key: cord-0773300-a402j879
authors: Muratori, Pietro; Ciacchini, Rebecca
title: Children and the Covid-19 Transition: Psychological Reflections and Suggestions on Adapting to the Emergency
date: 2020-04-03
journal: Clinical neuropsychiatry
DOI: 10.36131/cn20200219
sha: 83cbeaeac15dbae69db7fd26ecc76181fe726ece
doc_id: 773300
cord_uid: a402j879

The current period of transition due to COVID-19 emergency may negatively affect the psychological functioning of children and require resources aimed at supporting post-transition adaptation. Few contributions exist which specifically focus on what to do in such circumstances in order to assist the mental health of both children and parents. It seems therefore critical to provide strategies, which support the adjustment of children during the pre-existing and post-transition periods. Furthermore, screening projects are required in order to identify those children with increased levels of emotional and behavioural issues, beyond the COVID-19 transition, in order to plan specific interventions.

On 30th January 2020, following reports from China (31st December 2019) of a cluster of cases of pneumonia of unknown etiology (later identified as Sars-CoV-2 coronavirus) in the city of Wuhan, the World Health Organization (WHO) declared the coronavirus epidemic in China to be a public health emergency of international concern. The following day, the Italian government, building on preliminary precautionary measures adopted on 22nd January, and considering the particularly widespread nature of the epidemic, proclaimed a state of emergency and implemented initial measures to contrast potential contagion across the country. Meanwhile, worldwide governments have ordered schools closure as an emergency measure to prevent spreading of the infection, leaving millions of children and adolescents confined to their homes. In Italy, a set of preventative measures declared that: 1) leaving the home is prohibited other than for reasons of work, health, or other motivated necessities 2) all gatherings in public places or those open to the public are forbidden throughout the entire country 3) sporting events and competitions of any kind or discipline are suspended, in both public and private locations (http:// www.salute.gov.it/nuovocoronavirus; access made on 14.04.2020 at 3.12 PM). Although all the measures mentioned above are highly necessary, as highlighted by Wang, Zhang, Zhao, Zhang, & Jiang (2020) in The Lancet, "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". Moreover, on 25 th March 2020, a statement by UNICEF Executive Director Henrietta H. Fore declared that children, as hidden victims of this pandemic, are affected by school closures in terms of "education, mental health and access to basic health services. The risks of exploitation and abuse are higher than ever, for boys and girls alike. For children on the move or living through conflicts, the consequences will be unlike any we have ever seen. We must not let them down" (https://www.facebook.com/ unicef/posts/10158076537159002:0; access made on 14.04.2020 at 4.14 PM).

In this context, the measures implemented by worldwide Governments thus placed children and their caregivers in a period of uncertainty and a process of transition for an indefinite time. Human life is characterized by several periods of transition, for which the initial condition is frequently known but the duration and characteristics of the transition unknown (Graber & Brooks-Gunn, 1996) . Transition periods such as that presented by COVID-19 are characterized by the disequilibrium of both the emotional state of individuals and interpersonal relationships. Overall, every sanitary emergency also generates a psychological emergency, which requires specific skills and interventions that must be delegated to mental healthcare professionals (Conversano, Marchi, & Miniati, 2020; Di Giuseppe, Conversano, & Gemignani, 2020; Orrù, Ciacchini, Gemignani, & Conversano, 2020; Brooks et al., 2020; Wang, Zhang, Zhao, Zhang, & Jiang, 2020; Cluver et al., 2020; Carmassi et al., 2017) . This specific aspect seems to be decisive for the long-term consequences of stressful high-impact events such as diseases and health emergencies, specifically on mood and PTSD PERSPECTIVE ARTICLE symptomatology (Jarvis, gordon, & novaco, 2005; Winje & ulvik, 1998; dell'Osso et al., 2011; dell'Osso et al., 2014; Veltri et al., 2012; Conversano, 2019) .

Childhood is typically characterized by multiple transitions, such as, for example, the transition from primary school to secondary school. during such periods of transition, the relationships of the child with their parents, peers, and teachers as well as their daily routine, may be no longer appropriate to the new situation. the mind of the individual child must therefore revise their beliefs as well as placing greater attention on the regulation of emotions under the pressure of increased arousal levels (James & Prout, 2015) .

the COVid-19 transition may be characterized by several unexpected changes for children such as, for example: (a) new intense emotions within the family context such as worries about the future; (b) little or no relationship with classmates and peers; (c) new teacherstudent relationships and new educational demands; (d) no possibility to practice sports and physical activities.

Other studies highlight that during quarantine children may be stressed by its duration, a fear of infection, feelings of frustration and boredom and a fear of asking questions about the epidemic (Sprang & Silman, 2013; Wang, Zhang, Zhao, Zhang, & Jiang, 2020; Cluver et al., 2020) . furthermore, recent unpublished Chinese data investigated sleep quality (reporting an increase in nightmares), appetite, physical discomfort, agitation and lack of attention, clinginess, and issues of separation (Jiao et al., 2020) .

This complex new situation requires children to adjust, leading to consequences for their psychological health. most children will experience a successful COVid-19 transition, while for others this adjustment may be associated with individual costs and may ultimately be unsuccessful. the chance of failure during this transition may, consequently, lead to an increase in children internalizing problems (depression, withdrawal, and anxiety) as well as externalizing problems (problems with self-regulation and aggressive behavior). following the research of lohaus et al. (lohaus, elben, Ball, & Klein-hessling, 2004 ), a number of gender-specific differences in coping with this new stressful situation may be identified: internalizing problems will be more likely for girls than for boys. Conversely, boys, rather than girls, report a greater frequency of the externalization of problems (forehand, neighbors, & Wierson, 1991) .

Fortunately, resources are available that may buffer against these negative outcomes associated with such a transition for children. Professional opinions in the field have therefore been gathered, taking into consideration the most authoritative research on strategies for dealing with emergencies in childhood. from an ecological perspective (Bronfenbrenner, 1979) , major transitions, such as with COVid-19, are associated with an increased need for external resources in order to adapt to new situations in daily life. several studies highlight the relevance of supportive social contexts and relationships (such as the family, peers, or schools) during stressful life events (Zimmerman et al., 2013; Gniewosz & Gniewosz, 2020) . Specifically, children can only count on the support of caregivers during the COVid-19 transition. it can therefore be supposed that the parent-child relationship serves as a buffer against the negative effects of transition in children. Moreover, findings regarding periods of transition emphasize that those children who perceive the emotional support and supportive care from their parents are less likely to demonstrate emotional issues during periods of life transition (Pettit, roberts, lewinsohn, seeley, & yaroslavsky, 2011) .

Parents can support their children in several ways during this period of their life. firstly, it is essential to understand how to address the health emergency with children. Children are entitled to information about the situation but must also be protected. it is important to use age-appropriate language, observe reactions and monitor children's anxiety levels. Children, unlike adults, are often unable to verbally express emotions, but manifest them through various signs of discomfort, such as sudden and unusual fears, excessive worry, and sleep disturbance (Weems & Costa, 2005; scharfe, 2000) . Parents may invite children to speak about COVid-19, while trying to understand what they already know about it and inviting them to communicate their knowledge through drawings, stories, and other activities. it is also important to create a safe environment where emotions can be freely expressed, thus allowing them to circulate. Parents should be able to recognize children's feelings and reassure them with sentences such as: "It is ok to be afraid", "Everyone would be scared in this situation" or "I understand your anxiety". at the same time, adults must pay attention to anxiety levels in children by observing their body language, their tone of voice and breathing, opting to postpone certain conversations if the child seems to be in a state of anxiety. it is also important to avoid exposing children to a barrage of news about the pandemic, especially prior to bedtime and during the evening in general. at the time when they are more tired, images and words can make sleep more difficult or restless. indeed, before going to sleep, the child's mind instead needs to relax and slow thoughts down. Parents may occupy children's evening/after-dinner time with pleasant activities: stories, movies, and family games. it is also important to provide information to children about the prevention of virus contagion with a sense of human agency, allowing them to feel actively involved in dealing with the emergency.

in the opinion of the authors, parents should also maintain, as far as possible, regular daily routines. Children need consistent routines to relax: the closure of schools and the impossibility of playing with others represent a major break in their routines. it is therefore important to create new routines while maintaining continuity with old ones. for example, parents can allow children to use technology to keep in touch with family, friends and classmates, every day at the same time. Parents should help children in organizing daily tasks by dividing them into smaller parts, planning breaks and short-term goals, helping them to manage time and plan, providing positive feedback. such planning could also serve as an opportunity to create new family activities.

e-learning and homework also play a key role within the maintenance of the daily routine. many children are struggling with distance learning: they spend hours in front of a screen, listening to a teacher, with higher levels of distraction and lower levels of attention. Planning brief breaks during e-learning could be a useful strategy every time parents detect inattentiveness.

finally, emotional well-being is at all ages intricately linked to the ability to make plans. Parents should be careful not to stop making plans, even if such plans may seem uncertain at the present time. Parents should therefore be encouraged to talk about the future; writing down everything the family will want to do once this period has passed.

Parents should reassure children about their fears and maintain contact with family members and friends, while spending time with relaxing and stimulating activities. they should not deny their negative emotions, where present, about the situation. adults can admit to children that they are concerned, but at the same time it is fundamental they show children how to modulate these emotions. minimizing the problem is usually not helpful: it may transmit the idea that the situation is so dangerous that it cannot even be discussed. in this period of transition, children deserve the love and attention of their parents and while parents cannot control the situation, they do have the opportunity to support their children.

the current COVid-19 transition may negatively affect the psychological functioning of children and calls for resources aimed at supporting post-transition adaptation. it seems necessary to provide resources in order to support the adjustment of children in the post-transition period. screening projects will be required to identify those children with increased levels of emotional and behavioral problems, beyond the COVID-19 transition. Detecting and buffering against such emotional and behavioral problems will be critical to promoting specific interventions and to preventing the development of severe behavioral problems (masi et al., 2016) . 

The ecology of human development: Experiments in nature and design

the psychological impact of quarantine and how to reduce it: rapid review of the evidence

new dsm-5 PTSD guilt and shame symptoms among Italian earthquake survivors: impact on maladaptive behaviors

Parenting in a time of COVid-19. The Lancet

Psychological common factors in chronic diseases

Psychological distress among healthcare professionals involved in the Covid-19 emergency: vulnerability and resilience factors

lifetime mania is related to post-traumatic stress symptoms in high school students exposed to the 2009 L'Aquila earthquake

impact of traumatic loss on post-traumatic spectrum symptoms in high school students after the L'Aquila 2009 earthquake in italy

the transition to adolescence: the role of gender and stress in problem behavior and competence

transitions and turning points: navigating the passage from childhood through adolescence

re-presenting childhood: time and transition in the study of childhood

Psychological distress of children and mothers in domestic violence emergency shelters

Behavioral and emotional disorders in Children during the COVid-19 epidemic

school transition from elementary to secondary school: Changes in psychological adjustment

Combined pharmacotherapy-multimodal psychotherapy in children with disruptive behavior disorders

Psychological intervention measures during the COVid-19 pandemic

developmental relations between perceived social support and depressive symptoms through emerging adulthood: Blood is thicker than water

The handbook of emotional intelligence: Theory, development, assessment, and application at home, school, and in the workplace

Posttraumatic stress disorder in parents and youth after health-related disasters. Disaster medicine and public health preparedness

& dell'Osso, l. (2012). methodological approach to depressive symptoms in fibromyalgia patients

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

developmental differences in the expression of childhood anxiety symptoms and fears

long-term outcome of trauma in children: The psychological consequences of a bus accident

adolescent resilience: Promotive factors that inform prevention