Since December 2019, health systems around the globe have struggled with an increasing
number of cases of a viral respiratory syndrome that emerged in China. The cause is
a new strain in the coronavirus family, provisionally named 2019 novel coronavirus
(2019-nCoV)
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, SARS-CoV-2 or COVID-19.
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The European Paediatric Association–Union of National European Paediatric Societies
and Associations (EPA-UNEPSA) has established a collaborative working group with key
Chinese academic institutions and medical centers with the purpose of facilitating
the reciprocal exchange of information and sharing scientific knowledge. The aim of
this commentary by the China-EPA-UNEPSA working group is to raise awareness regarding
children's psychological needs during epidemics and report early data collected in
the COVID-19–affected areas in China during the current outbreak, emphasizing the
role of families and caregivers in the timely recognition and management of negative
emotions.
Epidemiology of COVID-19
The COVID-19 outbreak first erupted in the city of Wuhan in the Hubei Province of
China, where several local health facilities reported clusters of patients with pneumonia
of unknown cause; they were epidemiologically linked to a seafood and wet animal wholesale
market.
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COVID-19 infection rapidly spread throughout China, involving the provinces of Chongqing,
Hunan, Anhui, Henan, Jiangxi, and Shaanxi.
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Over the next 3 months, COVID-19 spread to other regions of the world, reaching >100
000 cases globally in the first week of March 2020, of which approximately 80% were
reported in China, 6% in South Korea, 3% in Iran, and 0.2% in the US. In Europe, the
first case of COVID-19 was registered in a patient hospitalized in Munich, Germany
in early January 2020, following contact with a traveler from China.
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Later, several other cases were reported in variable numbers in Germany, Spain, Italy,
France, and other European countries, together representing roughly 5% of the cases
of COVID-19 recorded worldwide.
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Genetic studies on viral strains isolated from patients affected by Coronavirus infection
throughout the world confirmed that they are all phylogenetically related to the original
Chinese mutant strain.
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In contrast to seasonal influenza, COVID-19 seems to cause a milder clinical infection
in children than in adults or older people. Early studies have suggested that children
are just as likely as older age groups to become infected with the coronavirus but
are far less likely to develop severe symptoms.
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The risk of severe disease and death is highest for seniors and those with severe
health conditions, such as heart disease, chronic lung disease, cancer, and diabetes.
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COVID-19 has been perceived worldwide as a major threat to health and a danger to
the global economy, affecting people's lives by influencing their everyday behavior
and causing feelings of panic anxiety, depression, and often triggering intense dread.
In China, COVID-19 has affected children aged 3 months to 17 years, most of whom had
close contact with infected persons or were part of a family cluster of cases.
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No official data are available on the number of symptomatic and asymptomatic individuals
positive for COVID-19 in the <18 age group. Infected children might appear asymptomatic
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or present with fever, dry cough, and fatigue, and few have upper respiratory symptoms
including nasal congestion and running nose. Some patients present with gastrointestinal
symptoms, including abdominal discomfort, nausea, vomiting, abdominal pain, and diarrhea.
Most infected children have mild clinical manifestations without fever or symptoms
of pneumonia, and the majority recover within 1-2 weeks after disease onset. Few progress
to lower respiratory infections.
Although children seem to be less vulnerable than adults to COVID-19, initial reports
from Chinese areas hit by the outbreak indicate that children and adolescents have
been impacted psychologically, manifesting behavioral problems, as discussed below.
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Early Investigation of Chinese Children's Behavioral and Emotional Reactions to COVID-19
Children are not indifferent to the dramatic impact of the COVID-19 epidemic. They
experience fears, uncertainties, and physical and social isolation and may miss school
for a prolonged period. Understanding their reactions and emotions is essential to
properly address their needs. A preliminary study conducted in Shaanxi Province during
the second week of February 2020, which was authorized by the local authorities, showed
that the most common psychological and behavioral problems among 320 children and
adolescents (168 girls and 142 boys) aged 3-18 were clinginess, distraction, irritability,
and fear of asking questions about the epidemic (unpublished data). Because of the
Chinese government's mobility restrictions related to epidemics, as enforced by local
and national authorities, the study was performed using an online questionnaire to
investigate the children's behavioral and emotional responses to the current epidemics.
Several children were confined at home under protective isolation because they resided
in highly affected areas.
The questionnaire, which was completed by the parents, incorporated the Diagnostic
and Statistical Manual of Mental Disorders (DSM-5) criteria
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commonly used for a cross-cultural assessment of anxiety disorders, including depression.
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Fear of asking about the epidemics and the health of relatives, poor sleep including
nightmares, poor appetite, physical discomfort, agitation and inattention, clinginess,
and separation problems were among the main psychological conditions investigated.
An important factor ensuring the reliability of results collected by questionnaires
investigating mental disorders in general and particularly during emergencies is the
procedure for data collection and statistical analysis followed by specialized personnel
responsible for data collection, registration, and statistical processing, as in this
case. The use of standard statistical methods ensures the comparability of the results
with other studies.
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,
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The purpose of the questionnaire used in the Chinese study was not to establish a
final diagnosis of mental disorder and depression or to monitor depression severity,
but rather to screen for behavioral and emotional disorders as a “first step” approach.
Subjects who screened positive at preliminary investigation of their behavioral and
emotional condition should be included in future programs to determine whether they
meet criteria for a depressive disorder.
Psychological distress in Children Exposed to Adverse Events
Although the knowledge base regarding children's responses to trauma and adverse events
in general has been expanding, descriptions of their responses during epidemics remain
scarce.
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Yet their vulnerability makes this an important group to study. Several studies have
documented the damaging effects of psychological stress due to negative events in
children. Anxiety, depression, lethargy, impaired social interaction, and reduced
appetite are commonly reported manifestations. Physiological effects include a weakened
or compromised immune system.15, 16, 17, 18, 19 In the course of adverse events, children
are often forced to stay home for long periods due to enforced isolation and school
closure, resulting in limited connection with classmates and reduced physical activity.
A preliminary study conducted in the Shaanxi province during the COVID-19 epidemic
by the China-EPA-UNEPSA collaborative working group showed that children in the younger
age group (3-6 years) were more likely than older children to manifest symptoms, such
as clinginess and fear that family members could contract the infection (P = .002).
Children aged 6 to 18 years were more likely to show inattention (P = .049) and persistent
inquiry (P = .003). Clinging, inattention, and irritability were the most severe psychological
conditions demonstrated by the children in all age groups (Figure; available at www.jpeds.com).
The rates of fear, anxiety, and other emotions were higher in children residing in
highly epidemic areas; however, the differences between areas identified by different
levels of epidemic risk were not statistically significant. Media entertainment was
largely successfully used by families over reading and physical exercise as a means
to relieve their children's distress and address their concerns regarding the negative
condition they were experiencing (Table; available at www.jpeds.com).
The Importance of Nurturing Resilience in Children Exposed to Epidemics
Children facing unexpected and unknown events typically exhibit various stress reactions,
as confirmed in the study performed in China during the COVID-19 epidemic. Resilience,
the personal attributes that help children manage everything from little disappointments
to big life traumas, should be nurtured and implemented by public health programs
in children and teens living in areas hit by calamities such as epidemics. If properly
supported by healthcare professionals, families, and other social connections, including
school environment, children and adolescents can appropriately overcome a condition
of distress and prospectively stabilize emotionally and physiologically.
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Conclusions
Pediatricians working in Shaanxi Province, China have pursued the strategy of nurturing
resilience in children and adolescents hit by the psychological consequences of the
COVID-19 epidemic. The measures suggested by Chinese pediatricians to parents and
family members, included increasing communication with children to address their fears
and concerns, playing collaborative games to alleviate loneliness, encouraging activities
that promote physical activity, and using music therapy in the form of singing to
reduce the worry, fear, and stress that the child may feel. All these measures are
focused on supporting the child to get through this difficult time. Furthermore, parents
should pay attention to sleep difficulties and nightmares, prevent increased daytime
sleep and suggest sleep hygiene and relaxation methods, model a positive psychological
attitude to reduce stress, and divert attention to more productive and positive directions.
The effect of this outbreak is unclear at present, as the situation is rapidly evolving.
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The China-EPA-UNEPSA working group believes that the preliminary report from the Chinese
province of Shaanxi includes useful information for professionals involved in the
care of children hit by the current and possible future epidemics.
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