After the declaration of coronavirus disease 2019 (COVID-19) as a pandemic by the World Health Organization on March 11, 2020, India declared a nationwide lockdown on March 25, 2020, to check the disease's spread. Although restrictions were lifted after 2 months in a phased manner, schools and colleges remained closed from February to December 2020. According to the United Nations, up to 1.5 billion children are affected by school closures and lockdown. Apart from the overall risk of physical illness, the cumulative disease containment experience can be stressful, leading to children's mental health problems. Worldwide, the pre-COVID pooled prevalence estimate of child mental health problems in the community was 13.4%.
In the background of the preexisting burden of child mental morbidity, the spread of COVID-19 has resulted in significant disruption of children's mental health status across the globe. Studies of children under home confinement during the COVID-19 pandemic reported depressive symptoms in 22% on the children's depression inventory. In the same study, 18% showed anxiety symptoms on Screen for Child Anxiety Related Emotional Disorder. Another study from China showed that 43% endorsed depressive symptoms, while 37% had experienced anxiety symptoms. In addition, factors such as age, gender, financial strain in the family, residence in highly infected areas, parental mental health, individual coping styles of children, and support systems were found to influence child mental health. Indian studies evaluating mental morbidity during the pandemic are limited to adults. An online survey conducted in 11 Indian languages to assess psychosocial impact found anxiety and depression in 40% of individuals. Another online survey using a self-reported COVID-19 Peritraumatic Distress Index questionnaire showed 20% experienced mild-to-moderate stress while 2.7% experienced severe stress.
Understanding children's behavioral and emotional difficulties is essential from a pedagogical standpoint and social outcomes, such as school absenteeism, social integration, and self-efficacy. Among many, the Strengths and Difficulties Questionnaire (SDQ) is a widely used screening tool for identifying such difficulties in children and adolescents. Studies show that the narrowband dimensions of the SDQ (emotional symptoms, peer problems, hyperactivity, and conduct problems) are a better predictor than the broadband dimensions (internalizing and externalizing) for socioemotional and academic output in educational contexts. Population demographics, vulnerability, resilience, health, and other support systems also influence the pandemic's direct and indirect effects. This study aimed to gather data on the extent and burden of behavioral and emotional difficulties after home confinement of school children and adolescents and describe the patterns during the COVID-19 pandemic.
MATERIALS AND METHODS
A cross-sectional online survey was conducted using nonprobability purposive sampling in town's English medium education system schools in the northeastern state Assam, India. The study assessed children and adolescents’ behavioral and emotional difficulties during the pandemic from caregivers’ and child's perspectives. A caregiver was defined as any parent, relative, or guardian above 18 years with the primary responsibility of child-rearing, attending to daily needs, and involved in the child's direct care for a minimum of 12 months. Principals of ten schools agreed to participate in the study and shared a digital flyer with caregivers of children aged 4–17 years through their digital platforms. The flyer contained links to YouTube videos describing the survey and a link for participation. Data were collected for 2 months, between August 2020 and September 2020.
Data collection tools
The sociodemographic questions included age and gender (both child and caregiver), occupation, work status during the lockdown, monthly income, siblings, type of family, caregiver's relationship with the child, and avenues for outdoor games. The brief clinical questionnaire about the child enquired about history of “physical illness requiring regular consultation,” “being on regular medications,” “delay in growth and development,” “ever being diagnosed with a mental health condition,” “consultation with a mental health professional in the past,” and “mental illness in the family.” Each item had two possible responses (yes/no).
Behavioral and emotional difficulties were assessed using parent and self-reported versions of SDQ, a brief behavioral questionnaire of 25 items. SDQ is a generic tool intended at screening rather than arriving at a specific diagnosis. The narrowband dimensions include subscales for emotional problems, hyperactivity problems, conduct problems, peer problems, and prosocial behavior. The responses are on a Likert-type scale scored from 0 to 2. All the subscales are added together to generate a total difficulty score. It also has an impact supplement, which further enquires about chronicity, distress, social impairment, and burden to others. Each subscale, as well as the total difficulty and the impact supplement scores, is categorized into “close to average,” “slightly raised/slightly lowered,” “high/low,” and “very high/very low,” according to the newer four-band categorization of the scoring system. Based on this, any child with SDQ scores equal to or above the “slightly raised” category in the total difficulties score was considered to have behavioral and emotional problems. Similarly, an SDQ score equal to or lower than the “slightly lowered” category in the dimension of prosocial behavior indicated some problem in prosocial behavior.
Descriptive statistics were used for frequency distributions and Chi-square and Pearson's correlation for inferential statistics using Statistical Product and Service Solutions (SPSS) IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. (Armonk, NY: IBM Corp.).
In the present study, a total of 304 responses were received through Google Forms for the survey. Excluding 35 responses for nonconsent and 27 responses to duplicate data, 242 caregiver responses and 86 child responses were eligible for analysis.
Sociodemographic and clinical characteristics
Table 1a and b describes the sociodemographic and brief clinical characteristics of the children in the study. Most of the children lived with both parents (90.5%), had siblings (63.63%), belonged to a nuclear family (64%), middle socioeconomic status (70.6%), and only one parent went to work during the lockdown (75.2%). The average age was 10.39 ± 3.53 years (range 4–17) and 125 (51.7%) were female. Only 8 (3.3%) were on regular medication for physical illness and 18 (7.4%) had delayed developmental history. The majority of the children did not have any mental health-related condition or a family history of mental illness.
Behavioral and emotional difficulties
The total difficulty score above the slightly raised category was observed in 23.1% by the parent-reported and 20.9% by the child-reported SDQ. In both parent-reported and self-reported SDQ, children had more peer problems (43.4% and 40.7%), followed by conduct problems (25.6% and 20.9%), emotional problems (23.1% and 19.8%), and hyperactivity (11.1% and 10.5%), as shown in Table 2. The majority (76.7%) of the children had close to average prosocial behavior on the self-reported SDQ compared to just 41.3% having such behavior in the parent-reported SDQ.
We tried to find out whether the behavioral and emotional problems were significantly different for the parent-reported SDQ and child-reported SDQ. A Chi-square test of independence showed that the responses did not differ much across the categories of emotional problems (χ =2.19, P = 0.138), conduct problems (X2 =0.996, P = 0.318), hyperactivity (X2 =0.002, P = 0.962), peer problems (X2 = 0.464, P = 0.496), and total difficulties (X2 = 1.662, P =0.197).
Correlation of prosocial behavior with behavioral and emotional problems
Prosocial behavior had a significant negative correlation with total difficulties (r = −0.260, P = 0.000), conduct problems (r = −0.258, P = 0.000), hyperactivity (r = −0.295, P = 0.000), and peer problems (r = −0.352, P = 0.000) and a positive correlation with emotional problems (r = 0.066, NS) for the parent-reported SDQ. The self-reported SDQ also showed a negative correlation of prosocial behavior with total difficulties (r = −0.429, P = 0.000), conduct problem (r = −0.358, P = 0.001), hyperactivity (r = −0.286, P = 0.008), peer problems (r = −0.467, P = 0.000), as well as emotional problems (r = −0.244, P = 0.023).
Parent's perception of lockdown effect in children
To explore the parents’ perception of the effect of lockdown, in a simple Yes/No question, 101 (41.7%) caregivers felt that the lockdown had significantly affected their child's well-being, whereas 141 (58.3%) did not. Of parents who responded as “Yes,” to the question, a higher percentage of their children had an abnormal SDQ score on all subscales, except peer problems [Table 3]. The other group, which responded “No” too, had children with abnormal SDQ scores, with a high percentage of peer problems. The total difficulty, conduct problem, and hyperactivity were significantly higher in children whose parent's perceived the lockdown as affecting their children.
Association of behavioral problems with sociodemographic variables
Next, to test the association between the behavioral problems and the sociodemographic variables, the Chi-square test was applied for analysis [Table 4]. The total difficulty was higher in children from 12 to 17 years’ age group, females, nuclear family, upper socioeconomic status, living with a single parent and sibling, and where both parents were working during the lockdown. However, only type of family was significantly associated with total difficulties (X2 = 6.608, P = 0.03), hyperactivity (X2 = 5.908, P = 0.05), and conduct problems (X2 = 8.492, P = 0.01). In addition, significant associations were seen between socioeconomic status and hyperactivity (X2 = 8.755, P = 0.01).
Investigations into the child mental health status during the COVID-19 pandemic in China and the United States of America have shown higher stress and anxiety levels. Indian studies have also explored the mental health status during the current pandemic. However, the focus on children was minimal. Inherent challenges in reaching and eliciting mental health information from children through online surveys during the lockdown period can be a few reasons for the lesser focus on children. Thus, we attempted to estimate the burden and patterns of behavioral and emotional problems in children during the current pandemic situation.
The majority of the present study samples belonged to a middle socioeconomic Hindu nuclear family with no significant past or family history of medical/psychiatric illness. Children under challenging circumstances such as institutionalized children, street children, and children in observational homes may experience unique risk processes, therefore were excluded. Thus, the majority of the children were less vulnerable to develop mental health problems.
A significant number of parents (58.3%) felt that lockdown had not affected their children's wellbeing. However, even in this subgroup, difficulties were detected in four dimensions of the SDQ [Table 3]. This highlights the importance of screening school children with a standardized tool for behavioral and emotional difficulties during adversity.
In the present study, behavioral and emotional problem estimates were less compared to other studies conducted during the COVID pandemic. The parent-rated SDQ scores showed 23.1% of children having emotional or behavioral problems during the last 6 months, which coincided with the lockdown period in the region of study. It is also noted that SDQ is a screening instrument with high sensitivity, and the children with slightly raised scores were considered to have problems in the present study. The differences in the severity of the pandemic, timing of the survey in relation to the pandemic phase, number of deaths due to covid in the region, and support systems could have contributed to the lower estimates. Further, a lack of diagnostic confirmation and differences in measurement tools and online survey methods could also contribute to the varied estimates.
Despite lesser estimates of child behavioral and emotional problems compared to other countries during the COVID pandemic in the present study, it is higher than the prepandemic estimates from India. A systematic review of sixteen community-based studies (n = 14594) from India showed a prepandemic prevalence of child psychiatric disorders 6.46%. Another Indian study estimated the prevalence of child psychiatric disorders for children between 4 and 16 years to be 12%.
Similarly, prevalence estimates obtained using SDQ in an Indian study of adolescent school children showed 15% had significant scores. Further, considering that the present study sample consisted of relatively risk-free children, the estimate of 23.1% could reflect an increase relative to prepandemic levels.
Peer problems were the most common, followed by conduct and emotional problems. Hyperactivity symptoms were among the least reported. Greater peer problems can hint towards the impact of social disruption due to lockdown restrictions. However, the present study's patterns are similar to the patterns obtained in studies conducted before the pandemic. In an epidemiological survey conducted before the COVID pandemic in India showed peer problems (28%) were most typical, followed by conduct (17%) and emotional (13%) problems. Respondents least endorsed hyperactivity symptoms (6%). Prosocial behavior in our study group had a significant negative correlation with total difficulties, conduct problems, peer problems, and hyperactivity, a pattern similar to other previous studies. This may be helpful from an intervention point of view – targeted approaches to promote prosocial behavior besides engaging with the problematic behaviors may prove beneficial. The presence of prosocial behavior in a larger portion of our study sample might also have been a reason for lower estimates of behavioral problems relative to other studies done during the pandemic.
An attempt was also made to find if sociodemographic variables were associated with behavior and emotional problems in the study participants. Type of family was significantly associated with “Total difficulties, Hyperactivity and Conduct problems.” Furthermore, socioeconomic status was associated with hyperactivity problems. Major epidemiological and longitudinal studies conducted before the pandemic have shown the association of family and socioeconomic factors with disruptive behaviors.
Limitations of the study include the unavailability of the response rate as the number of respondents receiving the forms was unknown. Self-selection bias can affect the estimates in an online survey. Further samples are drawn from English medium schools and smartphone-handling parents, which may affect the generalizability. The absence of a baseline estimate of child mental health problems in the study population also leads to challenges in understanding the pandemic's impact on children. Lack of corroboration and confirmation following SDQ screening can affect reliability. Finally, the self-reported behavioral difficulties observed by the SDQ may not always align with the assessment by a mental health professional.
The present study provides preliminary estimates of child behavioral and emotional problems in the context of a pandemic using an online survey platform. Significant number of children have emotional and behavioral difficulties during the lockdown period. Peer problems appear to be the pressing concerns for children in the current context. Peer-directed programs focusing on rebuilding positive peer interactions can be relevant during postlockdown school resumption. Further enquiry into the psychological risk processes relevant during lockdowns and follow-up evaluations can provide insights for interventions and preventive programs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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