lThis is the first study to directly investigate, from the viewpoint of Italian primary and middle school students, the impact of the COVID-19 quarantine on the perceived changes in their routine and psychological distress. Italy was, after China, the second most highly affected country at the time, with the pandemic spreading very fast around Milan, one of the most involved cities. In that period, the emergency level was very high and Italian population was living in an unusual situation. The preventive measures were very tight, people had to remain at home and it was forbidden for children to go outside to the park or meeting friends. These preventive measures were necessary to avoid the spreading of the virus, but they were very struggling for the youngest. Even if there is still significant controversy about the role of children in spreading the virus, school closures resolution showed that in that period children were considered the main spreaders [2], impacting their worries about infecting their parents and grandparents. Results of our research reveal that children were more concerned for their loved ones health condition than for their own.
For most children and youth, the normal routine was disrupted: with the implementation of social distancing interventions, direct human contact became highly restricted, with most activities that typically occupy youths’ lives – schooling, extracurricular activities, and socialization with peers – transitioning to electronic-based platforms.
Routine normally gives the young an increased feeling of safety in the context of uncertainty. Consistent evidence demonstrates that the structured environment of weekdays may help to protect children by regulating obesogenic behaviours, most likely through compulsory physical activity opportunities, restricting caloric intake, reducing screen time occasions, and regulating sleep schedules [20].
For this reason, most of the guidelines recommend creating new routines and structures each day to adapt to the pandemic situation.
Our results show that almost half of responders completely changed their dietary habits during the lockdown, eating different amounts of food and consuming more junk food. Sleep habits were also affected by the lockdown measures, with changes in sleep pattern, especially concerning difficulties in falling asleep and waking up many times during the night. Many children and adolescents also wished to sleep in their parents’ bed.
The findings of the present study are consistent with another Italian survey, completed by parents of 2 to 14 years old children [11]; they suggested that one in four children (26.5 %) showed the regressive symptom of the demand for physical proximity to their parents during the night, and almost one in five (18.2 %) manifested fears that they had never had before. Half of the children (53.5 %) showed increased irritability, intolerance to rules, whims and excessive demands, and one in five presented mood changes (21.2 %) and sleep problems, including difficulty in falling asleep, agitation, and frequent waking up (20 %). According to the literature, we can confirm our expectations among negative consequences on perceived changes habits due to the quarantine period.
The current study strongly supports the hypothesis positing that the COVID-19 pandemic will “exacerbate all of the risk factors for weight gain associated with summer recess” [14]. Specifically, a longitudinal study of children and adolescents with obesity affirmed that eating, activity, and sleep behaviors changed in an unfavorable direction 3 weeks into their confinement during the national lockdown [21].
Are changes in sleep temporary, or will a subset of youth experience longer-term sleep disturbances that originated during the COVID-19 pandemic? Will changes in sleep patterns (such as an increasingly late bedtime in adolescents) result in difficulties once normality starts to return (e.g., when schools reopen and early mornings are required once more) [15].
Moreover, the reduction of outdoor activities and social interaction may have been associated with an increase in children’s emotional and behavioral difficulties. Our findings showed mostly mild to moderate anxiety symptoms, but also significant anxiety in some youth, and nearly half of the responders reported frequent mood swings.
Compared to previous research conducted before the pandemic, this study found high levels of self-reported anxiety. The worldwide prevalence of any anxiety and depressive disorder among children according to Diagnostic and Statistical Manual (DSM) and International Statistical Classification of Diseases and Related Health Problems (ICD) was shown to be 6.5 and 2.6 % respectively [22]. However, the criteria for DSM and ICD were not used in the current study and children reported their symptoms focusing on their own perspective, compared to how they felt before the COVID-19 outbreak.
Our results reveal higher rates of perceived symptoms than those found in another survey conducted in China with primary school students during the Coronavirus-19 outbreak [9], although these studies cannot be compared due to different assessment tools.
This study suggested that 403 Chinese students (22.6 %) and 337 students (18.9 %) showed depressive and anxiety symptoms, respectively.
Our findings are not consistent with those of a Chinese study in which secondary school students yielded the highest prevalence and levels of depressive, anxiety and stress symptoms, and primary school students the lowest [23]: in the current study we didn’t find any significant difference in symptomatology between primary and middle school students. There is mounting evidence of increased mental health problems during the acute stages of COVID-19 [6, 9, 24]. For a subset of children and youth, however, the consequences of pandemic-related stress will not be immediately observable, and will only be detectable following a certain period of development.
It is important to highlight that the presence of depressive symptoms (even if sub-threshold) or psychological unease in a few children may be hidden by an apparently adaptive behavior. The effects of stress exposure may not manifest until a certain degree of neurobiological development has occurred or alterations in the social environment lead to change: new difficulties for children who initially appeared well-adapted may surface later in development. The mental health ramifications of COVID- 19 are likely to be longstanding, but not simply chronic [25]. The results confirm our expectations about psychological distress generated by the quarantine period. Moreover, these results highlight that the most important things for children and adolescents are social interactions, what they missed the most are friends, sports and school. There is a pressing need for giving importance to the children priorities.
Strengths and limitations
There are several limitations to this study.
Socioeconomic details such as household income and number of rooms in the house were not collected, and these data could be helpful in planning future requirements with respect to quarantine. Moreover, this could be considered as a potential limit because of the findings are less generalizable and slightly representative of children in Milan.
We could not calculate how many people refused to participate because we’ve advertised the study on different channels and only those parents and children who wanted to be enrolled contacted us.
Our evaluation was conducted in the first phase of the pandemic, unfortunately baseline data (prior the COVID-19 outbreak) are not available. This has a significant impact, since we can’t guarantee that the perceived symptomatology arose in the quarantine and was not even present before. The results indicate the changes that the children, themselves perceived, but without an appropriate comparison or a baseline measure, we cannot be certain that these perceptions were actually reflected in reality. Another limitation is that our current study could not evaluate whether these outcomes will be long-lasting after the COVID-19 outbreak. It will be interesting to continue to follow up with these participants to improve our understanding about how long these outcomes will last.
Implications and future research direction
The COVID-19 crisis highlights that school fulfils not only an educational mission of knowledge acquisition, but it also satisfies the socialisation needs of young people.
School provides a structured setting in which children can learn and develop social skills, such as self-confidence, friendship, empathy, participation, respect, gratitude, compassion, and responsibility [26].
Children facing unexpected and unknown events typically exhibit various stress reactions: 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 [24]. In conclusion, we would like to highlight that children with pre-existing mental and physical disability are at utmost risk given the current situation [27, 28].
The challenges of online learning coupled with a lack of recreational activities that can be done at home can prove to be frustrating for children with physical disabilities. It becomes even more important to keep children with physical and mental disability not only physically safe, but also look after their psychological and emotional wellbeing. In particular, social distancing and its effects are extremely novel and difficult to understand for children, especially those experiencing developmental and intellectual delays. This affects their wellbeing and places them at a higher risk for clinically significant mental health issues [29]. Taken into consideration the small number of children with special needs included in the present study, we didn’t find any significant difference amongst children with special needs and the rest of the sample in all the considered variables. This study has highlighted the high levels of perceived distress experienced by children during the quarantine; furthermore, it is necessary to take into consideration that those symptoms are likely to be exacerbated for children with additional needs, frustrated due to disruptions in their daily routines and possible interruption of their regular therapy sessions.
Conclusions
In summary, we found that 78 % of the Italian children aged 6 to 14 experienced anxiety symptoms due to the COVID-19 epidemic quarantine measures; nearly half of the sample (43.9 %) reported significant mood symptoms. In general, a large proportion of participants described having struggled to adjust to home learning and completely changed their dietary and sleeping habits.
Children are not indifferent to the dramatic impact of the COVID-19 epidemic: our data confirm their difficulties in adapting to the quarantine measures. The effects of stress exposure may not manifest later on during the children’s development, and, for this reason, it would be interesting to follow up on these participants to improve our understanding of how long these outcomes may last.
