Life or death has been the chief focus of State and society as we froze for more than two months, watching and counting in sorrow Covid-19’s ravaging of predominantly older, frail bodies.
But as the life-saving restrictions begin to loosen, attention is turning to the collateral damage at the other end of the age spectrum. What imprint will the Covid-19 era leave on the soft putty of children’s bodies and minds?
The National Public Health Emergency Team (NPHET) is examining measures to ease the lockdown burden on children. But as early childhood education expert Prof Nóirín Hayes of Trinity College Dublin, and a number of her academic colleagues pointed out in a joint letter to this newspaper: "There is no expert on child development, or child psychology, or early childhood education and care on the expert group or its subgroups."
For parents, Article 42 of the Constitution that acknowledges families as primary educators of children has never seemed so literal since the closure of all early years centres and schools in March. Not only have educational supports been diluted into distance learning but the services we rely on for helping us care for the physical and mental wellbeing of our growing children have, in the most part, been suspended too.
Even though GPs have been operating throughout, they worry about appointments that haven’t been made, such as for childhood vaccinations.
The Health Service Executive (HSE) reviewed all its services as part of its overall Covid-19 plan and prioritised based on impact and feasibility of continuation during the lockdown period, says a spokeswoman.
For example, visits by public health nurses to mothers and babies after discharge from maternity hospitals were continued, with infection control and prevention measures in place. But other services, including child health developmental checks, had to stop.
As the country slowly reopens, the HSE is preparing to re-establish services but the delivery of these is “contingent on the advice received from the NPHET and the Government plan for the easing of Covid-19 restrictions over the coming weeks and months”.
For every service, there will not only be the time lost through lockdown but the new conditions under which they have to operate will almost inevitably increase the backlog.
Here key professionals working in various areas of child health and wellbeing pinpoint a few of their chief concerns:
GPs have been prioritising childhood immunisations as one of the extremely important services to be continued during this era, yet parents' fear or inability to bring babies to surgeries means the timing of vaccinations have been disrupted. At the start of the pandemic, patients were reluctant to visit GPs for childhood vaccinations but there has been a gradual return, reports Dr Tony Cox, medical director of the Irish College of General Practitioners.
“However, in some cases a small number of patients are [still] fearful,” he says. But he points out that, with the introduction of community assessment hubs, those with suspected Covid-19 symptoms are no longer going to GP practices, so the risk of infection at a practice is low.
GPs are also encouraging pregnant women to ensure they continue their ante-natal care with them.
Public health doctor
"Vaccine preventable diseases have not gone away during Covid-19 so it is important that we all continue to play our part and ensure babies can be vaccinated at two, four, six, 12 and 13 months of age," says the director of the HSE National Immunisation Office, Dr Lucy Jessop. Pregnant women should also continue to get vaccinated against pertussis (whooping cough).
The HSE offers vaccines against 13 infectious diseases, says Jessop, yet the uptake for many is not reaching the 95 per cent target set by the World Health Organisation to stop outbreaks of vaccine-preventable diseases. In the first 19 weeks of 2020, the Health Protection Surveillance Centre reported 2,654 cases of mumps, 65 cases of rotavirus, 55 cases of pertussis, as well as cases of other vaccine-preventable diseases. The vaccine programmes in schools were paused when schools closed in March but interrupted courses of vaccines do not need to be restarted, says Jessop, so the children and young people can complete their course when this is offered to them.
Various sub-groups of disadvantaged children who will have been hit hardest by the pandemic are outlined by paediatrician Prof Alf Nicholson.
His concerns include: children with complex care needs who have home-care packages that have stalled because of restrictions; families living in direct provision who always have a very difficult time but, in view of clusters of cases, are at greater risk of getting sick with the virus; adolescents with mental health issues who are under added pressures with reduced CAHMS services and less supports from the multidisciplinary team in the community; general isolation of adolescents with very reduced social outlets, and no sport to participate in or watch, putting pressure on their mental health; children with autism spectrum disorder who attend ABA schools “and who now are at home and no doubt proving to be a great challenge for their parents”.
With attendance at emergency departments down, he worries parents may not seek medical help for their acute unwell child when they might need to.
However, adds Nicholson, formerly of CHI at Temple Street and now head of medicine at RSCI Bahrain, an upside to the crisis has been an emerging model of care whereby parents and GPs would be supported in the community via hot lines to paediatricians, guidelines and virtual clinics for patients, reducing precautionary referrals to hospital.
Consultant paediatric dental surgeon
Children who have dental pain and infection, affecting their sleeping and eating, are the number one concern of Dr Eleanor McGovern of CHI at Temple Street in Dublin. She is aware of some who have had three or four rounds of antibiotics through the lockdown but badly need dental work completed, as HSE and private dental emergency services have been simply “buying time” for the worst cases.
Expressing particular worry for disadvantaged families who may not know who to call about a dental crisis, she says any parent with a child in pain should contact their local HSE or private dental service right away.
Dentists face huge challenges in working the “new normal” she points out, which will inevitably reduce their capacity to see patients, so prevention of dental decay has never been more important.
Yet she fears good dental care habits may have slipped among many families as the pandemic upended routines, which probably also led to greater consumption of sugary snacks and drinks. She appeals to parents to make sure their children brush twice their teeth twice a day, sugary items should only be eaten at meal times and give water for drinks.
McGovern has also noted an increase in consultations about front teeth injuries in children who have gone over the handlebars of their bikes, as cycling became a more popular pursuit during the lockdown.
Trauma and loss have been at the centre of our lives for months now, along with uncertainty about the future, so increased anxiety and depression is normal. But these are particularly challenging times for adolescents who are developing a sense of self identity through exploration of personal values, beliefs and goals, says Paul Gilligan, CEO of St Patrick's Mental Health Services.
An adolescent’s mental health, both now and into the future, is determined by their personality, emotional resilience and support systems. But their individual experiences throughout this crisis are going to have a significant impact as well, he says.
Child protection is everyone's responsibility
While the class of 2020 have had their lives upended by the cancellation of exams they had been working towards for the past six years, all teenagers are emerging from domestic containment to a changed world.
His advice to adolescents for “psychological resolution” includes: tackle your fears with accurate information; take back control of your life by making plans for the future but knowing they might have to change; be prepared to re-evaluate your lives and fight for what enhances your happiness and sense of worth; address any negative lifestyle patterns that might have developed during lockdown and focus on skills that support your emotional resilience.
Fewer opportunities at this time for individuals to identify that a child is at risk or experiencing abuse is of grave concern to the CEO of the ISPCC, John Church.
“Families are not currently having contact in a traditional sense with their community, while children are not attending crèche, school, afterschool, youth groups or other extracurricular activities. In this sense, they are in contact with fewer adults who could report concerns in relation to their welfare.”
Children now in constant close proximity to parents/guardians or other family members who are abusing them may not feel they have anyone to turn to.
“Child protection is everyone’s responsibility,” says Church, who urges anyone with knowledge or suspicion a child might be at risk, to contact Tusla or the Garda. “This is always of vital importance, but particularly so in the current time where other routes to reporting may not now be available.”
The ISPCC’s Support Line for members of the public in relation to children’s welfare operates Monday-Friday, 9am-1pm, with updated contact details published on a daily basis on ispcc.ie/ispcc-support-line.
The plight of children at risk of abuse and neglect is also pinpointed by the CEO of Barnardos, Suzanne Connolly.
“It is a particularly challenging time for children known to Barnardos whose parents don’t have the capacity to look after them – and we are seeing evidence of an increase in substance misuse and domestic violence.”
As Covid-19 restrictions are lifted, Barnardos expects an increase in child welfare and child protection concerns that are currently undetected. Schools, she says, account for a third of Tusla referrals.
Barnardos is also worried about the impact on the social and emotional wellbeing of all children as a result of social distancing – for example the limitations placed on who a child can hug.
“The potential extent of the damage this may have on a child development will be related to the child’s age and level of understanding. For example, a 15-year -old can make some sense of why it is necessary to limit who they touch but this is not the same for a young child,” says Connolly, who stresses the importance of balancing physical safety and medical advice with social and emotional wellbeing for all children and their families, in managing the return to school, early years services, sports etc.
Essential services for vulnerable children and their parents, she adds, need to be fully funded and prioritised in government budgetary planning.
Developmental psychology professor
The potentially negative impact of current lockdown measures on very young children is highlighted by Elizabeth Nixon, assistant professor in the School of Psychology, Trinity College Dublin.
“They don’t have the cognitive capacity to understand why people are wearing face masks, why people are social distancing from them, and why they can no longer attend crèche or school or interact with their friends,” she says.
Aside from the loss and social isolation through being deprived of opportunities to engage in normal childhood activities, such as going to the local playground, children may come to perceive the world as an unsafe place, she warns.
“Achieving a sense of safety and trust in the world is a key milestone of early childhood: we want children to feel secure in their world so that they can explore and learn.”
Social distancing is bewildering, unnatural and distressing for young children, and communicates the idea that other people are a threat and to be feared, she adds.
Campaigner for children with special needs
The emerging crisis in special needs education is a huge concern of Enda Egan, CEO of Inclusion Ireland, the national association for people with an intellectual disability.
“For children with complex behaviour and medical needs home education is very difficult or non-existent, despite the best efforts of parents and teachers,” he says. “Parents have major concerns around regression of their child and an undoing of many years of hard work and dedication by teachers and SNAs.”
A recent Inclusion Ireland survey of more than 700 parents of children with a disability or autism found that almost half had no access to high-speed broadband, a third were juggling working from home with the home-schooling and more than three-quarters reported that their child was not motivated to learn at home.
Parents are also very worried about how the Department of Education is planning to reintroduce children with special needs to the school environment under new public health protocols.
“Inclusion Ireland recommends that these children are brought back to school first, so as they are given the best opportunity to acclimatise and adapt to the new school environment,” he says, adding that long-term planning must start now for accessible home education for about 500 children with very complex medical needs who are very unlikely to return to school at the same time as their peers.
Speech and language therapist
Waiting lists for speech and language therapy were already "dire" before the pandemic, says Vickie Kirkpatrick, chairperson of the Irish Association of Speech and Language Therapists (IASLT).
Some 19,000 children were waiting for SLT assessment and intervention in December 2019. With many paediatric services halted under the public health lockdown just three months later, thousands remain on waiting lists and others face additional delays in having their needs identified.
While the IASLT welcomes developments in telehealth technologies as an alternative SLT support, it is concerned that growing waiting lists and breaks in service will have adverse effects on a child’s communication and educational potential.
“The risk to child development without adequate SLT assessment and interventions has long been evidenced,” says Kirkpatrick. “Impaired communication skills are a barrier to normal human relationships.”
We’ve all experienced in lockdown how the lack of real connections through “social distancing” affects our mental wellbeing, she says. “Imagine, this isolation is often the lived experience for those living with communication impairments.”
Parent helpline CEO
The number of calls to Parentline, the national confidential helpline, is up 15 per cent since the beginning of April, reflecting domestic tension behind closed doors.
Parenting is challenging at the best of times, says Parentline CEO Aileen Hickie, but the Covid-19 crisis has meant many parents have to juggle working from home along with childcare and home schooling, against a backdrop of increased anxiety for all.
“This can result in conflict as parents struggle to impose rules and deal with the various stresses within the family home.”
In some instances, this has resulted in abusive and violent behaviour directed at parents by their children. Parents and carers who have become afraid of their own children – usually, but not always, male and aged 14 years and up – are seeking support in greater numbers, she reports.
There is also an increase in the number of new mothers calling with symptoms of post-natal depression.
“This may be a result of increased loneliness and isolation, along with the other biological and lifestyle factors.”
Parentline has started a temporary and limited weekend service for the first time in its 30-year history. Its helpline now operates on Saturdays and Sundays from 10am to 2pm, as well as Monday to Thursday, 10am to 9pm, and Friday, 10am to 4pm. Call 1890-927277 or 01-8733500
Read: Dr Elizabeth Nixon on the potential impact on our children