key: cord-0885849-o5yn07vt
authors: Xiao, Han; Liu, Qi; Mei, Hong; Xue, Qi; Cai, Xiaonan; Xie, Xinyan; Xia, Zhiguo; Zhou, Yu; Li, Hui; Zhu, Kaiheng; Wan, Zihao; Liu, Zhisheng; Song, Ranran
title: Behavioral problems of pediatric patients recovered from COVID-19 in Wuhan, China
date: 2022-03-21
journal: Acta Psychol (Amst)
DOI: 10.1016/j.actpsy.2022.103571
sha: b0f325355cb63589b1c44496936f897d7ae65ad6
doc_id: 885849
cord_uid: o5yn07vt

BACKGROUND: Coronavirus disease 2019 (COVID-19) is profoundly affecting lives around the globe. Previous studies on COVID-19 mainly focused on epidemiological, clinical, and radiological features of patients with confirmed infection. Little attention has been paid to the follow-up of recovered patients. As a vulnerable population to adverse events, the health status of the COVID-19 recovered pediatric patients is of great concern. We aimed to investigate the prevalence of behavioral problems among pediatric patients recovered from the COVID-19 in Wuhan, China. METHODS: A total of 122 children who were suspected or confirmed COVID-19 cases and hospitalized for treatment were enrolled in the study between April 2020 and May 2020 in Wuhan, China. We collected related information about hospitalization and discharge of the children and emotional symptoms of their parents through electronic medical records and questionnaire. The behavioral problems of children were examined by applying the parent-reported the Strengths and Difficulties Questionnaire (SDQ). RESULTS: The participant children were discharged from hospital after about two months. Among them, 76 (62%) were boys, and the mean age was 6.71 years old. The highest prevalence of behavioral problems among pediatric children with COVID-19 was for prosocial behavior (15%), followed by total difficulties (13%), emotional symptoms (11%), hyperactivity (10%), conduct problems (9%), and peer problems (1%). With regarding to their parents, 26% reported having symptoms of anxiety and 23% as having symptoms of depression. The scores of SDQ were higher in those children whose parents have emotional problems compared to parents without. CONCLUSION: Long-term follow up studies on the psychological and behavioral problems of COVID-19 recovered children and their parents are warranted.

In December 2019, an outbreak of the coronavirus disease 2019 was first reported in Wuhan, Hubei province, China. As of 18 June 2020, the COVID-19 pandemic has been responsible for more than 8,061,550 infections worldwide, with a mortality rate of almost 5.5% (WHO, 2020a) . People of all ages are susceptible to COVID-19 infection, including children. According to the Chinese Center for Disease Control and Prevention, approximately 1% of pediatric cases were younger than 10 years (Wu & McGoogan, 2020) . Children were less susceptible to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and most pediatric cases appeared to have milder clinical symptoms, and lower mortality rates (Dong, et al., 2020 ; National Institute of infectious diseases; Su, et al., 2020; Tian, et al., 2020) .

The potential effect of the COVID-19 outbreak on recovered pediatric patients may be more important but is easily neglected issue and must be made a priority. In response to the transmission of the COVID-19 outbreak, the Chinese Government has implemented strict domestic quarantine policies. Children infected with or suspected of being infected with COVID-19 will be quarantined for professional treatment in the local hospital, and J o u r n a l P r e -p r o o f

The present study was conducted between April and May 2020 at Wuhan Children's Hospital, the only center assigned by the central government for treating children infected with COVID-19 in Wuhan. About two months after discharge, children who were suspected or confirmed COVID-19 cases and hospitalized in the study hospital for treatment were invited to participate in the study. There were two recruitment approaches: when children came to the hospital for the follow-up visit, they were invited to participate in and complete the questionnaire survey in the hospital; and for those children who did not return to the hospital for follow-up, an electronic questionnaire was sent through the official platform of the hospital to invite them to participate in the survey. The diagnosis of COVID-19 infection was made according to the guidelines for diagnosis and management of COVID-19 (in Chinese) released by the National Health Commission of China (the Fifth and Six Editions). A clinically-diagnosed case is defined as suspected patients with typical pneumonia manifestation (only in Hubei province) (National Health Commission of People's Republic of China, 2020). Some children were admitted to hospital as suspected cases but were negative on multiple nucleic acid tests and thus were excluded as cases. All subjects signed an electronic informed consent before answering the online questionnaire surveys. The research protocol was approved by the ethics committees of Wuhan Children's Hospital, Tongji Medical College Huazhong University of Science&Technology (number: 2020R003-E01, the approval date: 9 March 2020).

to 21, with a scores of 5 representing a positive anxiety symptom. The PHQ-9 is a nine-item self-reported scale that is used to screen for depressive symptoms (Spitzer, et al., 1999) . Responses are scored on a four-point Likert-type scale from "0" (not at all) to "3" (nearly every day). The PHQ-9 scores of 5 indicates a positive depressive symptom (Kroenke, et al., 2001) .

In the study, we assessed the distribution of general characteristics and then examined the prevalence of behavioral problems among the children. Categorical variables were expressed as number (%), and continuous variables as mean [standard deviation (SD)].

The independent sample t-test was used to determine the differences between independent groups in terms of continuous outcomes, whereas the χ 2 test was used to determine categorical outcomes. We also calculated effect sizes (Cohen's d) to describe the standardized mean difference of an effect. Cohen's d is directly related to the t-test as follows: small (d = 0.2), medium (d = 0.5), and large (d = 0.8) (Lakens, 2013) . Statistical analysis was performed in SPSS 22.0 (SPSS Inc., Chicago, IL, USA). A P < 0.05 (two-tailed) was considered to be statistically significant.

A total of 270 suspected or confirmed COVID-19 pediatric cases aged 3-9 years were hospitalized in the study hospital for treatment. Among them, 121 children came to the hospital for follow-up, and 149 children did not attend follow-up. There were 81 children who came to the hospital for follow-up and 41 children who did not come to the hospital for follow-up included in the study. Finally, 122 participants were recruited for analysis. Table 1 shows the general characteristics of the pediatric cases in the study that were J o u r n a l P r e -p r o o f Journal Pre-proof followed up/not followed up and included/excluded. Compared with the pediatric patients without follow-up, the children who came to the study hospital for follow-up were older and included more confirmed cases by the nucleic acid polymerase chain reaction (PCR) test. Included and excluded children were similar in term of their demographic and clinical characteristics (all p < 0.05). Among the included participants, 76 (62%) were boys, and the mean age were 6.71 years. Most participants (42%) were PCR-diagnosed cases and the average hospitalization time was 11.89 days.

J o u r n a l P r e -p r o o f Table 1 . The general characteristics of the pediatric cases that were followed up, not followed up, included and excluded in the study.

All populations Missing

Abbreviations: PCR, Polymerase Chain Reaction. a P-Values were derived using χ 2 test to examine the distribution of general characteristics between the children with the two groups. b P-Values were derived using independent sample t-test to examine the distribution of general characteristics between the two groups. c Expressed as mean (standard deviation).

Sociodemographic and clinical characteristics Table 2 lists selected characteristics of the study children and their parents from the questionnaires, approximately 40% of which were completed by fathers. The prevalence of positive anxiety and depression symptoms in parents were 26% and 23%, respectively.

The time from symptom onset to hospitalization was 3.62 days, on average, and the discharge time was 59.99 days. Around 40% of children were not exposed to suspected or confirmed COVID-19 cases before symptom onset. During hospitalization, the majority of parents talked with their children 1-3 times a day (28%), and 55% of them talked for less than 10 minutes each time. After returning home from hospital, children were likely to take slight physical exercise (58%), with 41% of them exercising 1-3 times a week. 

The scores of the SDQ and the prevalence of behavioral problems among the children J o u r n a l P r e -p r o o f infected with COVID-19 are shown in Table 3 . The mean score of the SDQ was 2.21 for emotional symptoms, 1.87 for conduct problems, 4.39 for hyperactivity, 2.54 for peer problems, 6.25 for prosocial behavior and 11.02 for total difficulties. The highest prevalence of behavioral problems among pediatric children with COVID-19 was for prosocial behavior (15%), followed by total difficulties (13%), emotional symptoms (11%), hyperactivity (10%), conduct problems (9%), and peer problems (1%). The distribution of behavioral problems among the study characteristics is summarized in eTable A. No significant differences were found for the SDQ score in children with regard to the following variables: gender, age, communication with parents during hospitalization and physical activity during discharge (all p < 0.05).

In the present study, we conducted an Internet-based cross-sectional study to assess the impact of the COVID-19 epidemic on the behavioral problems of recovered pediatric COVID-19 patients two months after discharge in Wuhan city, Hubei province, China.

The prevalence of behavioral problems in pediatric patients was increased slightly, the highest of which was prosocial problems (15%), followed by total difficulties (13%), emotional symptoms (11%), hyperactivity (10%), and conduct problems (9%). With regarding to their parents' emotional problems, 26% of parents reported positive anxiety symptoms and 23% reported positive depressive symptoms. The behavioral problems of children with positive parents having anxiety and depressive symptoms were more than those of children with parents having no emotional symptoms.

Our analysis reveals that pediatric patients, despite apparent clinical recovery at discharge, had obvious behavioral problems when evaluated approximately two months later. Extensive research has examined the mental health burden in adults discharged from hospital with COVID-19 in China Chen, et al., 2021a; Huang, et al., 2021a; Huang, et al., 2021b; Huang, et al., 2021c; Ju, et al., 2021; Liang, et al., 2020; Liu, et al., 2020a; Liu, et al., 2021b; Putri, et al., 2021; Qu, et al., 2021; Tu, et al., 2021; Wu, et al., 2020a; Wu, et al., 2020b; Xiong, et al., 2021a; Xiong, et al., 2021b; Yuan, et al., 2020) , Italy (Mattioli, et al., 2021; Tomasoni, et al., J o u r n a l P r e -p r o o f 2021), Australia (Darley, et al., 2021; Rass, et al., 2021 ), Netherlands (de Graaf, et al., 2021 Vlake, et al., 2021) , the UK (Halpin, et al., 2021; Zavala, et al., 2021) , France (Garrigues, et al., 2020; Horn, et al., 2021; Morin, et al., 2021) , Germany (Augustin, et al., 2021; Daher, et al., 2020) , Iran (Khademi, et al., 2021; Mirfazeli, et al., 2022) , Egypt (Kamal, et al., 2021) , Brazil (Damiano, et al., 2022; Todt, et al., 2021) , the USA (Daugherty, et al., 2021; Graham, et al., 2021; Jovanoski, et al., 2021; Martillo, et al., 2021) , and Korea (Chang & Park, 2020 ) (see details in e . A study from the UK reported that children with symptomatic COVID-19 had a slightly higher prevalence of ongoing symptoms than symptomatic controls (Zavala, et al., 2021) . This might be due to the relatively long COVID-19

isolation period, which prevents infected children from immediately returning home to their family. Furthermore, some patients may complain about psychological and/or somatoform disturbances after vaccination (Lutzen, et al., 2017; McMurtry, 2020; Poddighe, et al., 2014) . Intervention with psychological distress may also help to prevent adverse psychological events related to vaccination in both children and adolescents.

Parents of COVID-19 patients might be at increased risk of experiencing psychological distress, with 26% and 23% suffering anxiety and depressive symptoms, respectively.

Previous studies had already identified that relatives of patients hospitalized with COVID-19 might be equally affected. It is suggested that both isolated COVID-19 J o u r n a l P r e -p r o o f patients and their relatives might suffer from similarly high levels of anxiety and depressive symptoms during the initial stage of hospitalization (Dorman-Ilan, et al., 2020) . Based on the above-mentioned reasons, the prevalence of emotional problems among parents is still high, even when their infected children are discharged after about two months. These individuals might therefore require increased clinical attention tailored to their needs in order to prevent an adverse long-term psychological burden.

In addition, the more anxious and depressed the parents were, the more behavioral problems the children had. The link between parents' and children's post-disaster distress has been well established (Bonanno, et al., 2010) . Previous studies have used parental distress to predict a child's symptoms, such as posttraumatic stress disorder (PTSD), after a disaster (Chemtob, et al., 2010; Furr, et al., 2010) . Childhood is the time when children are most dependent on their parents and families. Parents play an important role in equipping young children to understand and cope with a disaster (Cobham, et al., 2016; Proctor, et al., 2007) . To further identify the potential risk factors for behavioral problems among pediatric patients, we have investigated related information on basic and clinical characteristics, communication with parents during hospitalization and physical activity during discharge. We found a downward trend in the SDQ scores for these the related factors, but no statistical significance, possibly due to the small sample size of the study.

Finally, we are aware of some limitations. As a cross-sectional design was applied in this study, some information (e.g. communication with parents during hospitalization) obtained from the questionnaire might introduce recall bias. In addition, potential influencing factors (e.g. socio-economic characteristics) may not be identified in the analysis, although we collected basic features and related information during J o u r n a l P r e -p r o o f hospitalization and discharge in the study. Furthermore, the follow-up period was relatively short and the study does not capture how problems evolve over time.

Long-term follow-up would aid in further understanding of the progression of psychological well-being after discharge.

A considerable proportion of pediatric COVID-19 patients show symptoms of psychological and behavioral distress two months after hospital discharge, as well as their relatives. Therefore, the long-term follow-up studies should be established for monitoring and ascertaining the psychological and behavioral problems of specific vulnerable populations under pandemic conditions.

The authors have indicated they have no potential conflicts of interest to disclose.

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