Parents' Stress and Children's Psychological Problems in Families Facing the COVID-19 Outbreak in Italy

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.

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) 1 , SARS-CoV-2 or COVID-19. 2 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. 3 COVID-19 infection rapidly spread throughout China, involving the provinces of Chongqing, Hunan, Anhui, Henan, Jiangxi, and Shaanxi. 4 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. 5 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. 4 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. 6 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. 7 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. 7 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. 8 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 9 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. 10 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 10 commonly used for a cross-cultural assessment of anxiety disorders, including depression. 11 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. 12 , 13 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. 14 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. 20 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. 21 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. 22

To control the transmission of coronavirus disease 2019 (COVID-19), the Chinese Government has implemented strict domestic quarantine policies. As of March 24, 2020, more than 80 000 individuals with COVID-19, and 690 000 individuals who have come into close contact with individuals with COVID-19 have been registered and quarantined, including a large number of children. 1 This quick action has effectively slowed the spread of new cases of infection on both the Chinese mainland and the rest of the world. However, researchers have realised that such measures might have adverse psychological effects on children who are quarantined. For children who are quarantined at home with their parents or relatives, the stress caused by such a sharp change in their environment might be eased to some degree. 2 However, children who are separated from their caregivers require special attention, including children infected with or suspected of being infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), who are quarantined in local hospitals or collective medical observation centres; and children whose caregivers are infected with SARS-CoV-2 or who have died from the disease and are thus under the care of social charity groups. These children might be more susceptible to mental health problems because of their higher risk of infection, and the grief and fear caused by parental loss or separation. Companionship is essential for children's normal psychological development and wellbeing. 3 Separation from caregivers pushes children into a state of crisis and might increase the risk of psychiatric disorders. 4 Sprang and colleagues 5 reported that children who were isolated or quarantined during pandemic diseases were more likely to develop acute stress disorder, adjustment disorder, and grief. 30% of the children who were isolated or quarantined met the clinical criteria for post-traumatic stress disorder. 5 Furthermore, separation from parents or parental loss during childhood also has long-term adverse effects on mental health, including a higher risk of developing mood disorders and psychosis, and death by suicide in adulthood.6, 7 The age of the initial separation is known to be relevant to psychological development. The parent–child separation initiated in the first few years after birth might disrupt the ongoing attachment processes, which might be associated with poorer mental health outcomes. 8 The Chinese Government has implemented a series of strategies to prevent the potential mental health problems that might arise among children who are quarantined during the COVID-19 pandemic. For example, in many Chinese tier 1 cities —typically the largest and wealthiest—like Shanghai, Guangzhou, and Hangzhou, nurses are guaranteed to be available 24 h per day in the children's isolation ward. Nutritionists are invited to give professional guidance for children's diets according to their medical conditions and normal developmental requirements. To reduce fear and other psychological discomfort, children who are quarantined can communicate with their parents via mobile devices at any time. Many citizens from the local community or district volunteers act as temporary mothers to care for recovered children after their discharge, when their caregivers are not available because of infection, quarantine, or death. In response to the notice on improving rescue and protection for children without effective guardianship issued by the Ministry of Civil Affairs, many cities like Zhengzhou opened free psychological counselling hotlines, which were available 24 h per day. 9 Most recently, the National Health Commission of China issued guidelines and listed specific intervention strategies for children who are quarantined in collective medical observation centres. For example, these measures seek to increase children's communication time with their parents; increase children's access to disease information via comic books and videos; guide children to establish a regular activity schedule; provide night lights and small gifts; and provide timely referrals to psychiatrists when children feel mental discomfort, such as worry, anxiety, difficulty sleeping, and loss of appetite. 10 Although great efforts have been made across China, the emerging psychological interventions are unlikely to be provided nationwide because most local support for unaccompanied children focuses only on meeting children's basic daily needs. We propose that paediatric health-care workers should receive formal training to facilitate the early identification of children's mental health problems by learning to discern children's normal and abnormal behaviours, recognise red flags indicating further intervention or referral are needed, and standardise the use of rapid screening tools for mental health. Furthermore, mental health professionals should establish evidence-based guidelines and easy operational strategies to cope with COVID-19 pandemic-related mental health problems in children. We also believe that children's access to mental health services can be improved through collaborative networks that are established nationwide and consist of psychiatrists, psychotherapists, researchers, and community volunteers. Additionally, the post-pandemic surveillance of mental disorders among these children should be considered. Since the global transmission of COVID-19 began, the total number of cases in countries other than China have already exceeded that in China. Following WHO's recommendation, an increasing number of countries have learned from China's experience with regard to quarantine policies. We suggest that the specific response to the mental distress of children who are quarantined should also be considered when designing psychological intervention strategies in response to COVID-19. © 2020 estherpoon/iStock 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.