Evaluating Behavioral Changes Prevalence Among Primary and Preschool Children Due to COVID-19 Epidemic

Coronaviruses belong to a large family of viruses that can cause zoonotic diseases. As a result of genetic modifications and pathogenicity extension, coronaviruses can be transmitted from an infected animal to humans, forming a new human coronavirus and causing a range of diseases from the common cold to more severe conditions such as the Middle East respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS) (1-3). In December 2019, a novel human coronavirus outbreak was reported in Wuhan, China, which was a modified form of previous strains, thus named SARS-CoV-2 (4, 5). The SARS-CoV-2 virus is the family's newest member and is responsible for a new disease called coronavirus disease 2019 (COVID-19) (1-3, 5). The number of patients diagnosed with this disease is increasing day by day, and the disease's mortality rate has been regarded as 6.8% (4, 5). Considering its high transmission rate, COVID-19 poses a severe threat to global public health (6). Due to its novelty and limited therapeutic options, the best way to cope with this virus is to confine its spread (7, 8).

Along with the risk of pathogenicity in the community, this disease can be associated with unbearable psychological pressure on people worldwide (5). Children are among the groups who are susceptible to psychological problems. In addition to suffering from clinical symptoms of the disease, they are also affected by psychological disorders resulting from social-behavioral changes. Ghosh et al. showed that children are more vulnerable and likely to suffer from psychological problems during crises, especially epidemics (9), due to their specific nutritional and behavioral patterns and their strong dependence on parents and caregivers (10). Children suffer a long-term fear of contracting the coronavirus and quarantine-associated unpleasant and boring thoughts and feel insecurity and physical and social isolation due to the lack of communication with classmates, friends, and teachers, the lack of proper space at home, and in some cases, parents’ financial problems (5, 11, 12).

Unfortunately, mental health and behavioral disorders have received low attention in Iran, as well as many countries across the world (13). Because the child is a vulnerable creature and incapable of self-protection, it is essential to implement behavioral disorder screening programs among children and manage these disorders to recognize the current situation and choose appropriate solutions (1, 5, 14, 15). Iran is a developing country, and almost half of its population is under 15 years old, so the health or disease of this population can significantly affect the health and disease of today and tomorrow communities (13). So far, no study has been conducted on behavioral disorders in children experiencing the social norms and constraints caused by the COVID-19 pandemic.

The present study aimed to investigate behavioral changes caused by the COVID-19 pandemic among under 12-year-old Iranian children in 2021.

The present descriptive-analytical study was performed on children under 16 years in South Khorasan Province. Based on the indices obtained by the formula of estimating a ratio, the sample size was determined as 314 (13). All children under 16 years of age who had no history of mental disorders or chronic diseases affecting behavioral changes were included. Exclusion criteria were parental separation, experiencing natural disasters during the recent two years, losing a first-degree relative or a family member in the recent two years, and diagnosis of any underlying disease in the child and first-degree relatives.

The research tools included a demographic questionnaire and the Rutter Children’s Behavioral Disorder Questionnaire (the parent version) (16). The test's total score for each individual ranged from zero to 62, and a score equal to or greater than 13 (the cutoff point) indicated that the child suffered from a behavioral disorder. Rutter reported the reliability of this questionnaire as 0.74. This questionnaire has also been used in many studies in Iran to assess behavioral disorders among children, and its validity and reliability have been approved (17). The validity of the questionnaire was confirmed based on the content validity approach, and its reliability was determined by the test-retest method (r = 0.82).

After obtaining the approval of the Ethics Committee of Birjand University of Medical Sciences (ethics code: IR.BUMS.REC.1399.044), an online questionnaire was designed. In the first part of the questionnaire, the study objectives were fully explained to parents, and guidance was provided on answering the questionnaire. Before entering the study, parents were asked to announce their consent for participation by checking a consent box on the form. Then, the demographic information checklist and the Rutter Children’s Behavioral Disorder Questionnaire were provided to the parents online, and they were requested to complete and send the questionnaire based on their observations of the child’s behavior during the COVID-19 pandemic.

Descriptive statistics, including frequency and standard deviation, and the chi-square test, ANOVA, and t-test were used to analyze the data. Statistical analyses were performed in SPSS 18 software.

Out of 312 participants in this study, 179 (57.4%) were girls, and 133 (42.6%) were boys. The means of children's age and weight were 11.05 ± 3.26 years and 36.96 ± 14.73 kg, respectively. Also, the mean ages of mothers and fathers were 38.59 ± 6.28 and 43.35 ± 7.79 years, respectively. Most subjects were the first child in the family. The highest level of education among the parents was a high-school diploma. Regarding occupation, most mothers were housewives, and most fathers were self-employed. Financially, most families had an average level (Table 1).

The analysis of behavioral disorders’ symptoms was done based on the questionnaire according to parents’ perspectives, showing that the prevalence of behavioral disorders, based on all variables studied, was 37.2% (n = 116). Also, the mean scores of aggression-hyperactivity symptoms, anxiety-depression, social maladaptation, antisocial behaviors, and attention deficit were 3.10 ± 2.23, 3.11 ± 3.08, 1.79 ± 2.65, 1.83 ± 2.34, and 1.59 ± 1.29, respectively. Regarding the relationship between demographic variables and behavioral disorders, none of the age, sex, occupation, parental education, number of children, and economic status variables was associated with behavioral disorders (P > 0.05).

Analyzing the relationship between the mean scores of behavioral disorder symptoms and demographic variables showed that age was significantly associated with social maladaptation and aggression-hyperactivity symptoms (P < 0.05). In addition, maternal occupation was significantly associated with anxiety-depression symptoms (P = 0.04), and paternal education had a significant relationship with aggression-hyperactivity symptoms (P = 0.009). Other demographic variables did not have a statistically significant relationship with behavioral disorders (P > 0.05). Table 2 shows the relationship between the mean scores of behavioral disorder symptoms and demographic variables.

The results showed that the prevalence of behavioral disorders in children during the COVID-19 pandemic was 37.2%. Also, the mean scores of aggression-hyperactivity, anxiety-depression, social maladaptation, antisocial behavior, and attention deficit were higher than normal. These findings show that a high percentage of the participants developed behavioral disorders during the coronavirus pandemic. Our results also revealed no significant relationship between demographic variables and behavioral disorders. This observation can reflect that all children, independent of their demographic features, can present the signs of behavioral disorders during the pandemic.

Behavioral disorders in children are usually not recognized by parents until the child presents behavior beyond his/her age. Although behaviors such as disobedience, playfulness, or mischief are natural behaviors during childhood, if they become too severe and excessively annoying or happen repetitively, they are considered behavioral problems and must be corrected by appropriate treatments. There are various behavioral disorders in children, most commonly aggression, stubbornness, attention deficit, fear, robbery, hyperactivity, depression, autism, and various forms of phobias (18-20). It seems necessary to assess various reasons for the development of behavioral disorders.

In a study conducted by Deolmi and Pisani to investigate the effects of psychological factors on children and adolescents during the COVID-19 pandemic, the results revealed a high prevalence of anxiety and depressive symptoms among these individuals due to factors such as the disease outbreak, social isolation, and parents’ stress. Also, the results indicated that students with higher education, girls, and children from low-income families were at a higher risk for developing psychiatric symptoms. In their study, Deolmi and Pisani highlighted an urgent need for planning and implementing new strategies and early psychological interventions to mitigate the impacts of the COVID-19 pandemic on the mental health status of children and adolescents (18). Therefore, it seems that with the outbreak of the COVID-19 disease, along with extensive efforts to improve therapeutic methods to cure patients, special attention should be paid to the mental health of people in all social groups, especially those who are more vulnerable.

In a study by Wang et al. in 194 cities of China during the COVID-19 pandemic, 53.8% of the respondents reported moderate to severe psychological impacts due to the COVID-19 outbreak. Also, 16.5% of the subjects reported moderate to severe depression; 28.8% had moderate to severe anxiety symptoms, and 8.1% reported moderate to severe stress levels. A recent study also showed that childhood, female gender, concomitant physical symptoms (muscle pain, dizziness, etc.), and a weak immune system were significantly associated with psychological disorders (19). Likewise, a cross-sectional study by Zhou et al. in China estimated the prevalence of depression and anxiety symptoms as 43.7% and 37.4%, respectively, among 12-18-year-old Chinese students. In addition, 31.3% of these students showed both disorder symptoms, and female students and those with higher education were at a higher risk for this condition. The results also showed adolescents' decreased interest in work, fatigue, anorexia/bulimia, irritability, restlessness, and easy temper (20). Consistent with the findings of the studies mentioned above, our results also indicated statistically significant relationships between the children’s age and social maladaptation and aggression/hyperactivity symptoms, between maternal job and anxiety-depressive symptoms, and finally between paternal education and aggression/hyperactivity symptoms. Therefore, it seems that demographic parameters such as age, gender, education, and the relationship between family members can be essential determinants affecting people's psychological and behavioral well-being and their responses to unfortunate events.

In a study, Jiao et al. investigated behavioral and emotional disorders in children during the COVID-19 pandemic and reported a high prevalence of fear, uncertainty, and physical and social isolation among the subjects studied (14). Also, Liu et al. assessed the relationship between home quarantine and children’s stress and showed severe symptoms such as fear and sorrow following the quarantine (21). In another study during the coronavirus outbreak, Zhang et al. showed a rise in the prevalence of mood disorders, acute stress, and behavioral problems among children due to the closure of medical centers and staying at home regulations (22). Besides, Ghosh et al. delineated problems such as abuse, negligence, sleep disorders, and education problems in children during the COVID-19 outbreak (9), which agreed with our results regarding the presence of behavioral problems and disorders among children. Moreover, studies suggest that in addition to children, adults can also develop behavioral disorders during the COVID-19 pandemic. It can be concluded that social isolation, quarantine regulations, and confined social communications can contribute to the development of behavioral and psychological disorders among children during the COVID-19 pandemic, leading to depression, anxiety, or physical symptoms. Some studies also suggest that social isolation and psychological disorders can culminate in psychotic attacks and suicidal thoughts, which are more prevalent among youths. In addition, addictive disorders may be raised following these problems. Furthermore, a history of underlying diseases may exaggerate the fear of death, anxiety, and depression in people who are quarantined (18). Therefore, it is essential to maximize efforts to resolve these detrimental factors during the pandemic.

Evidence suggests that during the COVID-19 pandemic, the feelings of fear, anger, and sorrow, as well as anxiety-related insomnia, are more common in quarantined children and adolescents than in their non-quarantined peers (23-25). Studies show that the COVID-19 pandemic has caused many changes in children and adolescents' daily lives; on the other hand, stressful events at an early age can lead to psychological collapse (26). In a study conducted by Ozamiz-Etxebarria et al. to assess stress, anxiety, and depression levels in the early stages of the COVID-19 outbreak in Spain, the findings showed significant increments in anxiety, stress, and depression compared to before the onset of the pandemic. Also, younger people with chronic diseases reported more symptoms than others. A recent study declared a rise in these symptoms after the announcement of global quarantine regulations. Altogether, researchers have suggested implementing psychological interventions to prevent and treat these conditions to alleviate the psychological impacts of the pandemic (27). These findings are consistent with those of our study. In this regard, we showed an increase in the mean score of anxiety and depression in the studied population during the coronavirus period, indicating the considerably adverse psychological effects of the COVID-19 pandemic on children.

In particular, the risk of some psychological disorders increases during adolescence (ie, when mental health is developing). Amid the coronavirus pandemic, social distancing can exaggerate mental imbalance and exacerbate psychiatric disorders in individuals with underlying mental illnesses. Disruption of daily activities and losing contact with peers may lead to insecurity in children. In addition, the closure of schools mainly affects children with special needs, who cannot expand their essential skills, so their families are compelled to take care of them at home without the help of instructors (28). The critical point is that even after quarantine, its long-term impacts can affect children's mental well-being and lead to a post-traumatic stress disorder, so that they may experience difficulties in resuming their social activities and establishing interactions with others. Nevertheless, with the closure of schools, social service providers, and healthcare centers, it is challenging to diagnose mental health problems in children and adolescents and reach appropriate psychological and psychiatric therapeutic interventions. These children must receive early psychological interventions in all cases, so it is necessary to seek more resources and implement new strategies to provide emotional support to them (29).

According to this study and other similar reports, it is possible to reduce the risk of mental disorders in children and adolescents by maintaining their communication with their peers through social media and regularly updating the government's instructions through mass media. Also, online resources on mental health education and preventive measures of psychological disorders, video-based counseling, and telemedicine psychiatry services can help reduce the psychosocial effects of the coronavirus pandemic.