In March 2021, recognising that “government-imposed lockdowns and school closures … have significantly disrupted the daily lives of children and adolescents”, UNICEF warned about their effect on “the mental health of children and adolescents … their caregivers, families and communities”, particularly on “children and adolescents with pre-existing conditions”.
By John Whitehall, Bijender Gautam & James Whitehall
UNICEF recognised “evidence gaps” on these matters and called for more research. Accordingly, from July to October 2021, a paediatric clinic in south-west Sydney investigated the effect of lockdowns on children and adolescents with neurodevelopmental disorders.
Parents bringing children for regular review of neurodevelopmental disorders such as ADHD, autism spectrum disorder and anxiety were invited to complete a questionnaire on the effect of lockdowns and school closures on their children’s “mental state” and “behaviour”, “parents’ mental state”, “progress of education”, “time spent on devices”, “state of sleeping”, and assessment on the state of the original condition.
Answers were quantified on a Likert scale of 1 to 5, with 1 being “much worse”, 2 being “worse”, 3 being “the same”, 4 “better” and 5 “much better”, and were grouped into those aged from five to ten, and eleven to eighteen, and according to sex. Up to two hours of “screen time” (excluding online learning) was considered “normal” in accordance with Australian Health Guidelines. Sleep was considered “worse” if interrupted by up to two hours.
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In all, there were 156 replies, concerning sixty-six younger and ninety older children. For the whole cohort, responses to all questions were statistically “worse” or “much worse”. “Behaviour”, however, was reported to be better in 19 per cent, “mental state” in 17 per cent, “learning” in 12 per cent, “family dynamics” in 13 per cent, and “parental mental state” in 4 per cent. “Screen time” was reduced in less than 1 per cent, and no one slept more soundly. Statistically, mental state and behaviour were worse in the younger group and, in both groups, were worse in females.
The study confirms worsening impact with prolongation of lockdowns. For example, an online survey of 213 parents conducted early in the pandemic in Australia in May 2020 by Scibberas et al concluded that “two-thirds of parents of children with ADHD reported some positive aspects”. In our study, however, they amounted to only 10 per cent of possible responses, compared to 61.6 per cent which denoted negative outcomes.
Sciberras reported little change in sleep patterns, but 114 (73 per cent) of our parents declared they had worsened. Scibberas also reported “negative changes” in preoccupation with television (41.2 per cent), social media (21.6 per cent) and gaming (32.8 per cent) but, while we did not specify the type, 77 per cent of our parents reported greater overall screen time among their children.
Another early Australian online survey, in April 2020, warned that the pandemic posed “significant risks to population mental health” but, reported that “no differences [were found] between pandemic and pre-pandemic datasets for parent emotion dysregulation or depression in children 12–15 years” and there were “no differences in family negative experiences”. To the contrary, our study found increased mental stress in 58 per cent per cent of parents and in 65 per cent of children, and worsened “family dynamics” in 44.8 per cent.
School closures have created a “uniquely stressful situation” for neurodevelopmentally challenged children because of the abrupt disruption of “carefully developed routines”, and the sudden addition of the responsibility for education thrust upon parents already burdened with financial and other challenges to their parenting skills. It is intuitive that added stresses to children would include isolation, disruption of sleep, and fear of the disease, as well as stresses imposed by even more challenged parents.
It should not be assumed, however, that responses of “positive” effect actually denote benefit. To the contrary, they may obscure a deeper cost. For example, some parents reported less family stress in the absence of the morning fight to get reluctant children to school. Others found greater peace in not having to deal with the social, behavioural and educational challenges incurred by their children’s school attendance. Others found peace in their child’s distraction on the web.
Thus, reported “positive effect” may have been at the cost of social and educational regression and worsening of screen addiction with its inherent neurological effects, compounded by its secondary interruption of restorative sleep.
Might the negative effects of lockdowns be permanent?
According to laboratory investigations on animals and observational effects on humans, stress may impose lasting effects on the developing brain. The normal “fight or flight” response to various challenges to well-being, defined as stress, involves the transducing of sensory input into electrical oscillations which are relayed on specialised circuitry to regions of interpretation, essentially based on memory which is, itself, an unfathomable repository of past electrical oscillations. After evaluation, again by unfathomable interpretation of electrical data, further oscillations travel by special circuitry to evoke emotional and physiological preparation to “fight or flight”.
Along the way, various hormones will have been recruited to participate in the response: to “ginger up” muscular activity (including the heart), or to command DNA in neuronal nuclei to produce various proteins, each with its specific but integral role in the overall response. In the meantime, the brain will attempt to obey the usual commands for normal growth in accordance with some primordial blueprint and timetable. All this cerebral activity will demand continued supply of brain fuel, removal of waste, quality control, repair of old circuitry and exhausted cells, while laying down the new in an expanding but uncharted grid.
The effect of chronic stress on the brain has been likened to sustained revving of a car engine. Few analogies are perfect and to strain this one further, we might imagine the effect of lockdowns on a developmentally challenged child as a driver-and-car unit which is restricted to the garage, losing road skills, while accumulating exhaust from an already defective engine with both driver and car denied fuel maintenance, repair and replacement.
In the brain, however, there is yet one more complication: the superimposition of various electrical oscillations from preoccupation with face-time. Clearly, the longer this process, the worse the outcome.
The value of stress.
In real life, physiological responses to stress are basic to the gaining of wisdom: the challenge is usually overcome, the response recedes, an experience is stored in the repository for future reference. Maturity is on the way.
Fortunately, given the capacity of the brain to both heal and grow, known as “plasticity”, even intense challenges, as incurred in a natural disaster or by a death in the family, may be “tolerated” by children without lasting damage. But sometimes intensity and duration may intersect, with sustained “toxic” effect.
The Adverse Childhood Events study in the US evaluated the effects of stress on children resulting from various types of physical and sexual abuse, neglect and family dysfunction. It confirmed a direct association with future dysfunctional behaviour, including alcoholism, drug addiction, violence, sexually transmitted diseases, suicidal attempts and unwanted pregnancies.
However, as well as behavioural disorder, as the magnitude of adverse events increased so did the rate of subsequent physical illnesses, including ischaemic heart, liver and lung disease. Perhaps the heart disease resulted from its chronic over-stimulation compounded by the effect of stress hormones on arteries and veins. Perhaps liver disease was similarly provoked. Indeed, all organs may have been rendered vulnerable to early degeneration by an immune system weakened, for example, by a surfeit of anti-inflammatory steroids secreted by the adrenal gland challenged by a glut of pro-inflammatory cytokines, all released in response to the disruption by stress.
In parallel with structural change in more obvious organs, it appears that chronic stress may exert functional and structural changes in the brain which may underlie observed behavioural disorder. Research suggests that under chronic stress, the development of co-ordinating centres may be delayed, and circuitry may be exaggerated by over-use, or thinned by neglect. Receptors for essential hormones may be exhausted by over-use. Errant stimulation of DNA in the nuclei of neurons may provoke “apoptosis” or programmed death, and regenerating cells may be aborted before their birth. In many ways, plasticity may be impaired.
The deleterious effect on the brain may be worsened through bi-directional influences. For example, receptors involved in anxiety may become “hypertrophied”, firing off at lesser provocation but with greater intensity along fortified circuitry, rendering the sensation of fear and uncertainty progressively more acute. Thus, anxiety may worsen itself. So may ADHD.
This troubled mix is worsened by the noxious contributions of sleep deprivation and increased screen time (which are, themselves, bi-directional).
It is wrong to consider sleep as merely rest. To the contrary, it is an intense time of cerebral restoration, fine-tuning and growth. For example, adequate sleep appears basic to “correcting the energy and nutritional imbalances” incurred by wakefulness, and seems to bring this about by “rebuilding the diminished cellular components”. Also, it facilitates removal of chemical and hormonal by-products of cerebral activity in wakefulness, such as adenosine, as well as the removal of disordered proteins which have resulted from up-regulation of various genes in response to stress.
Thus, in ways not yet understood, sleep promotes “neurogenesis, neurological and emotional development, memory formation and learning”. In corollary, sleep deprivation is believed to be “a cause of neuronal loss”. In animals, sleep disruption has been shown to reduce social bonding. To emphasise the propensity for damage, it should be noted that in experimental animals, complete deprivation “leads to death within three weeks”.
Human studies are, of course, limited. But, in 1959, a world record for staying awake was established by thirty-two-year-old US radio personality Peter Tripp in a fund-raising exercise conducted in a glass booth in Times Square. He lasted 201 hours but, after a few days, had begun to suffer from hallucinations. Undeterred, his assistants kept him revving on chemical stimulants until psychosis appears to have reached such intensity they threw in the towel. How much money was raised through this spectacle is unknown. Nor is it known if the assistants were on an hourly rate. Tripp, however, was never the same again.
The world record for duration of internet gaming appears to have been won by an Australian who put in, by comparison, a paltry 135 hours and fifty minutes. No ill effects were reported apart from an “intense and dishevelled” appearance, as confirmed by cursory observation of his published photograph. The accompanying article, however, did report two youthful deaths in lengthy gaming sessions, but these appear likely to be due to non-cerebral causes .
While death from internet addiction is unlikely, microstructural changes in cerebral architecture have been reliably reported in young screen-time addicts. Structurally, reduced grey matter and abnormalities in white matter have been demonstrated, and revealed to increase with duration of addiction. Functionally, electrical inter-connectivity between regions of the brain has been shown to be interrupted. Not surprisingly, these structural and functional findings have been associated with impaired psychological well-being, academic failure and reduced work performance among adolescents.
Lastly, the effects of lockdowns on the unborn should not be overlooked because, one way or another, mental stress on the mother has been associated with neurodevelopmental complications in the offspring. Perhaps there is genetic influence. Perhaps the foetal brain is affected by higher levels of maternal stress hormones. Perhaps higher levels of maternal adrenaline interfere with blood supply to the uterus and, hence, to the baby’s brain. Perhaps the mother is not eating well, or taking medications, or drugs, including alcohol, to mitigate distress.
Whatever the cause, it will be interesting to review the incidence of neurodevelopmental disorder in babies born during Covid restrictions. An increase would be plausible.
The good news.
The good news is that individuals vary and therefore prediction of the future in any particular child is uncertain: some children endure frightful abuse without apparent long-term effect. Conversely, it should be emphasised that the appearance of neuropsychological problems in a child does not necessarily indicate abuse.
The bad news.
The bad news is that universal lockdowns and school closures will have seriously challenged a very large number of Australian children for a very large percentage of their lives in which very large developments should have been occurring in their brains. Up to 8.2 per cent of Australian children are reckoned to suffer from ADHD, 6.9 per cent with anxiety, and one in seventy from autism. Thus, many brains will have been further challenged by compounding forces, and the epidemic is not yet over.
We are not judging the imposition of public health measures; the consequences of rampant disease are not difficult to imagine. All we maintain is that the vulnerable brains of many children will have been further challenged by a “perfect storm” of intersecting adverse events, and the prevalence and intensity of neurodevelopmental disorder is likely to increase. As the Covid war subsides, casualties of “friendly fire” are likely to become more obvious.
 UNICEF. Mental health alert for 332 million children linked to COVID-19 lockdown policies: UNICEF. https://news.un.org/en/story/2021/03/1086372
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 Hong SB, Zalesky A, Cocchi L et al. Decreased brain connectivity in adolescents with internet addiction. PLOS One. 2013. https://doi.org/10.1371/journal.pone.0057831 Affiliations Melbourne Neuropsychiatry Center, Department of Psychiatry, University of Melbourne and Melbourne Health, Parkville, Victoria, Australia, Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia, Division of Child and Adolescent Psychiatry, Department of Psychiatry, College of Medicine, Seoul National University, Seoul, Republic of Korea. Affiliation Melbourne Neuropsychiatry Center, Department of Psychiatry, University of Melbourne and Melbourne Health, Parkville, Victoria, Australia
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