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      Mitigate the effects of home confinement on children during the COVID-19 outbreak

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          Abstract

          In response to the coronavirus disease 2019 (COVID-19) outbreak, the Chinese Government has ordered a nationwide school closure as an emergency measure to prevent spreading of the infection. Public activities are discouraged. The Ministry of Education estimates that more than 220 million children and adolescents are confined to their homes; this includes 180 million primary and secondary students and 47 million preschool children). 1 Thanks to the strong administrative system in China, the emergency home schooling plan has been rigorously implemented. 2 Massive efforts are being made by schools and teachers at all levels to create online courses and deliver them through TV broadcasts and the internet in record time. The new virtual semester has just started in many parts of the country, and various courses are offered online in a well organised manner. These actions are helping to alleviate many parents' concerns about their children's educational attainment by ensuring that school learning is largely undisrupted. Although these measures and efforts are highly commendable and necessary, there are reasons to be concerned because prolonged school closure and home confinement during a disease outbreak might have negative effects on children's physical and mental health.3, 4 Evidence suggests that when children are out of school (eg, weekends and summer holidays), they are physically less active, have much longer screen time, irregular sleep patterns, and less favourable diets, resulting in weight gain and a loss of cardiorespiratory fitness.3, 5 Such negative effects on health are likely to be much worse when children are confined to their homes without outdoor activities and interaction with same aged friends during the outbreak. Perhaps a more important but easily neglected issue is the psychological impact on children and adolescents. Stressors such as prolonged duration, fears of infection, frustration and boredom, inadequate information, lack of in-person contact with classmates, friends, and teachers, lack of personal space at home, and family financial loss can have even more problematic and enduring effects on children and adolescents. 4 For example, Sprang and Silman 6 showed that the mean posttraumatic stress scores were four times higher in children who had been quarantined than in those who were not quarantined. Furthermore, the interaction between lifestyle changes and psychosocial stress caused by home confinement could further aggravate the detrimental effects on child physical and mental health, which could cause a vicious circle. To mitigate the consequences of home confinement, the government, non-governmental organisations (NGOs), the community, school, and parents need to be aware of the downside of the situation and do more to effectively address these issues immediately. Experiences learned from previous outbreaks can be valuable for designing a new programme to tackle these issues in China. 7 The Chinese Government needs to raise the awareness of potential physical and mental health impacts of home confinement during this unusual period. The government should also provide guidelines and principles in effective online learning and ensure that the contents of the courses meet the educational requirements. Yet it is also important not to overburden the students. The government might mobilise existing resources, perhaps involving NGOs, and create a platform for gathering the best online education courses about healthy lifestyle and psychosocial support programmes available for schools to choose from. For example, in addition to innovative courses for a better learning experience, promotional videos can be useful to motivate children to have a healthy lifestyle at home by increasing physical activities, having a balanced diet, regular sleep pattern, and good personal hygiene. 8 To make these educational materials truly effective, they must be age-appropriate and attractive. They require professional expertise and real resources to create. Communities can serve as valuable resources in managing difficulties of family matters. For instance, parents' committees can work together to bridge the needs of students with school requirements and to advocate for children's rights to a healthy lifestyle. Psychologists can provide online services to cope with mental health issues caused by domestic conflicts, tension with parents, and anxiety from becoming infected. 7 Social workers can play an active role in helping parents cope with family issues arising from the situation, when needed. Such a social safety net could be particularly useful for disadvantaged or single-parent families, 9 but action is needed to make it accessible to them. Schools have a critical role, not only in delivering educational materials to children, but in offering an opportunity for students to interact with teachers and obtain psychological counselling. Schools can actively promote a health-conscious schedule, good personal hygiene, encourage physical activities, appropriate diet, and good sleep habits, and integrate such health promotion materials into the school curriculum. 3 A Chinese child studies from home during the COVID-19 outbreak © 2020 Fan Jiang 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. In the event of home confinement, parents are often the closest and best resource for children to seek help from. Close and open communication with children is the key to identifying any physical and psychological issues and to comforting children in prolonged isolation.10, 11 Parents are often important role models in healthy behaviour for children. Good parenting skills become particularly crucial when children are confined at home. Besides monitoring child performance and behaviour, parents also need to respect their identity and needs, and they need to help children develop self-discipline skills. Children are constantly exposed to epidemic-related news, so having direct conversations with children about these issues could alleviate their anxiety and avoid panic.10, 11 Home confinement could offer a good opportunity to enhance the interaction between parents and children, involve children in family activities, and improve their self-sufficiency skills. With the right parenting approaches, family bonds can be strengthened, and child psychological needs met. 12 Since the COVID-19 epidemic is no longer confined to China, 13 school closure and home confinement-related issues also become relevant in other affected countries. As children are vulnerable to environmental risks and their physical health, mental health, and productivity in adult life is deeply rooted in early years, 14 close attention and great efforts are required to address these emergency issues effectively and avoid any long-term consequences in children. Any sustainable programme must involve local professionals to culturally adapt the interventions to the administrative system and to the regional and community environment, and it must develop contextually relevant material for children and adolescents. 7 Finally, children have little voices to advocate for their needs. The latest Commission 14 on the future of the world's children urges a holistic strategy in preparing for the uncertainty that all children are facing. It is the responsibility and keen interests of all stakeholders, from governments to parents, to ensure that the physical and mental impacts of the COVID-19 epidemic on children and adolescents are kept minimal. Immediate actions are warranted.

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          Most cited references7

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          Online mental health services in China during the COVID-19 outbreak

          At the start of 2020, the 2019 coronavirus disease (COVID-19), originating from Wuhan in Hubei province, started to spread throughout China. As a result of the rapidly increasing numbers of confirmed cases and deaths, both medical staff and the public have been experiencing psychological problems, including anxiety, depression, and stress.1, 2 Since January, 2020, the National Health Commission of China have published several guideline documents, starting with the notification of principles for emergency psychological crisis intervention for the COVID-19 epidemic on January 26, then the notice on establishing psychological assistance hotlines for the epidemic on February 2, and most recently, guidelines for psychological assistance hotlines during the COVID-19 epidemic on February 7. 3 During the severe acute respiratory syndrome epidemic in 2003, internet services and smartphones were not widely available. Therefore, few online mental health services were provided for those in need. 4 The popularisation of internet services and smartphones, and the emergence of fifth generation (5G) mobile networks, have enabled mental health professionals and health authorities to provide online mental health services during the COVID-19 outbreak. Fast transmission of the virus between people hinders traditional face-to-face psychological interventions. By contrast, provision of online mental health services is safe. To date, several types of online mental health services have been implemented widely for those in need during the outbreak in China. Firstly, as of Feb 8, 2020, 72 online mental health surveys associated with the COVID-19 outbreak could be searched for via the WeChat-based survey programme Questionnaire Star, which target different populations, including medical staff (23 of the surveys), patients with COVID-19 (one survey), students (18 surveys), the general population (nine surveys), and mixed populations (21 surveys); in Hubei province (five surveys), other provinces (15 surveys), all provinces, municipalities, and autonomous regions (36 surveys), and unspecified areas of China (16 surveys). One such multicentre survey involving 1563 medical staff, with our centre at Nanfang Hospital, Southern Medical University (Guangzhou, China) as one of the study sites, found the prevalence of depression (defined as a total score of ≥5 in the Patient Health Questionnaire-9) to be 50·7%, of anxiety (defined as a total score of ≥5 in the Generalized Anxiety Disorder-7) to be 44·7%, of insomnia to be 36·1% (defined as a total score of ≥8 in the Insomnia Severity Index), and of stress-related symptoms (defined as a total score of ≥9 in the Impact of Events Scale-Revised) to be 73·4%. These findings are important in enabling health authorities to allocate health resources and develop appropriate treatments for medical staff who have mental health problems. Secondly, online mental health education with communication programmes, such as WeChat, Weibo, and TikTok, has been widely used during the outbreak for medical staff and the public. In addition, several books on COVID-19 prevention, control, and mental health education have been swiftly published and free electronic copies have been provided for the public. As of February 8, 29 books associated with COVID-19 have been published, 11 (37·9%) of which are on mental health, including the “Guidelines for public psychological self-help and counselling of 2019-nCoV pneumonia”, published by the Chinese Association for Mental Health. Finally, online psychological counselling services (eg, WeChat-based resources) have been widely established by mental health professionals in medical institutions, universities, and academic societies throughout all 31 provinces, municipalities, and autonomous regions in mainland China, which provide free 24-h services on all days of the week. Online psychological self-help intervention systems, including online cognitive behavioural therapy for depression, anxiety, and insomnia (eg, on WeChat), have also been developed. In addition, several artificial intelligence (AI) programmes have been put in use as interventions for psychological crises during the epidemic. For example, individuals at risk of suicide can be recognised by the AI programme Tree Holes Rescue, 5 by monitoring and analysing messages posted on Weibo, and alerting designated volunteers to act accordingly. In general, online mental health services being used for the COVID-19 epidemic are facilitating the development of Chinese public emergency interventions, and eventually could improve the quality and effectiveness of emergency interventions.
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            Posttraumatic Stress Disorder in Parents and Youth After Health-Related Disasters

            This study investigated the psychosocial responses of children and their parents to pandemic disasters, specifically measuring traumatic stress responses in children and parents with varying disease-containment experiences. A mixed-method approach using survey, focus groups, and interviews produced data from 398 parents. Adult respondents completed the University of California at Los Angeles Posttraumatic Stress Disorder Reaction Index (PTSD-RI) Parent Version and the PTSD Check List Civilian Version (PCL-C). Disease-containment measures such as quarantine and isolation can be traumatizing to a significant portion of children and parents. Criteria for PTSD was met in 30% of isolated or quarantined children based on parental reports, and 25% of quarantined or isolated parents (based on self-reports). These findings indicate that pandemic disasters and subsequent disease-containment responses may create a condition that families and children find traumatic. Because pandemic disasters are unique and do not include congregate sites for prolonged support and recovery, they require specific response strategies to ensure the behavioral health needs of children and families. Pandemic planning must address these needs and disease-containment measures. (Disaster Med Public Health Preparedness . 2013;7:105-110)
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              Is Open Access

              Understanding differences between summer vs. school obesogenic behaviors of children: the structured days hypothesis

              Background Although the scientific community has acknowledged modest improvements can be made to weight status and obesogenic behaviors (i.e., physical activity, sedentary/screen time, diet, and sleep) during the school year, studies suggests improvements are erased as elementary-age children are released to summer vacation. Emerging evidence shows children return to school after summer vacation displaying accelerated weight gain compared to the weight gained occurring during the school year. Understanding how summer days differ from when children are in school is, therefore, essential. Discussion There is limited evidence on the etiology of accelerated weight gain during summer, with few studies comparing obesogenic behaviors on the same children during school and summer. For many children, summer days may be analogous to weekend days throughout the school year. Weekend days are often limited in consistent and formal structure, and thus differ from school days where segmented, pre-planned, restrictive, and compulsory components exist that shape obesogenic behaviors. The authors hypothesize that obesogenic behaviors are beneficially regulated when children are exposed to a structured day (i.e., school weekday) compared to what commonly occurs during summer. This is referred to as the ‘Structured Days Hypothesis’ (SDH). To illustrate how the SDH operates, this study examines empirical data that compares weekend day (less-structured) versus weekday (structured) obesogenic behaviors in U.S. elementary school-aged children. From 190 studies, 155 (~80%) demonstrate elementary-aged children’s obesogenic behaviors are more unfavorable during weekend days compared to weekdays. Conclusion In light of the SDH, consistent evidence demonstrates the structured environment of weekdays may help to protect children by regulating obesogenic behaviors, most likely through compulsory physical activity opportunities, restricting caloric intake, reducing screen time occasions, and regulating sleep schedules. Summer is emerging as the critical period where childhood obesity prevention efforts need to be focused. The SDH can help researchers understand the drivers of obesogenic behaviors during summer and lead to innovative intervention development.
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                Author and article information

                Contributors
                Journal
                Lancet
                Lancet
                Lancet (London, England)
                Elsevier Ltd.
                0140-6736
                1474-547X
                4 March 2020
                4 March 2020
                :
                Affiliations
                [a ]Department of Developmental and Behavioral Pediatrics, Pediatric Translational Medicine Institute, Shanghai Children's Medical Center affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
                [b ]Child Health Advocacy Institute, Shanghai Children's Medical Center affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
                [c ]MOE-Shanghai Key Laboratory of Children's Environmental Health, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
                Article
                S0140-6736(20)30547-X
                10.1016/S0140-6736(20)30547-X
                7124694
                32145186
                9a03bf9b-7d08-42df-a4ee-6b52d65f9c59
                © 2020 Elsevier Ltd. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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