databases with the help of a librarian, as shown in Chart 1. The search and selection of the studies occurred in October 2020, by two reviewers and, in case of divergences, a third reviewer participated as a judge in order to strengthen the quality of the study.

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Data extraction was performed through the use of an instrument based on JBI 16 recommendations and adapted by the reviewers, containing the following information: Study Title, Year, Authorship, Journal, Title, Country of Study and Main Reported Evidence.
After reading and evaluating the texts in full, the extracted data were submitted to descriptive analysis, based on the design of the research according to the adopted reference 16 .
The databases consulted were the Medical Literature Analysis AND Retrieval System Online via The National Library of Medicine (MEDLINE/PubMed), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Latin American and Caribbean Literature in Health Sciences (LILACS) and Web of Science (WOS). Figure 1 shows the process of searching, deleting and selecting the studies found. The selected studies were exported to Mendeley ®, the reference manager software.
For the characterization of the included studies, data were extracted regarding the identification, authors and year of publication, as well as the journal and the country in which the study was conducted. Chart 2 is available below.

Impacts on child violence Study
Decrease in complaints and increase in unconfirmed cases E1 19 , E2 20 , E11 28  These impacts permeate and are permeated by broader issues that have been summarized around three axes: school closures, increased risks and decreased reports of violence; economic changes, parental stress and increased violence against children; health professionals, protection services and negligence in the area of violence against children.

DISCUSSION
The mapping shows important evidence regarding the impacts of the Covid-19 pandemic on violence against children and its most varied causes 8, .The discussion took place by means of the following three axes.

School closures, increased risks and decreased reports of violence
School is an important environment for the physical, mental and social development of children and adolescents and is characterized as part of the protection network 22,24 . In March 2020, numerous states in Brazil decreed the closure of schools and day care centers as one of the containment measures of the new Coronavirus, causing children and adolescents to take online classes and interrupt their face-to-face contact with teachers and other school professionals.
According to Art. 245 of the Statute of the Child and Adolescent (ECA) 44 , teachers are obliged to notify suspected or confirmed cases of violence. Thus, teachers are part of the main whistleblowers of cases of violence against children 28 , and the contact between these protective adults and children during the school period is essential for notification and protection against violence.

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According to studies conducted in the USA 19,29 and Australia 38 , it is quite common to notice a reduction in the number of reports of violence against children during the school holidays and in situations of natural disasters, which usually increases soon after school return; these findings strengthen the idea that, during the Covid-19 pandemic, child abuse may have increased, although many of them will not be reported due to the increased difficulty in identifying and reporting cases 8,22 . -24,33 In Brazil, April 2020 showed a 19% decrease in the number of reports of child sexual violence compared to the same period in the previous year. 11 In the US, it is estimated that, in Florida alone, around 40,000 cases of violence against children have not been confirmed due to the closing of schools. It is noteworthy that the decrease in notifications and complaints was strongly reported as the main impact of the pandemic on violence against children 19-20, . [28][29] For children at risk or in situations of violence, the constant and daily presence of their aggressors ends up reducing escape routes and the possibilities of asking for help, as well as increasing the risk of violence 8,26 .
In addition, another fact that deserves to be highlighted is that the closure of schools and longer time at home caused children to spend more time on the Internet, both for the monitoring of school activities and for other types of use, generating greater exposure of them to online sexual crimes 21,36,38 , and, due to the home office and the accumulation of parents' domestic responsibilities, many do not have adequate supervision 37 .
During the period of social distancing, there was an increase in the search for child sexual material, as well as the exchange of information on how to have access to children for the production of sexual material. 21 Although all children are possible victims and risk suffering online sexual violence, those with a history of abuse and neglect are even more vulnerable 38 .

Economic change, parental stress and increased violence against children
The pandemic brought about the emergence/intensification of the economic crisis, the loss of jobs and work adaptations 19,22,24 . The economic changes brought about by social distancing mainly impacted parents who lost their jobs or were already unemployed. This has resulted in increased parental stress and anxiety which, as a result, increase the risks of physical and psychological abuse, sexual exploitation and neglect 20,22,25,[30][31] .
Feelings generated by job loss are related to physical violence among family members, especially children 42 . Concerns about financial insecurity, economic crisis and health, as well as toxic stress are the main factors of increased risk of child abuse [36][37] . In addition, changes in working conditions (home office), domestic responsibilities and the closure of schools intensified the emergence of parental stress and, consequently, presented an increased risk of violence 20,24,38 .
The increase in parental stress also stems from restrictions in contact with family members who usually offered support in home care and with children. Many grandparents and grandfathers had to discontinue contact with children as a measure of protection against the disease, thus reducing social support for families 33 .
Sexual exploitation and child marriage also increased during the pandemic, and this growth is mainly linked to the economic crisis. Many parents resort to planning child marriage or sexual exploitation to lower household expenses and alleviate the economic impacts brought by the pandemic 26,36 .
In Brazil, the unemployment rate reached 14.4% with the number of unemployed at 13.8 million 45 . Also in this context, it is emphasized that it is possible that most students have been left hungry due to the absence of school meals during the pandemic 7 . Although no Brazilian studies on the subject have been found, with the coexistence of the two factors exposed, it is possible to assume that, for Brazilian children and adolescents, the risks of sexual exploitation and forced labor for the supply of family economic expenses are real, dangerous and need to be modified.

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Health professionals, protection services and neglect with violence against children According to Art. 11 of the ECA, comprehensive health care for children and adolescents must be ensured by the Unified Health System (SUS), in order to guarantee universal and equal access in health protection, promotion and recovery actions 44 . During the pandemic scenario, there was an intensification in the inequality of access to health services, impacting on the increased risks of violence and vulnerability of children 20 and hindering their protection. This inequality will have immediate and long-term impacts post-pandemic 8 .
Ordinance No. 115 of March 20, 2017, in its Art.65, Item I, says that it is the responsibility of the Department of Special Protection to plan, organize, regulate and perform services and programs for cases of violence, exploitation and sexual abuse. 46 The flow of care for cases of suspected or confirmed cases of violence is organized from the reality of each state/municipality, but there are services that are integrated into the protection network, common throughout Brazil: Specialized Reference Center for Social Assistance (CREAS), Reference Center for Social Assistance (CRAS), Hospital, Schools, Guardianship Council, Police Stations and Public Prosecutor's Office [46][47] .
Before the pandemic, the flow of care, in general, involved the identifying unit (Basic Health Unit, hospitals, schools, day care centers), which was responsible for performing childcare and notification to the Guardianship Council [46][47] . The path to be followed later in the protection network varied according to the needs of victims, family members and the severity of risk factors and violations 47 .
During this period, the protection services remained the same, but there was a reorganization of flows and face-to-face functioning. Each State and municipality carried out their decrees and determined whether the protection services would be opened or closed, culminating in different realities of care and strategies to combat child violence in the country 48 .
Among the strategies designed to combat violence against children during the pandemic are: prioritizing care and remote care follow-up for risk cases; reorganize face-to-face care in a decentralized manner where there is greater demand to avoid agglomerations; conduct, remotely, appropriate awareness for different genders and ages [48][49][50][51] .
Among the studies included in the review, only two brought suggestions for protection and confrontation of violence against children, in order to place the child at the center of the actions [39][40] , in other words, working from the perspective of prevention, educating children to identify signs of abuse and guiding ways to ask for help quickly and efficiently.

CONCLUSION
It is concluded that the Covid-19 pandemic has had numerous impacts on violence against children. The need for social distancing demanded the closure of schools, with consequent reduction of escape routes and calls for help. The interruption of monitoring by the child protection services was followed by the increase in unconfirmed cases and the difficulty in identifying and reporting cases of violence with a consequent decrease in complaints. It is also important to mention the increase of the following factors: maltreatment; negligence; psychological abuse and exploitation; trauma and cranial trauma due to physical child abuse; child online sexual exploitation; number of child rapes perpetrated by family members; in addition to the reduction of the most serious forms of injuries from the use of firearms and cold weapons.
In addition to contributing to the research area, this study is expected to contribute to the dissemination of the theme and encourage actions that favor the identification, notification and monitoring of cases of child abuse as an important part of the responses against the Covid-19 pandemic. This problem must be an ethical and political commitment of the whole society.