Introduction
In a relatively short time, the COVID-19 epidemic has radically changed the life of the worldwide population.1 Unlike adults, children are not unaffected by the COVID-19 pandemic's devastating effects.2, 3 They are afraid, apprehensive, and have significant alterations in their habits, along with physical and social isolation.4 It is critical to understand their behaviors and feelings in order to effectively meet their needs, as companionship and social connection are necessary for children's natural psychological development.3, 5
To check the spread of the virus, many countries have implemented various preventive strategies including serious social restrictions.1 The most significant public health measure implemented during this pandemic has been extended periods of ‘lockdown’ where whole populations have been advised to remain in their households. In India, the lockdown was strictly imposed from March 2020, and gradually eased around the month of September 2020. As the second wave of pandemics has started to occur in a few states of India particularly Maharashtra, many districts in the state have started imposing strict lockdown. In Nagpur district, the strict lockdown was implemented once 22nd March 2021.
To interrupt the chain of transmission of this deadly sickness, the lockdown included the closure of schools, educational institutes, and public utility areas.6 Prior to the lockdown, children and teens learned mostly via one-on-one interactions with mentors and peer groups all throughout the world. Countrywide school and institution closures have touched more than 91 percent of the world's student population.7 As a result of disruptions in their schooling, physical exercise, and social opportunities, children and adolescents who are restricted to their homes suffer uncertainty and worry.3 Being away from a structured educational setting for an extended length of time produces disruption in routine, boredom, and a lack of new ideas for engaging in various academic and extracurricular activities.
Because they are unable to play outside, physically meet friends, or participate in in-person school events, some of the youngsters have exhibited decreased levels of affect.7, 8, 9 It's expected that children would avoid returning to school once the lockdown is lifted and that they will have trouble re-establishing contact with their mentors once the schools reopen. As a result, the restriction of their movement may have a long-term detrimental impact on their general psychological well-being and social development.7, 10 It’s not too late to avert them.10 The WHO also highlighted the need to invest in mental health services during the pandemic.11 In addition to the illness itself, this pandemic has presented a number of obstacles, with mental health issues at the forefront. Apart from the mental health issues caused by the pandemic, addressing psychiatric problems is a major concern in and of itself.12
Understanding the effects of the lockdown, as well as subsequent school closures, on the mental health and well-being of children and young people during the COVID-19 epidemic is critical. (6) However, the long-term effects of such policies on children's well-being remain unknown. (1). There are some studies on the impact of lockdown on the mental health of adults and adolescents but very few studies have focussed on young children. Therefore, this study will provide an insight into the psychological impact of lockdown on young children.
Materials and Methods
The ethical clearance from the institutional review board was obtained before the commencement of the study. The participants were invited to participate in the study and informed consent was obtained after explaining the details of the study. The data privacy, security, anonymity, and confidentiality were ascertained through standardized procedures. The data security was ensured through the safe storage of the data and limiting access of the data only to the investigator.
Study design, duration, and participants
The current study is a questionnaire-based cross-sectional study. The research was done among parents of children ranging in age from 4 to 10 years old who attend various schools in Nagpur city. The research ran from March 2021 to August 2021, for a total of six months. The study enlisted the participation of parents of kids aged 4 to 10 years old who were willing to participate. Incomplete forms of the questionnaires and wrong answers or missing responses or a child reported as infected with COVID-19 were excluded from the analyses. Also, those with some physical or mental disability (developmental delay, Autism spectrum of disorders,, etc) and if the parents were not willing to participate in the study, were excluded from the study.
Sample size and sampling technique
In a study conducted by Ghanamah et al in 2020 among Arab Israeli children for assessing the behavioural impact of the lockdown imposed by the pandemic, it was observed that 46.2% of the study population experienced one or the other psychological and behavioral changes. Based on this prevalence, with a 5% margin of error at a 95% confidence level for a two-tailed hypothesis, the expected sample size was obtained to be 385.
Sampling technique
The respondents were selected using a multi-stage random sampling procedure. As a part of the first step, schools were randomly selected using a random number table. In the second stage of sampling, the parents of all the consecutive children between the age group of 4 to 10 years (from junior kindergarten to fourth grade) from the selected schools and who were not diagnosed with a physical or psychological problem (like developmental delay, Autism spectrum of disorders, Attention deficit hyperactivity disorders) were invited to participate in the study.
Data collection tools and procedure
The data was collected online using predesigned and validated Google forms. The questionnaire was tested and validated from the members of the teaching staff members at our institute who had children in the age group of 4-10 years. It was also pilot-tested in a sample of 25 parents from the selected schools before initiation of the final data collection. The suggestions from the teaching faculty members and the parents were incorporated to assuring the simplicity of the language and understanding of the questions in order to make it more user-friendly.
All the participating schools were provided with the online consent form and the Google form links accompanied by an audio clip introducing the research goals that were shared with the parents (primary survey respondents) through the online classes’ platforms used by the schools respectively. For those who did not respond on these platforms the link of the designed Google Form of the survey was shared on social media like WhatsApp. They were requested to fill the questionnaire within a time span of 15-20 days.
The questionnaire is divided into five sections: I socio-demographic questionnaire (age, gender, educational level, socio-economic situation, occupation, location of residence, and whether or not any family member or the kid was Corona positive or in quarantine); Psychological effects were assessed based on semi-structured questionnaire for sadness, aggressiveness, depression and anxiety in children. All the responses were in dichotomous format of yes and no. Questionnaire had six questions for answering sadness, seven questions for aggression, five questions for depression and anxiety respectively. The responses were marked on a Likert scale. Those who responded often and always were considered as positive and those who responded sometimes, rarely and never were considered negative for the question. Those who responded positive for more than three questions in each condition were considered positive for the concerned attribute like sadness, depression, anxiety,, etc. In order to study the associations of the socio-demographic factors and other covariates like the type of family, siblings, education and occupation of parents, time spent with children, etc. on the psychological condition of the children cut off points for each of the psychological domains like sadness, aggressiveness, anxiety, and depression were devised using which if the score on the questions determining these attributes was greater than 50%, then the child was considered to be having the attribute in question.
Data analisis
The data was received by the investigator after the completion of the forms by the respondents. This data was then exported to Microsoft Excel for further analysis and drawing inferences. The basic demographic characteristics of the respondents and the children were described using descriptive statistics. The chi-square test was used to measure the association of the variables, with children’s behavioral, emotional and psychological health.
Results
Table 1
Socio-demographic profile of study subjects
In these study gender wise 96 (49.48%) were male and 98 (50.52%) were female child. Overall, 96 (49.48%) of study subjects belonged to the nuclear family, 89(45.87%) belongs to joint and 9 (4.62%) belongs to single parent family. Among majority children, 97(50%) only fathers are working, while in 93(47.94%) both parents are working. In these study i.e. 126(64.95%) belongs to upper middle class and only 4 (2.06%) of study subjects belongs to lower socioeconomic class. 111(57.22%) of study subjects were having siblings. (Table 1)
Table 2
Prevalence of Sadness, Aggressiveness, Depressionand Anxiety
|
Psychological effect |
Frequency (n=194) |
Prevalence |
|
Sadness |
132 |
68.04% |
|
Aggressiveness |
103 |
53.09% |
|
Depression |
113 |
58.25% |
|
Anxiety |
144 |
74.23% |
Table 2 depicts the prevalence ofpsychological effect due to COVID 19 lockdown in children. Prevalence of Anxiety, sadness, depression and aggressiveness was 74.23%, 68.04%, 58.25% and 53.09% respectively.
Table 3
Distribution of Sadness in children during lockdown
Table 3 shows the distribution of sadness in children during lockdown. It was found that children of both working parents are significantly sad as compared to non-working or only any 1 parent working (p= o.008). Also, children who are using smartphones <2hours for playing games are significantly sad than others. (p=0.001)
Table 4
Distribution of Aggressiveness in children during lockdown
Table 4 depicts the distribution of aggressiveness in children during lockdown (p= 0.002). Children of <7 years are significantly more aggressive than >7 years.
Table 5
Distribution of depression in children during lockdown
Table 5 shows the distribution of depression in children during lockdown. None of the variable was found to be significant for depression.
Table 6
Distribution of Anxiety in children during lockdown
Table 6 illustrates anxiety in children during lockdown. It was observed that anxiety was significantly more amongfemales compared to male children (p=0.03). Also, children belonging to single parent and joint family were significantly more anxious compared to nuclear families (p=0.04).
Discussion
A cross-sectional questionnaire-based study was conducted to study the psychological impact of lockdown among children aged 4 – 10 years. The psychological parameters like sadness, aggressive behavior, anxiety and depression were taken into account in the present study to find out the impact of lockdown on the children.
The sudden close down of routine activities has not only impacted the adults but has also reflected children adversely. The closure of schools, playgrounds, and outdoor activities has led to 24 hours of home confinement for the children with parents. Shah et al 2020 have stated that Children's mental health has been impacted in a variety of ways since this unusual scenario has altered the way kids generally develop, learn, play, interact, and regulate emotions.13 Home confinement with no activities and parents’ stress due to the pandemic had a paramount effect on the psychology of the children
In this study 96(49.48%) were male and 98(50.52%) were female children. Overall 96(49.48%) of study subjects belonged to the nuclear family, 89(45.87%) belongs to the joint, and 9(4.62%) belonged to single parent families. Among the majority of children, 97(50%) only the father was working, while in 93(47.94%) both parents are working. In this study 126(64.95%) belongs to the upper-middle class and only 4(2.06%) of the study subjects belong to the lower socioeconomic class. 111(57.22%) of study subjects were having siblings.
Prevalence of Anxiety, sadness, depression, and aggressiveness was 74.23%, 68.04%, 58.25%, and 53.09% respectively. Li Duan et al (2020) also reported that During the COVID-19 epidemic, the prevalence of clinical depression in children and adolescents was 22.28 percent, far higher than the commonly expected frequency, and total anxiety levels in children were 4.01±3.03. They estimated that roughly 25%–50% of depressed youth displayed comorbid anxiety disorders and about 10%–15% of anxious youth had depression.9 Morgul et al 2020 stated that the caregivers reported sadness in 43.4% of children; anxiety in 45.2% of children and 29.7% of children had aggressive behavior.1 Panda et al (2020) also reported similar findings regarding children’s psychological health, they stated that 34.5%, 41.7%, 42.3%, and 30.8% of children were found to be suffering from anxiety, depression, irritability, and inattention.2 The findings of the above studies were similar to the present study. Most of the authors reported that the children face various psychological issues like irritability, restlessness, anger, anxiety, sadness, and worry. The frequently reported symptoms by children were anxiety, depression, lethargy, impaired social interaction, and reduced appetite.1, 3
It was observed that anxiety was significantly more among females compared to male children (p=0.03). Similar findings were reported by Li Duan et al (2020).9 This may be due to the home confinement with no outdoor activities and no interaction with friends. Panda et al (2020) have reported that the anxiety was significantly higher in females than male children during the lockdown.2 Also children belonging to single parent and joint families were significantly more anxious compared to the nuclear family (p=0.04). Imran et al (2020) reported that the parent’s stress reflects on the children which they can display as misbehavior, oppositional/defiant behavior, and temper tantrums.
When the association of sadness was seen with other variables, it was observed that children whose both parents were working were significantly more sad (p=0.008) than those whose either one parent or no parent was working. Singh et al (2020) have reported because of the lockdown, which caused a disruption in their routine, the youngsters have grown clingier, more attention-seeking, and more reliant on their parents. Children who were using smartphones for less than 2 hours were also found to be sadder (p=0.001). The working parents though at home were busy working from home and confined to their rooms to avoid disturbance from children, this may have led to sadness in children as the parents were not available. The children in the lockdown were not able to go out and hence were addicted to gadgets and their restricted use would have led to sadness.6
The present study also reported that the children younger than 7 years were more aggressive than those with ages more than 7 years. This may be due to the smaller children cannot express their feelings as the older ones.
Conclusion
The lockdown due to the Covid-19 pandemic has caused profound psychological effects and has increased the rates of depression, anxiety, sadness, and aggressiveness in children. The anxiety was significantly higher in female children, while the sadness was more common in children whose both parents were working and who were spending less time on the internet. Children below 7 years behaved more aggressively than above 7 years. Children belonging to single-parent and joint families were significantly more anxious compared to nuclear families.
Limitations
This study does not represent the general population as the participants were from private English medium schools not from government or aided schools or local medium language schools. The sample size is small as the sample was mostly collected during the summer vacation period so very few parents responded to school mail. It is suggested that a similar study should be conducted on large scale including urban and rural setups and all types of schools.
