Revista Portuguesa de Investigação Comportamental e Social 2021 Vol. 8(2): 1–16
Portuguese Journal of Behavioral and Social Research 2021 Vol. 8(2): 1–16
e-ISSN 2183-4938
Departamento de Investigação & Desenvolvimento • Instituto Superior Miguel Torga

ARTIGO ORIGINAL*

Mental health and social protection of children during times of crisis: The case of the COVID-19 pandemic

Saúde mental e proteção social de crianças em tempos de crise: o caso da pandemia de COVID-19

Rafael Nicolau Carvalho 1

Antonia Picornell-Lucas 2

1 Federal University of Paraiba, Department of Social Work, Center of Human Sciences and Arts (CHSA), Brazil

2 University of Salamanca, Department of Labor Law and Social Work, Spain

* Estudo apresentado no CEDH, III Conferencia Euroamericana Para o Desenvolvimento Dos Direitos Humanos, 2021

Recebido: 13/05/2022; Revisto: 14/09/2022; Aceite: 02/11/2022.

https://doi.org/10.31211/rpics.2022.8.2.264

Introduction

Humanity has faced numerous periods of crisis throughout history, such as wars, natural disasters, and pandemics. The world has also dealt with crises' social and economic repercussions, as severe as the crises themselves. These situations have brought people intense suffering, impairing their physical and mental health. Children and adolescents have dramatically experienced those emergencies and their effects, often being their main victims.

The current global health crisis was associated with a new infectious disease called COVID-19 caused by a new coronavirus (SARS-Cov-2). The fast global spread led the World Health Organization to declare the infection a new pandemic on March 11, 2020, given the community contagion in several countries (World Health Organization [WHO], 2020). Once again, children and adolescents were affected by the deepening new crisis. In 2020, there was scientific evidence of impacts on children's mental health, with the development of different symptoms (Avila et al., 2020; Miranda et al., 2020; Wang et al., 2020). During the deepening of the pandemic, new evidence emerged about the impacts on mental health and the challenges to social protection systems (Almeida et al., 2022; Katz et al., 2022). Moreover, how the crisis affected families broadly compromised children's mental health and capacity to respond to the situation (Bai et al., 2022; Prime et al., 2020). Therefore, children are undergoing this crisis, experiencing its impacts and worrying about their families, friends, and the community's social situation (James et al., 2022; Saurabh & Ranjan, 2020).

As the COVID-19 pandemic spread and deepened, there was a significant increase in mental health reports, many of which related to the children's situation. These reports also highlighted cases of violence and abuse against children and adolescents (The Alliance for Child Protection in Humanitarian Action, 2020; Ritz et al., 2020; United Nations International Children's Emergency Fund [UNICEF], 2020), which compromise mental health and are major violations of their rights. In addition, many international organizations, research centers, and professional societies from several countries have published warnings and recommendations on the well-being of children during the quarantine and social distancing measures (Coordinadora de Organizaciones para el Desarrollo, 2020; International Federation of Social Workers, 2020; Jones et al., 2020; Marques et al., 2020; UNICEF-Spain, 2020a, 2020b).

The initial evidence motivated us to reflect on these processes, articulating our areas of expertise, mental health care, and social protection of children. These areas are present in health networks and social welfare systems that meet children's demands. In some contexts, they are articulated in broad care networks composed of different social services.

This article reflects on mental health care and social protection for children and adolescents, focusing on the social crisis caused by the COVID-19 pandemic. This reflection is supported by an analysis of literature conducted during the critical period of the pandemic on its impact on children's mental health. Furthermore, we adopt an interdisciplinary approach, as we believe that different knowledge can be integrated to understand complex situations and a perspective that understands children's and adolescents' mental health and comprehensive protection as a fundamental human right (Newell, 2001; UN High Commissioner for Human Rights, 1989, 2017).

The worldwide pandemic containment measures today have decreased in many countries due to the widespread vaccination of the population, which has resulted in the gradual reduction of infections and deaths. However, given the evidence of the onset of the pandemic and its worsening during its course, and based on our analysis, we believe that the articulation of mental health care with social protection networks should be strengthened for a post-pandemic context. 

Methods

Our reflections are based on a bibliographic non-systematic review (narrative review), used when the researcher needs to identify, map, and characterize concepts or identify knowledge about some problem. It differs from systematic review research because it seeks to answer broader questions and does not intend to evaluate results or evidence (De-la-Torre-Ugarte-Guanilo et al., 2011). For this reason, we chose only one database. We conducted this bibliographic review on the Scopus database, an internationally reputable abstract and citation database for academic literature that includes important journals from different areas of knowledge with high-quality publications.

We proceeded with a search on the Scopus database, with the following terms: "COVID-19", "Mental Health", "Children", and "Childhood". The terms were combined using "AND" as a Boolean operator. The search was conducted in 2020, during the most critical phase of the pandemic, when much empirical evidence about the impact on children's mental health emerged. As a language parameter, we chose material published in English. We performed two searches on the platform, one combining the terms "COVID-19, Mental Health, AND Children", and, in the second search, we changed the last term to "Childhood".

With the first combination, we identified 264 publications and 28 with the second. This number of publications demonstrates the theme's emergence and importance for different research areas. However, the results included various texts such as articles, book chapters, conference papers, and editorials. We chose to focus the analyses only on journal articles because they were peer-reviewed publications and were mostly based on empirical evidence and theoretical discussion. After applying the filter of publication type on the Scopus platform, we identified 161 articles for the first descriptor and 17 for the second.

Another methodological procedure was to apply the following selection and exclusion criteria.

1. Selection criteria:

a) Studies with primary data collection, review studies, guidelines, editorial, and brief communications;

b) Studies regarding children's and adolescents' mental health and associated factors;

c)  Articles that focused on children and adolescents and their social relationships.

2. Exclusion criteria:

a) Studies that dealt exclusively with professional practice with children and/or adolescents.

b) Duplicated and non-peer-reviewed studies.

c)  Studies focused on other population groups.

After applying the selection and exclusion criteria, 35 articles remained. Most articles (32) were related to the first combined descriptor: "COVID-19, Mental Health, AND Children". Three articles were associated with the second combined descriptor: "COVID-19, Mental Health, AND Childhood".

The following procedure was the entire reading of articles and searching for elements that might answer our two research questions: 1) How did the pandemic impact children's and adolescents' mental health? 2) What measures can mitigate its effects on children? These questions were also applied as the criterion to include the articles in the narrative synthesis. After these analyses, we included 27 articles: 25 related to the first descriptor and two connected to the second.

We systematized the information extracted from the articles in two protocols. The first one was to identify studies, and the second comprised relevant information extracted from the articles, such as statistical data, theoretical approach, related studies, and discussions of aspects.

We proposed three main thematic categories and subcategories to synthesize the information and discussions:

1. Impacts on children's mental health;

a) Individual risk;

b) Family relationships;

c)  Social vulnerability;

2. Community resources;
3. Mitigation strategies of pandemic impact.

The thematic categories emerged from the analyses of the 27 articles selected. This categorization and our reflections were based on the formulation of a recommendation guide with mental health and social protection strategies for health professionals, families, schools, governments, and social protection systems. These proposals can be adopted to minimize the mental health pandemic effects and strengthen social protection for children and adolescents in a post-pandemic context. Although the literature review was done in 2020, the categories remain current, and the guide has been revised considering the most recent publications.

Analyzing the articles allowed us to find the first evidence published of the extension of pandemic impacts on children's mental health.

The following section presents the results and the main aspects of the 27 articles.

Results

As part of the results from the literature review, we consolidated some information from included articles that provided preliminary conclusions. For example, regarding the type of article, we identified studies with empirical data collection (n = 11); reflection articles (n = 11); literature review articles (n = 3); systematic review (n = 1), and research report (n = 1) (Table 1).

Table 1

Categories and Characteristics of the Articles Analyzed

Eleven articles presented results from studies conducted with children and their caregivers during the pandemic. Eleven reflective articles discussed important aspects of the impact of the COVID-19 pandemic on children's and adolescents' mental health, linking different theoretical approaches and exploring the role of the family, health services, and the school. Three literature review articles addressed issues emphasizing the effects of quarantine and especially the importance of the school system as a protective space for children. Only one included article was based on a systematic review that analyzed publications on psychological impacts on children during isolation, showing increased fear, acute stress, social exclusion, and stigma associated with the disease (Imran et al., 2020). An article, classified as a report, presented an experience with child mental health developed by a project team in Shanghai, China. It described a platform that gathered information about COVID-19 and provided consultations with children and family members in addition to promoting events and conferences to guide the population (X. Zhang et al., 2020).

Regarding the authors' country, we identified the following frequencies: USA, n = 7; Italy, n = 6; China, n = 4; Australia, n = 3; Brazil, n = 2; Canada, South Korea, Pakistan, India, and Bangladesh, with one publication each. These results may indicate a concern with children's and adolescents' mental health in different countries. However, the number of studies did not numerically express the gravity and extent of the problem.

According to the categorization that emerged from the analyses, we classified most articles as impacts on children's mental health (n = 17). This main category comprised three subcategories: individual risk (n = 9), family relationships (n = 5), and social vulnerability (n = 3). The other categories had lower frequencies: community resources (n = 5) and mitigation strategies (n = 5). 

Most articles discussed the impacts of the pandemic on children's mental health with more emphasis on individual risks. However, it is worth mentioning that there was an intertwining between the themes. Therefore, the articles were classified according to the greater emphasis on each category.   

The following section presents our reflections associated with each thematic category and the synthesis of findings and discussions from the included articles.

Discussion 

In this section, we organized the analysis into thematic categories, taking elements from the included articles and our reflections. We also introduced in each category some notes about the current context of the pandemic to demonstrate the topic's timeliness.

Impacts on children's mental health

In general, all the reviewed articles addressed the impacts of the COVID-19 pandemic on children's and adolescents' mental health; however, not all had this subject as a central objective. The content analyses suggested three subcategories associated with the mental health impacts of the pandemic, already mentioned in the method section: individual risk, family relationships, and social vulnerability.

Individual risk

The revised articles addressed the emotional and psychological consequences for children's emotional and cognitive development caused during a pandemic. These articles emphasized the increase in anxiety, fear, anguish, perceived stigma related to the disease, and depression in children in various contexts. These symptoms were related to the increased stress caused by the isolation measures, the restriction of contact with loved ones, and the closing of institutions involved in children's human development, such as schools and other social services (Duan et al., 2020; Li et al., 2020; Yeasmin et al., 2020). A study also suggested that the increase in children's suffering during the social distancing period was related to the psychosocial impact caused by the pandemic on families, such as job loss and precarious socioeconomic conditions (Saurabh & Ranjan, 2020).

The articles also emphasized the consequences for children with mental health problems, such as Attention Deficit Hyperactivity Disorder and autism (Colizzi et al., 2020; J. Zhang et al., 2020). The study by J. Zhang et al. (2020) investigated the mental health conditions of children with ADHD during confinement. The study was carried out with 241 parents who had school-age children with ADHD and revealed that, during isolation, the symptoms were intensified by breaking the daily routine and lacking social interaction.

Avila et al. (2020) developed a cross-sectional online study conducted in Brazil with 289 children and their guardians. The results indicated a prevalence of anxiety of 19.4% using the Children's Anxiety Questionnaire and 21.8% using the Numerical Rating Scale. Compared to previous studies, this data revealed a high prevalence of anxiety in the participants. The authors pointed out that although the development of COVID-19 among children was less dangerous than in other age groups, they were subject to negative outcomes due to economic and social disruption. The lack of access to public services can increase the children's risk of violence and abuse, as reported during the confinement. The pandemic broadly affected children's health, safety, education, and well-being.

Duan et al. (2020) conducted a study in China assessing the mental health status of children and adolescents affected by the COVID-19 pandemic. The cross-sectional study was conducted online with 359 children (7–12 years) and 3,254 adolescents (13–18 years) in 20 provinces. The survey revealed a prevalence of anxiety in children of 23.87% and 29.27% in adolescents. In addition, the authors demonstrated that 22.28% of participants suffered from some depressive symptoms.

Imran et al. (2020) developed a systematic literature review in three databases to analyze the impact of quarantine and isolation on children's and adolescents' mental health. The authors pointed out significant evidence of emotional effects on children and adolescents' mental health in studies conducted in Italy, Spain, and China. They concluded that quarantine and social distance negatively affected children's mental health and that the stigma resulting from the disease and quarantine contributed to the increase in psychological distress.

We can conclude that the articles classified in the subcategory of individual risk presented evidence that the impacts on children's mental health were due to the measures adopted to curb the contagions, such as quarantine and social isolation. This impact was related to the children's responses to the stress and uncertainty that threatened their and their families' well-being (Li et al., 2020). These studies recognized that the social conditions of families and the way they faced confinement measures interfered with family life, disrupting and intensifying relationships and consequently affecting children, as the stressful events to which families were subjected were significant and long-lasting (Linhares & Enumo, 2020; Yeasmin et al., 2020).

Children and adolescents' mental health impacts continued to be analyzed in the years following the pandemic. We also emphasize other issues that emerged, such as the return to school, vaccination difficulties, and the transition to a post-pandemic context (Baxter et al., 2022; Esposito et al., 2022). 

Family relationships

In this subcategory, the articles addressed how the COVID-19 pandemic may threaten children's well-being. Studies demonstrated this impact on families' and children's adjustment by considering other crises, such as disasters, terrorism, economic upheavals, and adverse social conditions, such as poverty. Considering this evidence, studies showed that children's adjustment to these situations depended on family relationships (Prime et al., 2020; Russel et al., 2020). The pandemic affected families due to its broad social and economic impact; however, those with precarious social conditions, pre-existing mental health problems, or who experienced violence and racism were more vulnerable. On the other hand, families that did not have their well-being affected could provide a more protective environment for children.

Russell et al. (2020) analyzed the impacts of the COVID-19 pandemic on parent-child relationships through an online survey in the USA with 420 parents/caregivers during the first months of the pandemic. The results indicated that 27.9% of participants belonged to racial-ethnic minorities. The study suggested that the pandemic produced post-traumatic stress with repercussions at the individual, family, and community levels. Participants spoke about the intensification of depression and overload in caring for children, increased conflicts, and difficulty perceiving the children's suffering. In addition, the data analyses indicated that how parents experienced trauma caused by the pandemic affected children's well-being.

Another issue was families' difficulties dealing with isolation, leading to increased stress in children. This situation placed children in touch with their parents' negative emotions, possibly impacting their well-being. Therefore, they needed support from their families to facilitate this process of understanding. However, with increasing family stress, adults may respond to children's needs with rude and aggressive attitudes. Consequently, the authors advocated support for the family through health services, school, and social services. Only with this support will it be possible to help parents and children overcome that critical period, minimizing the long-term effects (Spinelli, Lionetti, Pastore et al., 2020; Spinelli, Lionetti, Setti et al., 2020). The importance of supporting families through social protection strategies seems to be evident. These issues should be further explored in other studies during the following years of the pandemic.

Social vulnerability

This subcategory is related to adverse social contexts. The articles demonstrated how the pandemic interacted with unfavorable social conditions, making them worse. Thus, the studies highlighted that precarious, unsafe, and violent environments could expose children and adolescents to abuse, especially during confinement.

Cuartas (2020) reflected on children's and adolescents' risks to violence during the pandemic. The author drew attention to family support services, particularly for those with financial difficulties, and the need for extensive psychosocial support through social services to reduce the consequences of stressful situations.

Teo and Griffiths (2020) emphasized children's risk of suffering abuse and domestic violence during the pandemic in Australia. Their study suggested a stronger risk in families with precarious socioeconomic conditions and children with disabilities, although the effects of the pandemic affected all families. Added to this situation was the closure of public services involved in the care of children, such as schools, daycare centers, and mental health services. The authors pointed out that it was already known that families in situations of poverty and with children with disabilities had higher rates of abuse. The closure of schools and the difficulty of accessing health services can limit the spaces that could prevent violence and abuse and help to forward complaints (Cuartas, 2020; Teo & Griffiths, 2020).

We can conclude the COVID-19 pandemic was an event with repercussions not only for health but also interacted with economic and social conditions and increased the risks of people who were already vulnerable. Poor economic conditions and an unsafe and violent family environment can expose children to abuse and violence in quarantine and confinement. It is worrying because there is evidence in the literature that early exposure to situations of violence has repercussions for children's adult lives in terms of mental health.

Community Resources

Community resources are important for developing children's and families' well-being. Several included articles already presented this theme as part of discussions and recommendations. In this category were included those articles which explored with greater emphasis the role of these resources, particularly the school and mental health services, as well as the articulation of these services in facing the effects of the pandemic (Bahn, 2020; Weisbrot & Ryst, 2020).

Phelps and Sperry (2020) stated that substituting face-to-face meetings for remote teaching activities to restrain the disease had been widely discussed. However, there was not much discussion about children who depended on school for social support, such as those who needed access to nutritious meals or with special educational needs and disabilities, as well as children with mental health problems.

Weisbrot and Ryst (2020) argued that schools and mental health services should work in a coordinated manner to assist children returning to school, especially the most vulnerable and with mental health problems. The authors also pointed out that educational inequalities would further amplify the negative impact on marginalized communities at risk of exclusion and without basic educational tools such as computers and internet access.

Some articles analyzed the role of the school, its importance, and the challenges faced when returning to classes in the new normal. Some analyses considered aspects such as access to technology, remote education, and overload of families when trying to reconcile remote work and teaching their children in the same home space during the pandemic (Petretto et al., 2020; Phelps & Sperry, 2020).

In the scope of health, proposals for attention to parents and children emerged through telehealth to support the most vulnerable families, reducing traumatic stress, anxiety, and depression in caregivers and preventing abuse (Gurwitch et al., 2020).

The Mitigation Strategies of Pandemic Impact

In this category, we classified articles that presented strategies to mitigate pandemic impacts on child health from various angles of analysis, considering parent-child care as an intervention model for social services. They emphasized strategies that considered existing conditions and for transition in the post-pandemic (Muratori & Ciacchini, 2020).

Some articles approached the ways of communication with children and suggested didactic resources to address the pandemic with them (e.g., Bellizzi et al., 2020). Others systematized actions to address the effects on children and young people (Jones et al., 2020) and reported experiences in caring for children and collective efforts with the population through digital platforms and telehealth (X. Zhang et al., 2020).

Muratori and Ciacchini (2020) discussed the importance of families in creating a safe dialogue using an accessible language. They suggested that parents should pay attention to their children's signs of stress, such as expressions of fear, anxiety, and sleep disorders. The authors warned that the closure of schools had changed the routine. Therefore, new ones needed to be created to maintain continuity, mainly in study and leisure activities.

Jones et al. (2020) analyzed the intensification of children's and young people's vulnerabilities due to the COVID-19 pandemic. The authors defined vulnerable people as those whose health and well-being results were lower than those of the general population and who had difficulty accessing support services. Therefore, they emphasize the need to strengthen the responses of social protection and health services.

The need for international cooperation and the exchange of experiences was also evident to overcome the devastating pandemic effects, especially on children's populations. These strategies became more noticeable as the pandemic deepened. Many institutions for the protection of children's rights published recommendations for the care of this population. The importance of the various support services for children was recognized, such as the school, shelter centers, spaces for coexistence, protection councils, and psychosocial care services, especially for the most vulnerable families.

Recommendation Proposal

The analysis of articles allowed us to find evidence of the worldwide extension of pandemic impacts on children's and adolescents' mental health and the challenges for social protection systems. Our analysis captured a particular moment of the pandemic; nonetheless, during its course, the deepening of many of the issues raised by the publications at that juncture was observed.

We have seen the challenges imposed on governments, professionals, and families in dealing with the impacts of the pandemic and how these impacts could be minimized by strengthening institutions and the rights of children and adolescents. Children and adolescents have rights recognized by the UN Convention on children's rights (1989); however, this recognition needs to be made effective by expanding their participation in the construction of policies that serve them to incorporate their voices.

The emergent analytical categories seem to be related to the fragility of care policies for children and the degradation of respect for their rights.

Considering our discussion and the organizations' recommendations on children's protection, we have systematized a guide with some strategies that can be utilized to mitigate the effects and impacts of mental health, taking into consideration the rights of children and adolescents (Table 2). The guide's categories emerged from the analysis of the 27 articles in the narrative review and some evidence and conclusions about individual risks, family relationships, socialization spaces, and children in vulnerable situations.

The suggested actions can be developed with different groups and can also be a topic for discussion among professionals who work in the health, education, and social protection systems. They can also be used as an agenda for the managers of public policies and social movements, groups, and organizations to demand these actions from their governments during times of crisis or to strengthen the action in a post-pandemic context. 

Table 2

Recommendations for Protecting Children's Rights During Crises

Final Considerations

The Covid-19 pandemic has affected all countries. Consequently, the governments have adopted harsh containment measures that, combined with the particularities of each context, affected mainly the physical and mental health of children and adolescents.

The measures imposed to contain the pandemic, such as the closing of schools, leisure spaces, and childcare services, as well as restriction of contact with family, friends, and peer relationships due to isolation, became risk factors that threatened child social development and emotional wellbeing, causing constant stress.

The pandemic has aggravated situations of exclusion for different population groups in many countries. During their development in the following years, we saw these effects on the most vulnerable children and adolescent populations.

These issues had a more profound effect on children and adolescents, especially in specific vulnerable groups (migrants and refugees, with special educational needs, living with disability, street children, or placed in a protection institution). Therefore, measures must be taken considering children’s rights and recognizing the social, cultural, gender, age, and race as determinants aspects.

This article problematized the impacts of the Covid-19 pandemic on children’s mental health and the measures that can be taken to mitigate its effects during a health crisis or to guide a transition to a post-pandemic scenario. The review of studies helped us systematize care strategies based on articulated and coordinated actions between the social protection, education, and health systems.

As a narrative review, this study focused on the main reflections from the articles included to construct a guide with recommendations for the social protection of children and adolescents based on their rights. Therefore, one limitation of our approach was the lack of a deeper evaluation of methodologies developed on the studies and a more comprehensive analysis of their results. Further studies should develop those critical analyses to suggest other methodological procedures. Despite this limitation, our reflections were based on important evidence that emerged during the development of the pandemic. These aspects from the included publications also suggested that the debate presented is current and relevant for post-pandemic social situations that children and adolescents are facing.

Based on the analysis, we argue that it is necessary to consider how this pandemic has affected social protection systems and deepened individual, family, and community vulnerabilities, especially for children. Children’s rights cannot be neglected in crises, especially the rights of children in situations of risk and/or social exclusion. On the contrary, the care system must be strengthened.

The need to have a mental health system that guarantees integral care for children, providing them with the maximum opportunities for their development, is justification for offering sustainable transversal policies and actions that promote specific measures and endorsing specific procedures with gender mainstreaming. In summary, this guide can be an important tool to advance child and family mental health protection systems based on children’s and adolescents’ rights.

Conflict of interest | Conflito de interesses: There was no conflict of interest.

Funding sources | Fontes de financiamento: This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001.

Contributions | Contributos: RNC:  Conceptualization: developed the initial argument and formulated the objectives. Methodology: planned the study methodology. Formal analysis: carried out the thematic analysis of the collected material. Investigation: conducted the investigation; Writing - Original draft: prepared the first version of the material with the introduction, methodology, and analysis. Funding Acquisition. AP-L:  Conceptualization: participated in the development of the initial argument and the formulation of objectives. Methodology: supervised the study methodology. Formal analysis: supervised the thematic analysis of the material. Writing - Review & Editing: performed critical review of the original draft.

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