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COVID-19 was declared a worldwide pandemic earlier in 2019. In response to this, the world including India went into strict lockdown. Most of the measures were very limiting and people found it hard to adjust initially. Quarantine, by itself, can cause variety of negative consequences on the mental health of a child and can have a huge impact on their daily functioning. Lockdown, along with the news of a novel virus outbreak, causes more anxiety and uncertainty among all ages. The prolonged closure of schools and the lockdown at home can cause drastic effects on the mental health of children [1].The psychological impact in the population subjected to isolation, in this case series, mainly children, would be highly unfavourable. Di Giovanni et al [2] found that adolescents had difficulty adhering to quarantine rules and were more likely to break quarantine. Although there is evidence on the association of the duration of lockdown and their negative impact on mental health in adults (increased risk of mood disorders, symptoms of depression, irritability, stress) [3], the available evidence in the paediatric population is more unreliable and the conclusions are limited. Co- SPACE Study’s early results showed increase in mental health difficulties among children during COVID-19 Lockdown .Many families bringing their children to the psychiatric OPD post lockdown, reported their difficulties experienced at home during lockdown. They reported their children feeling unhappy, worried, being clingy, and experiencing physical symptoms associated with worry [4]. Most parents reported behavioural difficulties, restlessness, irritability, boredom in their children .There were also increases in temper tantrums, arguments, children not doing what they were asked, greater levels of restlessness, frustration, fidgety behaviour, difficulty in concentration. These kinds of symptoms were interpreted as abnormal by most parents’ in-spite of it being normal behaviours for children of that age group and in quarantine. Studies should be performed on an urgent basis in the current context to establish the psychological impact of lockdowns and health-related crises in children and to assess the effectiveness of any related short- or long-term interventions [5]. One in every six children within the age group of 2- 8 years old have some neurodevelopmental, behavioural or emotional difficulty. These children have low tolerance for uncertainty and symptoms are aggravated due to the enforced restriction and unfriendly environment which does not correspond with their regular routine [6]. The following five cases describe normal behavioural changes during the lockdown that would otherwise be considered abnormal.

Case 1

An 8 year old boy, studying 3rd grade at a private school was brought to the Psychiatrist by his mother with the complaints of gaze avoidance, especially with his mother, sudden crying spells without any apparent reason, repeatedly saying that he is not a good boy and a refusal to attend online academic classes. On taking a more detailed history, we found that after lockdown began in India, he was always at home. He was not allowed to go out and play as well as interact with his peers in the neighbourhood. His school started online academic classes from July 2020. Everyday, the child would wake up and complete his usual morning routine with the help of his mother. He would attend online academic sessions that continued for 2 hours each day. He was allowed to use a smartphone, which he would do for around 2 hours daily. One day, on browsing, he accidentally stumbled upon a mermaid picture. His immediate reaction to this picture was fear along with curiosity. Following this, he began ruminating about the picture of the mermaid. Gradually, whenever he saw his mother or any other lady, he started getting thoughts of the mermaid picture. Upon looking at his mother’s hips, or the hips of any other woman, he started to get distressed. He would begin to cry and would state that he should not look at those parts of a woman. This resulted in him saying that he is a bad boy and he would cry even more due to this. This not only distressed the child but his family experienced a significant amount of distress due to this situation.

Case 2

An 8 year old boy was brought by his mother to the Psychiatric OPD. The complaint, as told by his mother, was a lack of interaction with everyone, as well as with his family. These complaints were also noticed by his teachers at school. Inspite of having normal speech and language development till 3 years of age, his interaction with his peers gradually decreased at school. He eventually stopped interacting with everyone, other than his family members. There was always a constant complaint of poor interaction from his school. After lockdown, he was staying at home with his family. He did not have any siblings and was an only child. He would watch TV continuously as he was not allowed to go out and play. There was no form of peer interaction. As lockdown extended, his mother noticed that his interaction with his family also started declining. This happened so gradually that nobody noticed at first. For the past 1 and a half months, the child stopped talking completely with everyone at home. This caused his mother to worry excessively about the nature of his problem. Though this can be a developmental disorder, the effect the lockdown had on the child is one aspect to consider as it caused a lack of external stimulation, and as he had an unlimited access to several gadgets, this eventually led to a lack of communication.

Case 3

A 10 year old child, studying in a Government school was referred from Neurology. He is the 2nd child and had an older brother. He was brought to the Psychiatrist with his mother. He had a history of frequent headache in the occipital region, precipitated whenever he gets angry, irritated or frustrated, unprovoked anger outbursts, aggressive behaviour and constantly wanting to play games on phone with his brother that would end up in fights between them. Despite interacting well with his family, he would keep throwing a lot of tantrums and fighting with them to let him play on the phone. If they did not give in to his demands, he would get angry and try to throw the phone and even break it. On waking up daily, he would demand for the smartphone. Before lockdown began, he was a very playful child. He would love going out and playing with his friends. He would adjust well and was quick in making new friends. He would enjoy outdoor games. After lockdown, he started using the smartphone excessively. He would demand his parents to give him the phone and if not, would yell angrily and would start hitting his parents. These demands and use of the phone eventually lead to frequent fights with his brother. His mother stated that in the past 2 to 3 months he became more demanding, aggressive and impulsive.

Case 4

A 11 years old female child, studying in 6th standard belongs to lower SES, was brought by her mother with complaints of watching YouTube videos for more than 5 hours, when mother checked, she was apparently watching kissing videos in YouTube and when asked about it, she denied it. The child was developmentally normal with normal biological functioning. She attends her online class regularly and takes care of her younger brother. She is a well-adjusted child with. Mother accidentally saw the child watching adult content a day ago. She was worried about her child’s behaviour.On examination of the child, rapport established with difficulty, child was cooperative for interview, Eye contact made and maintained except when asked about her behaviour. No gross psychopathology could be elicited. Brief counselling and psycho education was given to child and the mother. Mother was reassured that this was a normal behaviour and not to be taken out of context and worried.

Case 5

A 8 years old female child who studying 3rd standard was brought by parents with complaints of sleep disturbances, bed wetting daily, temper tantrums, assaultive towards elder sister for the past 1 year, increased in past 2 months after lockdown.She sleeps around 1 am and wakes up at 10 am, she attends her online classes regularly but uses the smartphone throughout the day watching YouTube and playing online games. She refuses to share any toys with her elder sister and throws tantrums whenever her sister asked for the toys. Child appears cheerful, answers appropriately and maintains eye contact throughout the interview. Alarm technique was advised for bed wetting, Behaviour therapy and activity scheduling was advised. Her screen time was reduced to less than 1 hour per day for which token economy technique was used. Alternative hobbies were suggested for the child like reading books, meeting her school friends. Parents were advised to spend quality time with her and encourage activities along with her sibling. Suggested to eat at least one meal together with children. After a month of follow up and strict activity scheduling and behaviour therapy, her temper tantrums have reduced , bed wetting stopped completely.

Discussion

The separation of a child from its primary caregiver for a long period of time can lead to increased distress in the child especially on a background of fear and anxiety following the pandemic. Hence, regular interaction is of utmost importance as separation can have its own impact on the mental health of a child. Before lockdown started, children and adolescents had a structured routine. Their daily activities would involve going to school, tuitions, extracurricular activities, homework assignments and play time with friends. School plays an essential role in the growth and development of a child’s cognitive, emotional, social and psychological makeup. Apart from the emphasis placed on academics, it offers children a safe space to interact with others, including their teachers, and engage in various forms of age appropriate activities. All this serves some form of psychological support. They were not under the constant supervision of their parents and were allowed some independence. These activities kept children occupied and conflicts with family members were not high. This population is particularly vulnerable to the effects long term confinement can have on them. During the 5 months of lockdown, there were many problems that were present in homes. Absence of structured setting of the school for a long duration can lead to a disruption in routine, boredom and lack of innovative ideas for engaging in various academic and extra- curricular activities. They lacked a proper routine and very minimal to nil interaction with anyone other than family. Resources such as Television, computers and outdoor activities were limited and prolonged use lead to boredom.They can also be clingier, attention seeking and more dependent on their parents due to them always being available at home. Confining children and adolescents to their home is associated with a lot of uncertainty and increasing anxiety which may eventually lead to disruption in their education, physical activities and opportunities for socialisation with others. As their parents were always at home, there was constant supervision which turned out to be more problematic than usual. The only means of being occupied was access to the internet, television, radio, using cellphones to access social media apps like Facebook, Instagram, Twitter etc. as well as playing games on their phones and prolonged use led to boredom. There was no means of physically interacting with their friends and they were restricted to going out. These restrictions impacted their mental wellbeing, especially being confined to their houses from a long duration. Parents would constantly supervise their children when they went online, for how long they would be online and the content they would access. This not only invaded their privacy but also created many trivial issues between family members. As regulations regarding COVID were stringently put in place, the use of the internet simultaneously increased as well. This lead to increased screen usage and irritability when parents tried to restrict such use. Apart from this, being confined or isolated for prolonged periods caused behavioural changes in many children and adolescents that their parents took out of context to the given situation. Many of these behaviours were actually within the normal range but due to parents being constantly at home, they perceived these otherwise normal behaviour changes as abnormal which lead to an increase in the number of psychiatric consultations.

Conclusion

The above discussed cases show the effect of lockdown on children as well as several psychological problems associated with it. Isolation or confinement, inability of the family to provide an age appropriate explanation of the situation, unclear information of the purpose of the lockdown, and lack of structured activities and a clear routine can all lead to irritability, frustration and agitated behaviours. It is important to distinguish normal behaviour changes from abnormal ones in specific situations, in this case, the COVID-19 lockdown. Help should be sought from a Psychiatrist, if a child or adolescent exhibits symptoms of severe and intense anxiety or depression, suicidal ideation, or marked irritability associated with the lockdown. It is important to remain alert for the development of symptoms, including changes in appetite, sleep disturbances, fear of being alone or social withdrawal. Many measures that were implemented focussed on improving and sustaining an individual’s physical fitness. There are so many precautionary, preventive and protective measures taken but hardly any effort was made to improve, sustain and strengthen the mental health of an individual. Physical health adds years to your life, whereas mental health adds life to those years.

1. Wang G, Zhang Y, Zhao J, Zhang J, Jiang F (2020) . Lancet 395: 945-947.

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2. DiGiovanni C, Conley J, Chiu D, Zaborski J (2005) . Biosecur Bioterror 2: 265-272.

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3. Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, et al. (2020) Lancet 395: 912-920.

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4. Oxford Health NHS Trust Co-SPACE Study by Cathy Creswell, Polly Waite, Department of Experimental Psychology & Department of Psychiatry at the University of Oxford
5. Shen K, Yang Y, Wang T, Zhao D, Jiang Y, et al. (2020) . World J Pediatr 16: 223-231

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6. CDC (2019) . Centers Dis Control Prevent.