In the UK, paediatricians are increasingly concerned that parental worries over visiting
healthcare centres are leading to a drop in vaccination rates and the late presentation
of serious illness in children. This is likely to cause avoidable deaths and illness
in the short and long term, a form of collateral damage from the COVID-19 emergency.
In Italy, hospital statistics show a substantial decrease in paediatric emergency
visits compared with the same time in 2018 and 2019 of between 73% and 78%.1 In April
2020, both the Clinical Commissioning Groups and the Royal College of Paediatrics
and Child Health provided guidance for general practitioners and paediatricians in
England that the threshold for face-to-face assessment hospital referrals in children
should not change because of the COVID-19 pandemic.2 This intervention is welcome;
however, we remain concerned about wider, perhaps less immediately visible collateral
damage of strategies used against COVID-19 on vulnerable children.
The Cambridge dictionary defines collateral damage as the ‘unintentional deaths and
injuries of people who are not soldiers, and damage that is caused to their homes,
hospitals, schools, etc’. In the fight against coronavirus, children are being put
at risk, in order to reduce the spread of a disease that mainly causes direct harm
to adults.
One of the unique characteristics of the COVID-19 pandemic is the low hospitalisation
and mortality rate (<0.2% for teenagers).3 However, children are experiencing additional
harm due to social isolation, lack of protective school placements, increased anxiety
and a drop in service provision from both the National Health Service (NHS), education
and social services. This is particularly true for the most vulnerable children (see
Box 1).
Box 1
Definitions of vulnerable children
Definitions of vulnerability, taken from the children’s commissioner technical paper
2 which defines seven groups of children as vulnerable.19
Formal categories of children in care of the state whether in care, or living in other
forms of state provision such as offender institutions, residential special schools,
mental health establishments or other forms of hospital.
Formal categories of need that may reflect family circumstances such as children receiving
free school meals or children in need, and asylum seeking children.
Categories of need that reflect features of child development such as children in
pupil referral units or with special education needs and disability. These groups
might also include wider categories such as children subject to assessment or supervision
under the Children Act, children subject to court orders or in receipt of youth justice
services and missing children.
Children who are in receipt of services following assessment even if they do not have
a formal status. For instance, those within CAMHS but with no formal diagnosis, those
receiving prevention services through children’s care, or youth justice, all of whom
have been assessed by statutory agencies as vulnerable in some manner.
Informal types of vulnerability that may be important to the practice of local agencies
such as, for example, when a child is referred to CAMHS who does not reach the threshold
required to access services but where unmet need and vulnerability may still exist,
or a child identified as part of a family experiencing domestic violence and abuse.
Definitions relating to national policy such as ‘troubled families’ or ‘just about
managing’ families. This category will often relate closely to other categories and
where children are identified as in need of support through such mechanisms they are
in scope of this review.
Scientific and academic literature on risk and resilience. and including tools and
approaches such as the measurement of adverse childhood experiences.
UK government definition of vulnerable children and young people during the COVID-19
pandemic20
Are assessed as being in need under section 17 of the Children Act 1989, including
children who have a child in need plan, a child protection plan or who are a looked
after child.
Have an education, health and care (Education Health and Care) plan whose needs cannot
be met safely in the home environment.
Have been assessed as otherwise vulnerable by educational providers or local authorities
(including children’s social care services), and who are therefore in need of continued
education provision.
“This might include children on the edge of receiving support from children’s social
care services, adopted children, or those who are young carers, and others at the
provider and local authority discretion”.
Impact of school closure and social isolation
School closures may have a limited impact on preventing deaths in adults.4 However,
the closure of schools and confinement to home has multiple impacts on children in
terms of education, social isolation, well-being and child protection. Almost all
European countries have closed their schools (Sweden is an exception) to prevent the
spread of COVID-19 and according to UNESCO, 91% of children have been impacted worldwide.5
Schools throughout the UK closed in March 2020 (see Box 2) and are only providing
places for some primary school children of key workers and some vulnerable children.
Uptake of these places in the latter group appears to be low.6 Some schools are providing
learning online, but completion rates are unknown, particularly for those children
with no or limited access to the internet. Children from poorer families have fewer
resources, may be reliant on school meals and playgrounds for exercise, are less likely
to have appropriate access to the internet/sufficient space to allow learning, or
have access to additional resources to support other activities for mental or physical
well-being. Children with special educational needs and disabilities should have the
special provision required to meet their particular needs specified in their Education
Health and Care Plan (EHCP). This has not necessarily been adapted for home learning
and many EHCPs specify provision that cannot be delivered outside of specialist settings.
Similarly, much of the wider support normally available to disabled children and other
vulnerable learners is provided through facilities that are now closed and unlikely
to be effectively replaced by efforts of volunteers.
Box 2
What restrictions have been placed because of social distancing on children and young
people in the UK? (government guidance updated 29 March 2020)
Children and young people are not allowed to attend school, college, nurseries unless
they are a vulnerable child (see UK government definition in Box 1)
Children and young people are allowed ‘one form of exercise a day, for example, a
run, walk, or cycle—alone or with members of your household’.
Where parents do not live in the same household, children under 18 can be moved between
their parents homes.
All public gatherings are of more than two people are stopped (including weddings,
baptisms and other religious ceremonies).
Schools provide a safe space for vulnerable children and play a key role in safeguarding
by detecting signs of abuse or neglect. The rapid closure of schools has not been
accompanied by strengthened processes to support those most in need. This has occurred
at the same time that the Coronavirus Act allows social services to reduce or suspend
services (see below) leaving vulnerable children without a safety net.
Social isolation, the withdrawal of peer support, the lack of structure and support
from school and the increased anxiety over COVID-19 infection and risk to parents
are all likely to have a negative impact on mental health in children and young people.7
Social isolation and loneliness in children, job loss, furlough and increased parental
distress may lead to subsequent mental health problems, resulting in a substantial
increase in need for Child and Adolescent Mental Health Services (CAMHS).
Increased risk to the mental health of children from social isolation will also result
from their exposure to domestic violence and abuse (DVA) during the pandemic. We know
that violence against women increases during epidemics, such as Ebola.8 9 Now, in
countries across the world that have imposed social isolation in response to COVID-19,
there is evidence from helplines and police reports that the incidence and severity
of DVA have increased.10–12 Children confined to home from school closure and young
people not being able to leave home to see their friends will be more exposed to DVA.
The stress and anxiety caused by forced isolation, economic uncertainty, home schooling
and potentially difficult living conditions drive the increase in abusive and controlling
behaviour. In over a third of families where DVA occurs, there is also direct child
maltreatment: physical and emotional abuse, exploitation and neglect.13 The greatest
risk will be to vulnerable children (defined in Box 1). Although the government has
issued guidance in relation to COVID-19 and DVA, there is no mention of exposed children
and young people.11 Moreover, as children’s services and DVA agencies scramble to
change their working practices to remote support, there is uncertainty about the effectiveness
of emergency methods of working in this field.
Reduction in protection: withdrawal of services
While the risk to children (and particularly vulnerable children) is increasing, the
support mechanisms in both the NHS and social services are being withdrawn.
Hospital outpatient clinics have closed, been suspended or moved to virtual home based
clinics. This will have the greatest impact on new appointments, or appointments requiring
an examination. Child and Adolescent Mental health services have reduced or suspended
assessment and treatment clinics in many parts of the UK at a time when children and
young people are experiencing higher levels of anxiety and depression. This is likely
to contribute to higher rates of mental health disorders, self-harm and ultimately
suicide. The impact is higher on vulnerable children
On the 3rd of March, the UK government introduced the Coronavirus Bill,14 which became
the Coronavirus Act on 25 March 2020. This included changes to the Care Act 2014 in
England and the Social Services and Well-being (Wales) Act 2014 to “enable local authorities
to prioritise the services they offer in order to ensure the most urgent and serious
care needs are met, even if this means not meeting everyone’s assessed needs in full
or delaying some assessments”.14 These changes meant that ‘local authorities will
not have to prepare or review care and support plans’.15 The intention of the bill
was for this to only come into effect if ‘if demand pressures and workforce illness
during the pandemic meant that local authorities were at imminent risk of failing
to fulfil their duties and only last the duration of the emergency’.15 However, in
the absence of coronavirus testing (which means that many families are self-isolating)
and with current government regulations on the movement of people, significant areas
of social care have ceased with a potentially devastating impact on the most vulnerable
children.
There are over 78 000 looked after children in England alone16 who are now at higher
risk because of the reduction or suspension of evidenced-based protective support
and interventions. A variety of parental interventions, Looked After Children Reviews,
social services input and respite care can improve children’s outcomes.17 Throughout
the UK, these services have been suspended or reduced as social services move to working
from home meaning that children and foster carers can no longer access face-to-face
support from their appointed social worker or their independent reviewing officer.
Respite care has generally been suspended, increasing the risk of physical, emotional
abuse or neglect in families that are struggling. Where looked after children were
receiving additional support from CAMHS, this has either stopped or is being continued
remotely. Inevitably, these reductions in support and safeguards will have the greatest
impact on the children with the most complex needs in the most challenged placements.
Transition planning for children leaving care has largely been suspended. Services
that were already struggling with workforce issues are now struggling even more as
recruitment is almost impossible currently because of practical and economic considerations.
It therefore seems likely that the decisions on social distancing contravene the UN
Convention of the child. This convention states (article 3): “In all actions concerning
children, whether undertaken by public or private social welfare institutions, courts
of law, administrative authorities or legislative bodies, the best interests of the
child shall be a primary consideration." We believe that the social distancing measures
introduced in the UK and elsewhere, may marginally reduce the infection rate in adults
but harms children. We do not believe that the “best interest of the child” are the
“primary consideration” and therefore these actions do not comply with this convention.
Can we mitigate these effects and minimise the ‘collateral damage’ experienced by
children and young people? Several strategies have been suggested to reduce the risks
of domestic violence including the organisation of safe spaces in hotels for women
and children experiencing DVA, already implemented in Spain and France. Improving
video and online access to services for which there is some evidence of effectiveness
(such as Cognitive Behavioural Therapy (CBT) from CAMHS) could improve children’s
resilience. The chronic underfunding and workforce crisis in social care and the domestic
violence sector will only be exacerbated by the current emergency. The chancellor’s
recognition of the need for greater financial support of the NHS18 should be matched
with additional support to local authorities. CAMHS and social services for children
are unlikely to be needed on the front line for COVID-19 and agile services could
develop alternative methods to assess and treat children using video clinics. The
physical and mental health needs of the UK’s children are unlikely to be short term,
and funding will need to continue well after the COVID-19 pandemic is over. Perhaps
more importantly, we all have a responsibility to promote the health and well-being
of children at home, and to ask questions and fight for service provision in areas
where clinicians are not needed to fight COVID-19, but are needed to protect children.
Supplementary Material
Reviewer comments
Author's manuscript