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Mental health considerations for children quarantined

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COVID-19, and 690 000 individuals who have come of strategies to prevent the potential mental health
into close contact with individuals with COVID-19 have problems that might arise among children who are
been registered and quarantined, including a large quarantined during the COVID-19 pandemic. For
number of children.1 This quick action has effectively example, in many Chinese tier 1 cities —typically the Lancet Child Adolesc Health 2020

slowed the spread of new cases of infection on both the largest and wealthiest—like Shanghai, Guangzhou, and Published Online
March 27, 2020
Chinese mainland and the rest of the world. However, Hangzhou, nurses are guaranteed to be available 24 h https://doi.org/10.1016/
researchers have realised that such measures might per day in the children’s isolation ward. Nutritionists are S2352-4642(20)30096-1

have adverse psychological effects on children who are invited to give professional guidance for children’s
quarantined. For children who are quarantined at home diets according to their medical conditions and
with their parents or relatives, the stress caused by such normal developmental requirements. To reduce fear
a sharp change in their environment might be eased and other psychological discomfort, children who
to some degree.2 However, children who are separated are quarantined can communicate with their parents
from their caregivers require special attention, including via mobile devices at any time. Many citizens from
children infected with or suspected of being infected the local community or district volunteers act as
with severe acute respiratory syndrome coronavirus 2 temporary mothers to care for recovered children after
(SARS-CoV-2), who are quarantined in local hospitals or their discharge, when their caregivers are not available
collective medical observation centres; and children because of infection, quarantine, or death. In response
whose caregivers are infected with SARS-CoV-2 or who to the notice on improving rescue and protection for
have died from the disease and are thus under the care children without effective guardianship issued by the
of social charity groups. These children might be more Ministry of Civil Affairs, many cities like Zhengzhou
susceptible to mental health problems because of their opened free psychological counselling hotlines, which
higher risk of infection, and the grief and fear caused by were available 24 h per day.9 Most recently, the National
parental loss or separation. Health Commission of China issued guidelines and listed
Companionship is essential for children’s normal specific intervention strategies for children who are
psychological development and wellbeing.3 Separation quarantined in collective medical observation centres.
from caregivers pushes children into a state of crisis For example, these measures seek to increase children’s
and might increase the risk of psychiatric disorders.4 communication time with their parents; increase
Sprang and colleagues5 reported that children who children’s access to disease information via comic books
were isolated or quarantined during pandemic diseases and videos; guide children to establish a regular activity
were more likely to develop acute stress disorder, schedule; provide night lights and small gifts; and
adjustment disorder, and grief. 30% of the children who provide timely referrals to psychiatrists when children
were isolated or quarantined met the clinical criteria for feel mental discomfort, such as worry, anxiety, difficulty
post-traumatic stress disorder.5 Furthermore, separation sleeping, and loss of appetite.10
from parents or parental loss during childhood also Although great efforts have been made across
has long-term adverse effects on mental health, China, the emerging psychological interventions are
including a higher risk of developing mood disorders unlikely to be provided nationwide because most local
and psychosis, and death by suicide in adulthood.6,7 The support for unaccompanied children focuses only
age of the initial separation is known to be relevant to on meeting children’s basic daily needs. We propose
psychological development. The parent–child separation that paediatric health-care workers should receive

www.thelancet.com/child-adolescent Published online March 27, 2020 https://doi.org/10.1016/S2352-4642(20)30096-1 1

formal training to facilitate the early identification Peking University Health Science Center (JJL, YB, JS), Institute of Mental Health,
Peking University Sixth Hospital and National Clinical Research Center for
of children’s mental health problems by learning to Mental Disorders (LL), Peking-Tsinghua Center for Life Sciences (LL),
discern children’s normal and abnormal behaviours, International Data Group/Mcgovern Institute for Brain Research at Peking
University (LL), and National Institute on Drug Dependence (JJL, YB, and JS),
recognise red flags indicating further intervention or Peking University, Beijing 100191, China; and Savaid Medical School, University
referral are needed, and standardise the use of rapid of Chinese Academy of Sciences, Beijing, China (XH).
screening tools for mental health. Furthermore, mental 1 National Health Commission of the People’s Republic of China. Update on
the epidemic situation of the new coronavirus pneumonia as of 24:00 on
health professionals should establish evidence‐based March 24, 2020. http://www.nhc.gov.cn/xcs/yqtb/202003/
b882c06edf184fbf800d4c7957e02dad.shtml (accessed March 24, 2020;
guidelines and easy operational strategies to cope with in Chinese).
COVID-19 pandemic-related mental health problems in 2 Wang G, Zhang Y, Zhao J, Zhang J, Jiang F. Mitigate the effects of home
confinement on children during the COVID-19 outbreak. Lancet 2020;
children. We also believe that children’s access to mental published online March 4. https://doi.org/10.1016/S0140-6736(20)30547-X.
health services can be improved through collaborative 3 WHO. The importance of caregiver-child interactions for the survival and
healthy development of young children: a review. Geneva: World Health
networks that are established nationwide and consist Organization; 2004.
of psychiatrists, psychotherapists, researchers, and 4 Norredam M, Nellums L, Nielsen RS, Byberg S, Petersen JH. Incidence of
psychiatric disorders among accompanied and unaccompanied asylum-
community volunteers. Additionally, the post-pandemic seeking children in Denmark: a nation-wide register-based cohort study.
Eur Child Adoles Psy 2018; 27: 439–46.
surveillance of mental disorders among these children 5 Sprang G, Silman M. Posttraumatic stress disorder in parents and youth
should be considered. Since the global transmission after health-related disasters. Disaster Med Public 2013; 7: 105–10.
6 Santavirta T, Santavirta N, Betancourt TS, Gilman SE. Long term mental
of COVID-19 began, the total number of cases in health outcomes of Finnish children evacuated to Swedish families during
countries other than China have already exceeded the second world war and their non-evacuated siblings: cohort study. BMJ
2015; 350: g7753.
that in China. Following WHO’s recommendation, an 7 Abel KM, Heuvelman HP, Jorgensen L, et al. Severe bereavement stress
increasing number of countries have learned from during the prenatal and childhood periods and risk of psychosis in later life:
population based cohort study. BMJ 2014; 348: f7679.
China’s experience with regard to quarantine policies. 8 Humphreys KL. Future directions in the study and treatment of parent-
child separation. J Clin Child Adolesc Psychol 2019; 48: 166–78.
We suggest that the specific response to the mental
9 Ministry of Civil Affairs of the People’s Republic of China. Notice on
distress of children who are quarantined should also be improving rescue and protection for children lacking effective
guardianship. http://www.mca.gov.cn/article/xw/
considered when designing psychological intervention tzgg/202002/20200200024310.shtml (accessed Feb 11, 2020).
strategies in response to COVID-19. 10 National Health Commission of the People’s Republic of China. Notice on
strengthening psychological assistance and social work services in response
We declare no competing interests. to the new crown pneumonia epidemic. http://www.nhc.gov.cn/jkj/
s3577/202003/a9b0bcb3bb7445298c480c5003c51d6d.shtml (accessed
Jia Jia Liu, Yanping Bao, Xiaolin Huang, Jie Shi, *Lin Lu March 5, 2020).
[email protected]

2 www.thelancet.com/child-adolescent Published online March 27, 2020 https://doi.org/10.1016/S2352-4642(20)30096-1