COVID-19 KIDS EVIDENCE UPDATE

Guest editorial by Professor Susan Sawyer – Director, Centre of Adolescent Health, Royal Children’s Hospital; Group Leader, Adolescent Health, Murdoch Children’s Research Institute; Chair of Adolescent Health, Department of Paediatrics, The University of Melbourne

The 28th edition of the COVID-19 Kids Research Evidence Update is finally coinciding with good news; the Melbourne lockdown, one of the world’s longest and most gruelling, will soon be coming to an end. Never has the number zero looked as sweet as it did for Victorians when earlier this week, we experienced our first day for many months of zero new cases and zero deaths. A milestone for Victoria, albeit bittersweet in the context of around 20,000 COVID-19 cases and over 800 deaths this year. Notwithstanding the controversies and challenges along the way, there is widespread appreciation that Victoria’s success has been achieved as a result of consistent political leadership, a solid public health system, community support for evidence-informed decision making, and good old-fashioned grit.

Yet as we emerge out of this strict lockdown, for how long will we remember this long COVID-19 winter? In lightening up, we will still be required to limit social contact, maintain physical distancing, wear face masks and wash our hands frequently. How well will we comply? Some countries have managed well, such as South Korea, whose experience is reported this week (1). However, the authors of this report urge caution around translating their success to larger populations with more geographically widespread epidemics, where managing clusters through finding, testing, and isolating cases may be more difficult.

Certainly, global experience from Europe suggests that different parts of our population may struggle to comply, especially young people whose lives have so extraordinarily been put on hold. And while all Victorians have had their lives upended by COVID-19, it increasingly doesn’t feel that “we’re all in this together”; families, children and young people whose lives are disadvantaged by poverty, job insecurity, poor mental health, poor education and poor internet connections have been much worse off.

In my weekly clinic, I marvel at the resilience of many of my adolescent patients as they have negotiated the impact of this topsy-turvy year on their schooling, friendships, sports and cultural pursuits. Yet while the elderly bear the brunt of fatal COVID-19 disease, it is young people who will carry the long-term scars of the pandemic from disruptions to their education and future employment and the weight of national economic debt that their generation will inherit.

Different parts of the world are grappling with different versions of the same challenges. On an International Association for Adolescent Health webinar about COVID-19 and adolescents last week, a
young Indonesian medical student described how much her life had changed over these past few months. She shared photographs of her pre-COVID-19 life where, just like Australian medical students, long hours of study were happily interspersed with fun times socialising with friends, eating out, and travel to interesting places.

Fast forward, and her current photos were all tinged with the pale blue of PPE. She described huge case numbers and the daily fear of infection – not for herself, but for her older relatives. In this editorial I wish to highlight three papers reviewed by our capable medical students which underline some of the common elements required by communities to maintain behavioural limit setting, namely the importance of poverty reduction, education and wider aspects of institutional trust.

The first is a study from the U.S. that reports short-term effects of COVID-19 on parent-child psychological well-being (2). Undertaken in the USA early in the pandemic, the authors utilised a sample of casually employed adults who had coincidentally been surveyed about their employment conditions before the health crisis. A subsample of parents with children aged 2-7 years were subsequently asked a set of questions about the impact of the pandemic on employment and financial stress and other worries on parent and child well-being. Even in the very short term, there was significant deterioration in parent-reported daily negative mood since the start of the crisis. Many families had experienced multiple hardships including job losses, income loss, caregiver burdens, and illness. Both parents’ and children’s well-being was strongly associated with the number of crisisrelated hardships that the family experienced.

This work is consistent with previous studies about economic downturns which reveal that adult mental health worsens in response to long-term deterioration in economic conditions (3, 4), and that family poverty affects children’s and adolescents’ mental health (5, 6). Victorian health services are experiencing significantly increased presentations of children and adolescents with various forms of emotional distress. Studies like this (2) are a reminder that while mental health services are needed, the economic measures that have been put in place in Australia to support jobs and safeguard family income are incredibly important protectors of parent and child mental health, both in the short- and longer-term.

The second paper explores factors associated with belief in misinformation about COVID-19 and its broader public health implications (7). Beyond implanting false information, the particular concerns of the “infodemic” are that these beliefs then contribute to the rejection of information from expert authorities with risks to public health, including vaccine hesitancy. The study used five national samples from the UK, Ireland, Spain, Mexico and the USA to examine predictors of belief in the most common statements about the virus that contain misinformation. Reassuringly, the authors found that public belief in misinformation (e.g. that COVID-19 was manufactured in a laboratory in Wuhan) was not particularly common. However, in each country, a substantial proportion viewed misinformation as highly reliable. Importantly, the authors found that increased susceptibility to
misinformation negatively affected people’s self-reported compliance with public health guidance about COVID-19 and belief in the value of a COVID-19 vaccine. Across the surveys, higher trust in scientists and higher numeracy skills were associated with lower susceptibility to coronavirus-related misinformation.

The third paper is a commentary in the New England Journal of Medicine that addressed the emotional well-being of clinicians (8). Even before the pandemic, the authors, who are experienced providers of peer support in the workplace, describe unacceptably high rates of burnout and suicide among clinicians. However, during the pandemic, grief from seeing so many patients die, personal fears of contracting the virus and infecting family members, and anger over health care disparities and other systems failures have added to the personable toll for clinicians. For some, these stressors have caused or exacerbated burnout, depression, or post-traumatic stress disorder, and have been implicated in suicides. The authors affirmed that clinicians’ emotional stress often comes from workplace issues that should be mitigated, such as inadequate resources; unsustainable clinical
volume and hours; colleagues’ unprofessional and problematic behaviours, including racist and sexist behaviour; and persistent health care disparities.

Just as trust in leadership has been critical to bringing the Victorian community along with the required behavioural changes during our prolonged lockdown, this commentary explicitly acknowledges the importance of institutional trust and the role of leadership. The authors noted that statements from organisational leaders about their desire to reduce clinician burnout will only erode trust in the absence of efforts to address its root causes. The authors also argue that institutional leadership should be accountable for clinician well-being. They suggested that leaders should empower clinicians to speak up about unsafe, highly stressful, or morally challenging workplace conditions and ensure that concerns are listened to and acted on. While the authors presented a range of strategies to respond to emotional distress, they highlighted the obligation of organisations
to assess and address concerns in order to treat the root causes of emotional stress rather than merely treating symptoms.

In moving beyond our harsh lockdown, I hope that these papers may help us reflect on some of the reasons that have enabled our community to respond as well as it has. They may also serve as a reminder of how we cannot take this for granted but must continue to invest in strategies that will recharge our community’s ability to remain resilient in the face of future adversity.

1. Dighe, A., Cattarino, L., Cuomo-Dannenburg, G. et al. Response to COVID-19 in South Korea and implications for lifting stringent interventions. BMC Med 18, 321 (2020). https://doi.org/10.1186/s12916-020-01791-8.
2. Gassman-Pines A, Ananat EO, Fitz-Henley J 2nd. COVID-19 and Parent-Child Psychological Well-being. Pediatrics. 2020 Oct;146(4):e2020007294. Epub 2020 6th August. PMID: 32764151; PMCID: PMC7546085. https://doi.org/10.1542/peds.2020-007294
3. Ananat EO, Gassman-Pines A, Francis DV, Gibson-Davis CM. Linking job loss, inequality, mental health, and education. Science. 2017 16th June;356(6343):1127-1128. https://doi.org/10.1126/science.aam5347. PMID: 28619903.
4. Catalano R, Goldman-Mellor S, Saxton K, Margerison-Zilko C, Subbaraman M, LeWinn K, Anderson E. The health effects of economic decline. Annu Rev Public Health. 2011;32:431-50. https://doi.org/10.1146/annurev-publhealth-031210-101146. PMID: 21054175; PMCID: PMC3855327.
5. Rutter M. Poverty and child mental health: natural experiments and social causation. JAMA. 2003 15th October;290(15):2063-4. https://doi.org/10.1001/jama.290.15.2063. PMID: 14559963.
6. Najman JM, Hayatbakhsh MR, Clavarino A, Bor W, O’Callaghan MJ, Williams GM. Family poverty over the early life course and recurrent adolescent and young adult anxiety and depression: a longitudinal study. Am J Public Health. 2010 Sep;100(9):1719-23. https://doi.org/10.2105/AJPH.2009.180943. Epub 2010 15th July. PMID: 20634459; PMCID: PMC2920957.
7. Roozenbeek J, Schneider CR, Dryhurst S, Kerr J, Freeman AL, Recchia G, van der Bles AM, van der Linden S. Susceptibility to misinformation about COVID-19 around the world. Royal Society Open Science. 2020;7(10):201199. https://doi.org/10.1098/rsos.201199
8. Shapiro J, McDonald TB. Supporting Clinicians during Covid-19 and Beyond – Learning from Past Failures and Envisioning New Strategies. N Engl J Med. 2020 14th October. https://doi.org/10.1056/NEJMp2024834. Epub ahead of print. PMID: 33053277

COVID-19 and adolescent health

This editorial was first published by the Department of Paediatrics within the Melbourne Medical School of the Faculty of Medicine, Dentistry and Health Sciences. Read the original editorial.