Impact of Covid-19 on Psychosocial Well-Being of School-Going Children: A Cross-Sectional Study

Introduction: The mandated closure of schools due to Covid-19 is likely to have a negative impact on school-going children. This study aimed to assess the psychosocial well-being of school children during the pandemic in eastern India. Methods: This cross-sectional study was conducted in the outpatient pediatric department of tertiary care teaching hospitals. Children between the ages of 4 and 14 were enrolled. The main outcome measures included the Emotional Symptoms Scale, Conduct Problem Scale, Hyperactivity Scale, Peer Problem Scale, and Prosocial Scale from the Strength and Difficulties Questionnaire (SDQ), as well as the Children’s Hope Scale. Results: Out of 169 children aged 4-14, 104 (61.5%) were male, 140 (82.8%) were from urban areas, 66 (39.1%) had a family member who was a healthcare worker or frontline worker, and 12 (7.1%) had experienced the death of a family member due to Covid-19. Anxiety-related and depressive symptoms were observed in 81 (47.9%) and 70 (41.4%) children, respectively. Psychosocial difficulties with a 'clinically significant problem likely' were observed in 26 (15.4%) children, more common in males (16.35%, P=0.035) and older children (12-14 years). Children from families with healthcare/frontline workers, Covid-affected families, loss of job in the earning member, and uninvolved parenting style were associated with more psychosocial difficulties. The mean (SD) hope score was 22.46 ± 6.42 in children above eight years. Conclusion: The psychosocial well-being of school-going children is adversely affected during Covid-19, particularly in families with frontline workers, loss of job, and death of family members due to Covid-19. The poor hope score in children aged 8 years and above indicates an adverse impact on their ability to achieve future goals.


Introduction
Social distancing was one of the primary public health interventions to reduce the spread of SARS-CoV-2, the virus-causing Covid-19.Though children appeared to be at low risk of developing severe disease and mortality, many interventions (closure of school, quarantine of family members, news and social media on Covid-19, separation of parents, death of near and dear ones, etc.) have significantly disrupted the lives of children [1].Past evidence has shown significant psychosocial effects on children during disasters, and reports of psychosocial distress in children have increased during Covid-19 [2][3][4].The core components of psychological well-being are emotional/personal, social/interpersonal and the ability to cope.During the initial crisis period, the 'emotional' and 'social' components are likely to be affected whereas during the protracted and recovery phase, the 'ability to cope' component is affected.
The objective of the present study was to describe the various components of psychosocial well-being of school-going children during the pandemic and their associated factors.Psychosocial components included are depression, anxiety, behaviour, emotion, conduct, socialisation, and goal-oriented thought.

Materials And Methods
This survey was conducted from June 2021 to December 2021 after receiving ethical approval from the Institutional Ethical Committee, Balangir.The parents of school-going children aged between 4 and 14 years were invited to participate in the study either in person or via WhatsApp, email, and URL-linked messages.After obtaining informed written consent, a pre-designed questionnaire was distributed to the parents.Children over the age of eight were asked to provide their assent to participate in the study.Children not attending school or known to have psychosocial, neuropsychiatric, or developmental disorders were excluded from the study.
The questionnaires were given to parents, who were encouraged to seek clarification if they didn't understand any items when scoring.Clarifications were given by the administrator by making the parents understand the item in local language or citing examples relevant to the question.No compensation was provided to the participants.The study aims and outcomes were not disclosed to the participants to avoid response bias.The parents were asked to involve family members and children aged eight or above to complete the survey together.Triangulation of data was encouraged to ensure the best response.Incomplete or missing data and inappropriate case selections were excluded from the analysis.

Survey instrument
The questionnaire includes identification and demographic information, five selected questions from the child depression scale, four questions from the anxiety scale, 33 questions from the Strength and Difficulties Questionnaire (SDQ), and six questions from the Children's Hope Scale [5,6].The SDQ can be downloaded for free from http://www.sdqinfo.org.It comprises five subscales, each with five items, measuring emotional symptoms, conduct problems, hyperactivity-inattention, peer relationship problems, and prosocial behaviors [5].The demographic section includes questions about age, sex, residence, parental occupation (whether a parent is a healthcare/frontline worker or not), and any loss of household income or death of a family member due to Covid-19.The items were selected from the Parent Report Measures for Children and Adolescents SDQ (P) 04-10 and Parent Report Measures for Children and Adolescents SDQ (P) 11-17.Six items from the Children's Hope Scale were included in the questionnaire as self-report questions for children aged 8-14.The collected data were analyzed.
The first 25 SDQ items were grouped into five scales: emotional symptoms scale, conduct problem scale, hyperactivity scale, peer problem scale, and prosocial scale.Each response was converted into a score (0 for 'Not true', 1 for 'Somewhat true', and 2 for 'Certainly true').For items 07, 11, 14, 21, and 25, a reverse scoring was applied (i.e., 2 for 'Not true', 1 for 'Somewhat true', and 0 for 'Certainly true').The total difficulty score was calculated as: The interpretation of the SDQ score was based on the information from its website and classified as 'Average', 'Slightly raised', and 'High'.If the score is average, it means that a clinically significant problem in the area is unlikely.If the score is slightly raised, it indicates that a clinically significant problem is likely.If the score is high, there is a substantial risk of a clinically significant problem.The Children's Hope Scale was administered to children above eight years old and labeled as 'Questions about your goals'.The total Children's Hope Scale score was achieved by adding the responses to the six items: 'None of the time' 1; 'A little of the time' 2; 'Some of the time' 3; 'A Lot of the time' 4; 'Most of the time' 5; 'All of the time' 6.

Sample size
Assuming a 12% prevalence of psychosocial problems during the pandemic and a precision of 5% with 95% confidence interval, we calculated a minimum sample size of 163.However, we gathered data from 169 subjects, which exceeds the required minimum sample size.

Statistical analysis
The data were analyzed using SPSS version 24.00.Descriptive statistics were used to analyze the descriptive data for both continuous and categorical variables.Categorical variables were presented as the number and percentage of patients and were compared, if necessary, using Pearson's chi-square test for independence of attributes or Fisher's exact test.Continuous variables were presented as mean and standard deviation and compared using unpaired t-test or analysis of variance (ANOVA).The association of psychosocial factors with different demographic parameters and styles of parenting was examined using Pearson's correlation coefficient.A difference was considered statistically significant when the p-value was less than 0.05.

Results
Out of 205 questionnaires that were distributed, 22 couldn't be collected and 14 were incomplete.A total of 169 questionnaires were completed and analyzed.

Discussion
The present study was conducted on school-going children during Covid-19.The children mostly belonged to urban areas, the majority having an employed adult in the family, and many were from families with frontline/healthcare workers.School closure, lack of outdoor activity, and aberrant dietary and sleeping habits have disrupted the children's usual lifestyle.Children of frontline/healthcare workers have suffered unique problems [7].Loss of a job in a family member, separation of a family member for being quarantined due to infection or job or death of any family member has significantly affected the psychosocial well-being of the school-going children.The mental health status of many children has been affected manifested by anxiety and depressive symptoms with reduced hope score in older children.
We evaluated the mental health status of children using anxiety and depressive symptoms.Anxiety-and depression-related symptoms are found in around 45% of children.Anxiety-related symptoms are reported to increase during lockdown as compared to before lockdown in Dutch children and adolescents [8].[12].However, loss of household income and being female is associated with higher odds of depressive and anxiety symptoms in school-going children from Florida during Covid-19 [13].
We have used SDQ for assessing the psychosocial difficulties and reported them as clinically significant problems likely.Conduct, hyperactivity and socialization problems were seen in around 24% of children.
Emotional problems were seen in 7.7% but peer relation problems in 40% of children.Using the SDQ scale, in Chinese adolescents the prevalence of emotional and behavioral problems was higher (31.6% for total difficulties score and 37.5% for prosocial problems) as compared to the school-going children in our cohort [14].Zainudeen et al. have reported that 38% of children with high psychosocial impact (score 14) in Malaysian families using the Impact of Event Scale-Revised (IES-R) and Children's Revised Impact of Event Scale (CRIES) [9].In a cross-sectional study of Hong Kong families, the risk of psychosocial problems was higher in children with special educational needs, acute/chronic disease, single-parent families and lowincome families [15].In a study from UAE, 17.5% of school-aged children had emotional problems [12].
Children from urban areas have fewer opportunities for interaction due to the stringent implementation of lockdown measures as compared to rural areas.We found more anxiety, depressive symptoms as well as psychosocial difficulties in urban children.In a study by Schneiderman et al. from Argentina during the Covid-19 lockdown, 96.3% of parents noticed emotional changes in their children.Boredom, irritability, and reluctance were more present during lockdown [16].
Anxiety and depressive symptoms were found in school-going children during pandemic and more so with those belonging to the family with healthcare or frontline workers.Psychosocial difficulties (emotional, prosocial, hyperactivity, peer relation and conduct problems) are lower in families with a frontline/healthcare worker as compared to those not having a frontline/healthcare worker.
Family is a protective factor against psychosocial difficulties especially at the time of lockdown and school closure when children don't have the opportunity to physically meet their friends.Family harmony gets disturbed when any earning family member loses a job, gets infected with Covid-  [18].On the other hand, an increased number of child abuse cases were reported during lockdown.National Crime Record Bureau in India estimated that around 40,810 children fell victim to sexual offences, and in 95% of cases, the perpetrator was known to the victim under regular circumstances before the pandemic [18].However, during the lockdown 50% increase in call rates to CHILDLINE India with around 30% reporting child abuse was noted [19].Poor mental health, unemployment and frustration of parents during the pandemic with the lack of a defense system (school teachers, friends) might be the reasons for the same [20].
Parenting style has an impact on the development of children.Uninvolved parenting style was associated with more anxiety, depressive symptoms, and psychosocial difficulties in our cohort.Authoritarian parenting was protective for psychosocial impact during Covid-19.Parenting under pressure had a mixed impact on family life during Covid-19, providing an opportunity to teach health concerns, and hygiene to kids, balancing the act of parenting (assisting with children's schoolwork and working from home), and improving family relationships and parent-child bonding [21].
In the present study, it was observed that psychosocial problems in school-going children are significant during Covid-19.Poor hope score in children (≥8 years) indicates an adverse impact on achieving future goals and can have devastating consequences if not addressed properly.Peer problems and socialization problems will adversely affect the social life of children and can affect their mental health leading to depression, anxiety disorders and substance abuse [22].Children with significant conduct problems are at risk of developing other mental disorders such as anti-social personality disorder, mood or anxiety disorders, violence, juvenile delinquency, suicidal and criminal behavior [23].Children with significant emotional problems are at risk of developing anxiety, major depressive disorder and suicidal behavior [24].Hyperactivity may be a sign of ADHD.A decline in the mean hope score indicates that more attention needs to be given to the children in the form of proper parenting and guidance by teachers.Early addresal of these issues can improve the psycho-social well-being of the children before it's too late.
The strength of the present study needs special mention.Gathering data from the parents on psychosocial aspect of school-going children especially during lockdown and school closure was difficult.However, it has several limitations too.The majority of the respondents belonged to urban areas, and many had an employed parents in the family.Sample size is small and does not represent the entire population of the state.However, the impact of the pandemic seems to be universal and applicable to all children of school going age.The psychosocial problems of the population prior to the pandemic are not available.Prospective studies that include evaluation of anxiety and depression post pandemic/lockdown in follow up can give a better representation of the magnitude of the problem.Further study with implementation of psychosocial intervention will be useful adjunct to the present findings.

Conclusions
Covid-19, along with mandated lockdowns and school closures, has had a negative impact on the mental and emotional well-being of school-going children.This impact is especially pronounced in families with frontline workers, job loss, and the death of family members due to the pandemic.Anxiety-related symptoms are more prevalent in female and older children, while depressive symptoms are more common in male and younger children.Children aged 8 and above with a low hope score may experience a negative effect on their ability to achieve future goals.These findings suggest that policymakers should develop effective coping strategies for school-going children.Schools should prioritize screening strategies, implement mental health interventions based on significant influencing factors, and focus on supporting the vulnerable group.

Appendices Psychosocial well-being of school-going children
Personal details :  All of the time Consent I do hereby give my consent to use the information submitted by me for analysis, which might help the researchers to find the psychosocial well-being and help the stakeholders to plan for psychosocial support measures for school going children.

Yes
No Signature :

28 1 ) 3 ) 4 ) 6 ) 7 ) 9 ) 13 ) 15 41 14 ) 16 ) 19 ) 20 ) 22 ) 23 ) 3 )
Considerate of other people's feelings (SDQ PS1) Restless, overactive, cannot stay still for long (SDQ H1) Often complains of headaches, stomach-aches or sickness (SDQ E1) Shares readily with other children, for example toys, treats, pencils (SDQ PS2) Rather solitary, prefers to play alone (SDQ PPS1) Generally well behaved, usually does what adults request (SDQ CPS2) Helpful if someone is hurt, upset or feeling ill (SDQ PS3) Often unhappy, depressed or tearful (SDQ E3) Not true Somewhat true Certainly true 2024 Pradhan et al.Cureus 16(6): e62561.DOI 10.7759/cureus.6256110 of Generally liked by other children (SDQ PPS3) Nervous or clingy in new situations, easily loses confidence (SDQ E4) Picked on or bullied by other children (SDQ PPS4) Often volunteers to help others (parents, teachers, other children) (SDQ PS5) Steals from home, school or elsewhere (SDQ CPS5) Gets along better with adults than with other children (SDQ PPS5) Good attention span, sees chores or homework through to the end (SDQ H5) of teacher/caregiver Over the last six months, have your child's teachers/caregiver complained of the following : 53 1) Fidgetiness, restlessness or overactivity No A little 2024 Pradhan et al.Cureus 16(6): e62561.DOI 10.7759/cureus.Acting without thinking, frequently butting in, or not waiting for his or her turn question, if answer is 'Yes', answer rest 7 questions 56 Overall, do you think that your child has difficulties in any of the following areas: emotions, concentration, behavior or being able to get along with other people ?difficulties interfere with your child's everyday life in the HOME LIFE ?difficulties interfere with your child's everyday life in the FRIENDSHIPS ?difficulties interfere with your child's everyday life in the CLASSROOM LEARNING ?difficulties interfere with your child's everyday life in the LEISURE ACTIVITIES ?63 Do the difficulties put a burden on you or the family as a whole ?Not at all A little 2024 Pradhan et al.Cureus 16(6): e62561.DOI 10.7759/cureus.62561A medium amount A great deal Questions about your goal ONLY FOR CHILDREN AT/ABOVE 8 YEARS.Please mark the most appropriate answer by asking the following six questions regarding goal of your kid.64 1) I think, I am doing pretty well.None of the time A little of the time Some of the time A lot of the time Most of the time All of the time 65 2) I can think of many ways to get the things in life that are most important to me.None of the time A little of the time Some of the time A lot of the time Most of the time All of the time 66 3) I am doing just as well as other kids of my age.None of the time A little of the time Some of the time A lot of the time Most of the time All of the time 67 4) When I have a problem, I can come up with lots of ways to solve it.None of the time A little of the time Some of the time A lot of the time Most of the time All of the time 68 5) I think the things I have done in the past will help me in the future.None of the time A little of the time Some of the time A lot of the time Most of the time All of the time 69 6) Even when others want to quit, I know that I can find ways to solve the problem.None of the time A little of the time Some of the time A lot of the time Most of the time 2024 Pradhan et al.Cureus 16(6): e62561.DOI 10.7759/cureus.62561

TABLE 2 : Psychosocial problems and Hope Score of school-going children in the study population Data
presented as n (%), * mean (SD)

Table 3
shows the socio-demographic factors associated with anxiety and depressive symptoms in schoolgoing children during Covid-19.Anxiety-related and depressive symptoms were more commonly seen in children from urban areas, families with healthcare/frontline workers, Covid-19-affected families, loss of jobs in the earning member of the family, and uninvolved parenting styles.Anxiety-related symptoms were more common in females, with 30 (46.15%) of them affected, and in older age groups (12-14 years), with 29 (47.54%)affected.However, depressive symptoms were more common in males, with 51 (49.04%) affected, and in younger children (4-8 years), with 34 (52.3%)affected.

TABLE 3 : Socio-demographic factors associated with anxiety and depressive symptoms in the study population
In Table4, we can see the psychosocial challenges and the average hope score from the SDQ questionnaire and Children's Hope Scale.The research indicates that older children (12-14 years old), city dwellers, families affected by Covid-19, those who have experienced job loss in the family, or those with uninvolved parenting styles are more likely to experience psychosocial difficulties.Additionally, the average Hope Score was lower in children who have experienced the death of a family member and those with permissive 2024 Pradhan et al.Cureus 16(6): e62561.DOI 10.7759/cureus.625615 of 15 parenting styles.

TABLE 4 : Socio-demographic factors associated with clinically significant psychosocial difficulties and Hope Score in the study population
Zainudeen et al. have reported 28.5% of children with anxiety, and 31.4% with depression in Malaysian families using the Depression Anxiety and Stress Scale (DASS) [9].Duan et al. have reported the anxiety level of children to be 23.87±15.79(Spence Child Anxiety Scale); 22.28% suffering from depressive symptoms (Child Depression Inventory) during the Covid-19 outbreak [3].Healthy children as well as children with special healthcare needs have a high prevalence (57.4%) of mental health problems during Covid-19 in several studies [10,11].Older children and females have more anxiety symptoms whereas younger children and males have more depressive symptoms.Saddik et al. have reported a high prevalence (59.8%) of anxiety in young people during Covid-19 with females having 1.91 times higher odds of reporting anxiety than males 19, or dies of Covid-19.We found more anxiety and depressive symptoms and psychosocial difficulties in the children from disturbed families.Moulin et al. reported elevated levels of ADHD and emotional symptoms in children from families with financial difficulties [17].Luijten et al. have reported worse mental/social health in children from families with a friend/relative infected with Covid-19 or negative change in work situation due to Covid-19 regulations For each item, please mark the most appropriate box.Choose the best one you think even if you are not absolutely certain.Please give your answers on the basis of your child's behavior over the last six months.

TABLE 5 : Psychosocial well-being of school-going children
SDQ: Strength and Difficulties Questionnaire