UNESCO estimates that over 90% of enrolled learners (over a billion young people) worldwide are now out of education. Not much is known about the long-term impact of large-scale disease outbreaks on the mental health of children and adolescents [1]. Population studies have reported prevalence rates of depressive disorders in children ranging between 0.4% to 2.5% in children and 0.4% to 8.3% in adolescents [2,3]. In our study, we employed a cut-off score of 12 for the short Mood and Feelings questionnaire (MFQ), which is the cut-off recommended by the Child Outcomes Research Consortium, United Kingdom [4]. It is a validated screening tool for depression in children. Boys were less likely to be depressed than girls (OR 0.495, P value 0.000). Eleven- to 16-year-olds were more likely to be depressed than 5- to 10-year-old children (OR 1.519, P 0.035). Our survey revealed the incidence of depression to be 13.7%, indicating that children are likely to be experiencing increasing depression exacerbated by the pandemic and the lock-down. Fear experienced by children can include the types of fears that are similar to that experienced by adults, which would include fear of dying, a fear of close relatives dying, or a fear of what it means to be admitted to hospital.
We tried to analyze potential causes and lifestyle issues contributing to childhood depression. a) Online classes
With regard to online classes, 41.2% had 1-2 hours of online classes per day, 40.2% had 3-4 hours a day, 9% had 5-6 hours, 2% had more than 6 hours a day, and 7.6% had no online classes. Children who had more than 4 hours online education had higher depression (OR 1.757, P= 0.037) (Table 1). Children who used a cell phone for online class had higher depression than children using devices such as tab or laptop (OR 2.142, P 0.000) (Table 2).
b) Screen time
Excluding online classes, the amount of screen time spent by children on television, laptops, cell phones, and video games was as follows: 36.4% spent 2-4 hours, 31.1% spent 1-2 hours, 14.4% spent 4-6 hours, 14.1% spent less than 1 hour, and 4% spent 6-8 hours. This is clearly in excess of the screen time limit recommended by the WHO, which is two hours a day [5]. There was no statistical significance for the relationship between screen time (excluding online classes) and depression.
c) Physical exercise
With regard to physical exercise, 40.6% spent less than 30 minutes on exercise, 25.5% spent 30 minutes to 1 hour, 18% did no exercise, 12.2% did 1-2 hours and 3.7% did 2-4 hours. The recommendations of the WHO are for children and youth aged 5–17 to accumulate at least 60 minutes of moderate- to vigorous-intensity physical activity daily [6]. However, there was no statistical significance for the relationship between physical exercise and depression.
d) Sleep
Sleeping patterns were variable. A total of 53.5% had 8-10 hours of sleep, 38.3% had 6-8 hours of sleep, 5.4% had 10-12 hours of sleep and 2.8% had less than 6 hours of sleep. Children who slept less than 8 hours a day had higher depression (OR 2.441, P 0.000) (Table 3). With regard to afternoon naps, 77.7% did not sleep in the afternoons, 11.8% slept 1-2 hours and 9.6% slept less than 1 hour and 0.9% slept 2-4 hours. Children who either did not sleep in the afternoon or slept less than 1 hour had less depression than children who slept more than one hour in the afternoons (OR 0.522, P 0.010) (Table 4). Sleep disturbances are not just a symptom or by-product of depression, but in many patients, insomnia contributes to depression onset and/or maintenance [7].
e) Interaction with family members
With respect to interaction with family members, 55.4% spent 2-4 hours, 31.1% spent 1-2 hours, 11.8% spent < 1 hour and 1.7% spent no time interacting with their own family. Statistical analysis demonstrated that the children who interacted with family members over 1 hour per day were less likely to have depression (OR 2.985, P 0.000) (Table 5). There is evidence in the literature suggesting that negative family interactions contribute to childhood depression [8,9]. We also analysed interaction with friends, but the results were not statistically significant.
If schools have closed as part of necessary measures, then children may no longer have that sense of structure and stimulation that is provided by that environment, and they end up with less opportunity to be with their friends and get that social support that is essential for good mental well-being.
While there is some research on the psychological impact of severe acute respiratory syndrome (SARS) on patients and health-care workers, not much is known about the effects on ordinary citizens. Evidence is especially scarce in children and adolescents. COVID-19 is much more widespread than SARS and other epidemics on a global scale. As the pandemic continues, it is important to support children and adolescents facing bereavement and issues related to parental unemployment or loss of household income. There is also a need to monitor young people’s mental health status over the long term and to study how prolonged school closures, strict social distancing measures, and the pandemic itself affect the wellbeing of children and adolescents.
Although the current school closures differ from summer holidays in that learning is expected to continue digitally, the closures are likely to widen the learning gap between children from lower-income and higher-income families. Children from low-income households live in conditions that make home schooling difficult. Online learning environments usually require computers and a reliable internet connection [10].
We anticipate a considerable increase in anxiety and depressive symptoms among people who do not have pre-existing mental health conditions, with some experiencing post-traumatic stress disorder in due course [11]. There is already evidence that this possibility has been underrecognized in China during the current pandemic [12].
Public health policy makers must address the psychological impact of this crisis on children. Collective trauma events have short- and long-term implications, including post-traumatic stress, anxiety and behavioural disorders [13]. Children in poverty are particularly vulnerable because of underlying psychosocial stressors (e.g., home instability) and developmental and behavioural disorders [9].
Psychologists have noticed three emerging patterns in school children during this pandemic [14]. A first group of schoolchildren seem to prosper mainly because they are at home in a quieter and more conducive environment where they can thrive with the structure and support provided by their parents. These children enjoy online learning, and notably, they are not exposed to any adverse events, such as bullying or social exclusion. Similarly, there exists a second group of children who seem to be mildly affected in an adverse manner. Their developmental opportunities are on hold, as due to relatively fewer available resources for online learning, they are unable to interact with peers and thereby improve their social skills and no longer have access to practice what they were learning in a social setting. The third group includes children who unfortunately find themselves in families with an increasingly negative environment, and these children may potentially feel deprived of the safe haven offered by their schools.
However, it must be noted that our cohort of school children had no pre-existing mental health disorders. This may be due to less awareness of psychological symptoms and emotional disturbance in India. A sample size of 874 children gives fairly valid and generalizable findings. However, as this study was limited to Chennai, it could be argued that these findings may not be generalizable to other parts of a diverse country such as India. Nevertheless, having seen the socio-demographic spread of our sample, we make the case that these findings are representative of the wider population of India and will offer useful pointers to public health policy makers, especially when dealing with future pandemics.