"We have found a significant increase in emotional and behavioral symptoms in children and adolescents during lockdown."

"Indeed, last November we shared these initial results with the scientific community in the article ' COVID-19 Pandemic: Increased risk for psychopathology in Children and Adolescents ? ' The journal where the article is being reviewed before publication requested the online dissemination of an unreviewed version of the manuscript (preprint), which is very common given the urgency of obtaining data related to COVID-19."

Our initial objective was to assess whether all the stressors of the lockdown and the COVID-19 crisis led to an increase in emotional and behavioral disturbances in children and adolescents, and specifically, the risk of developing a mental health problem. To this end, we initiated a longitudinal study, that is, a study that collects data over several months. We began the study in early May and will conclude it in January 2021, but we have already analyzed the data from the first assessment of the participating families, which is the data we have published.

From this initial study, we observed that the risk of developing a mental health disorder in children and adolescents may have more than doubled compared to the year prior to the pandemic. Specifically, it shows an increase from 13% to 34.7% in the risk of experiencing a mental health disorder, primarily with symptoms of depression and anxiety. This does not mean we have diagnosed any anxiety or depression disorders, but rather that we have found a significant increase in these symptoms compared to pre-pandemic levels. Furthermore, it is expected that this percentage will decrease over the following months, and some of what we have observed may be part of an adaptation process. Therefore, we need to conduct further evaluations in the months that follow to understand whether this risk—based on parental observations—has persisted.

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"No, one of the most interesting facts is precisely the difference between children and adolescents."

Children between the ages of 4 and 9 are twice as likely to have significant symptoms (risk of mental disorder) in the areas that We have asked about: anxiety, depression, hyperactivity, behavior, that adolescents.

We understand that the lesser impact on adolescents may be related to their greater development on various levels. For example, adolescents have a greater command of the tools they use to maintain their social circles and a greater capacity for self-management of their daily routines, while these skills are still developing in younger children, who depend more on their parents and/or caregivers. In fact, in our study, symptoms of anxiety and stress in parents or caregivers predicted higher levels of general symptoms (anxiety, depression, hyperactivity, behavioral problems) in younger children (under 9 years old). Another important point is that younger children's interaction is more interactive, more physical, and more play-based than that of adolescents—aspects that were easily curtailed during lockdown with the closure of schools and parks.

One of the study's limitations was the poor representation of the lowest socioeconomic levels, which prevented us from assessing the relationship between this factor and the increased risk of developing a mental disorder. Other studies do indicate this relationship, and therefore, it seems that increased monitoring of this doubly vulnerable population would be justified.

"We know that, in situations of high stress, the normal responses of children and adolescents can involve a certain degree of expression of anxiety (including fears, restlessness and other expressions of anxiety (somatizations, such as headaches or stomach aches), also sadness, or they may even present certain behaviors that we call regressive (behaviors such as nighttime urine leakage when they already controlled it and that reappear due to the effect of stress).

At Sant Joan de Déu Hospital in Barcelona, there had been an increase in consultations for mental health problems in recent years, related to the economic and social crisis of 2007, especially in more vulnerable populations.

Faced with this new situation, we immediately considered how COVID-19 would impact the mental health of children and adolescents, and how it could also affect care services if there was a significant increase in users.

We were clear that we wanted to collect data on what was happening, also considering that, for some families, with healthy children or with sick children, perhaps the lockdown had been positive."

"When we were preparing this first article, the whole public debate arose about whether children should return to school. We felt that this data was our small contribution to all the knowledge being generated about the impact of COVID-19 and that it should ultimately contribute to decision-making. Some of these measures may involve greater sensitivity in detecting symptoms in more vulnerable populations, such as children."

"It's difficult to give general advice, but the important thing is to be attentive to warning signs. For example, if a child's anxiety lasts a long time and begins to interfere with their normal life, you should seek help, initially consulting with their primary care physician."

In the study, based on the scores obtained by the children and adolescents, we provided parents or caregivers with general recommendations specifically aimed at preventing the onset or worsening of emotional and behavioral symptoms. These recommendations included facilitating routines, giving young people space to talk about their concerns with their parents, increasing the quality of time spent together, relaxation strategies, and even tools for setting limits more consistently, depending on the areas most affected in the child or adolescent. Obviously, there is no single recommendation; rather, it will depend on the specific symptoms presented by the child or adolescent. Finally, it is essential to remember that, for the well-being of any child or adolescent, it is important for parents to have adequate self-regulatory and adaptive mechanisms.

At Sant Joan de Déu Hospital, the various Psychiatry and Clinical Psychology units have provided specific recommendations for patients and their parents. However, it should be noted that, unlike most of the study participants, these recommendations are aimed at a clinical population (with a formal diagnosis of a mental disorder).

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