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Epidemiology
Original research
Psychosocial dysfunction of children and adolescents during the COVID-19 lockdown in Ecuador: a cross-sectional study
  1. Carlos V Erazo1,
  2. Amelia C Cifuentes1,
  3. Adriana M Navas1,
  4. Freddy G Carrión1,
  5. Jose D Caicedo-Gallardo2,
  6. Mateo Andrade1,
  7. Ana L Moncayo3
  1. 1 Facultad de Medicina, Pontificia Universidad Católica del Ecuador, Quito, Ecuador
  2. 2 Facultad de Economía, Pontificia Universidad Católica del Ecuador, Quito, Ecuador
  3. 3 Centro de Investigación para la Salud en América Latina (CISeAL), Pontificia Universidad Católica del Ecuador, Quito, Ecuador
  1. Correspondence to Dr Ana L Moncayo; amoncayo708{at}puce.edu.ec

Abstract

Objective Although the risk of morbidity and mortality of children and adolescents was lower during the COVID-19 pandemic, it appears that their mental health was strongly impacted. The goal of this study is to document psychological dysfunction among children and adolescents who underwent confinement due to COVID-19 in Ecuador.

Design A cross-sectional, internet-based questionnaire.

Setting Ecuador.

Participants A total of 1077 caregivers of children and adolescents (4–16 years old).

Outcome measures Caregivers responded to Pediatric Symptom Checklist-35 to assess psychosocial dysfunction.

Results The prevalence of psychosocial dysfunction was 20.8%, with internalising symptoms being the most common (30.7%). The prevalence of psychosocial dysfunction was higher in children who had a poor family relationship during confinement (prevalence ratio (PR) 2.23; 95% CI 1.22 to 4.07), children who never helped with housework (PR 2.63; 95% CI 1.13 to 6.14) and those whose caregivers were worried about children’s need for emotional therapy (PR 2.86; 95% CI 1.97 to 4.15). Never playing video games (PR 0.34; 95% CI 0.17 to 0.69) or playing video games infrequently (PR 0.39; 95% CI 0.20 to 0.79) was a protective factor for the psychosocial problems of children and adolescents.

Conclusion Our study demonstrates that children and adolescents have experienced a deterioration of mental health due to the pandemic. Family factors played an important role in the mental health of children during the lockdown. When a public crisis occurs, supportive mental health policies should be developed and implemented to promote children’s psychological welfare.

  • COVID-19
  • EPIDEMIOLOGY
  • MENTAL HEALTH
  • Community child health

Data availability statement

Data are available upon reasonable request. Data are available upon reasonable request through the corresponding author.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjopen-2022-068761

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    STRENGTHS AND LIMITATIONS OF THIS STUDY

    • This study is one of few to investigate the psychosocial dysfunction of children and adolescents during the COVID-19 lockdown in Ecuador and in developing countries.

    • The Spanish version of the Pediatric Symptom Checklist has proven to have strong validity and reliability as a screening tool for psychosocial dysfunction in Hispanic children.

    • This was a convenience sample and as such may not be representative of all children and adolescents in Ecuador.

    Introduction

    The 2019 novel coronavirus illness (COVID-19) outbreak has severely affected most of the world’s population. Ecuador reported its first case on 29 February 2020, and the Ministry of Health declared a State of Emergency on 11 March due to its rapid spread and mortality burden. Consequently, a national lockdown and quarantine period was imposed on 16 March to prevent the spread of the virus.1 In this context, non-essential activities were suspended, including the closure of educational institutions at all levels.2 Ecuador was one of the countries in the region that kept schools closed for the longest time during the pandemic (>40 weeks until January 2022).3

    The quarantine modified the children’s daily routines, healthy behaviours, physical activity, diet and sleep habits.4 5 Confinement negatively influenced their academic performance, social-emotional learning and the social interaction necessary for their overall well-being and development.4 5 Although children and adolescents are the groups that are less affected by the virus in terms of morbidity and mortality,6 the pandemic strongly impacted their mental health. The fear of infection, death of relatives and family financial loss have all contributed to increasing the feeling of anxiety and stress among this vulnerable age group.4 5

    Previous systematic reviews and meta-analyses have looked at the impact of the lockdown during the COVID-19 pandemic on the mental health of children and adolescents.7–11 High levels of anxiety and depression, insomnia, emotional disorders or post-traumatic stress disorders have been identified. Some studies have been carried out in Ecuador on the general population12 13 and adolescents1 14; however, to the best of our knowledge, there are no studies that have focused on the impact of confinement on children’s mental health. Therefore, this study aims to investigate the psychosocial functioning of children and adolescents during the COVID-19 lockdown in Ecuador. A better understanding of how the government restrictions during the COVID-19 pandemic affected children and adolescents’ mental health can help guide current and future interventions.

    Methods

    An online cross-sectional survey was conducted with residents of Ecuador aged 18 or older who had at least one child between the ages of 4 and 16 years. The study was carried out in 2020 (July and August) while Ecuador was under a strict COVID-19 lockdown. The method used was snowball sampling starting with the authors’ networks. Using the Google survey tool (Google Forms), a structured questionnaire was created, and the resulting link was distributed to the public on social media (ie, Facebook, WhatsApp, Instagram and Twitter). Participants were informed that the study was completely anonymous and participation was voluntary. Participants had access to the questionnaire after confirming their willingness to participate and completing two screening tasks to verify their age and place of residence.

    Patient and public involvement

    This study was designed and conducted without patient and public involvement. Our results will be disseminated to the public through publication in this journal.

    Measures

    The psychosocial functioning of children and adolescents was assessed by employing the Pediatric Symptom Checklist (PSC),15 which is made up of 35 items divided into three subscales that identify specific types of child psychosocial problems: internalising/anxiety/depression symptoms, externalising/conduct symptoms and attention symptoms.16 Each question has three alternative responses: never (scored 0), sometimes (scored 1) and frequently (scored 2). Item scores are summed, and the total score is recoded in a dichotomous variable. For children aged 6–16 years, the cut-off score is 28 or higher. For 4 and 5-year-old children, the PSC cut-off is 24 or higher.15 A positive score for each subscale is as follows: 5 or greater for the internalising subscale and 7 or greater for the externalising subscale and attention subscale. The Spanish version of PSC-3516 has been proven to have high validity and reliability as a screening tool for psychosocial dysfunction in Hispanic children.17–20 The survey also collected demographic and socioeconomic data, as well as family, household and lockdown information.

    Statistical analysis

    Descriptive statistics were used to summarise PSC scores according to age and gender and to determine the prevalence of psychological dysfunction in the study population. We computed prevalence ratios (PR) for the association between the psychological problems and independent variables using generalised linear models with a binomial family and a log link with robust SEs. All significant variables at p<0.20 were included in the multivariable model to obtain adjusted PR with their 95% CIs. Finally, only significant variables (p<0.05) were maintained for the final model. The analysis was conducted using Stata V.15.0.

    Results

    Sample characteristics

    In this survey, 1124 caregivers answered the questionnaire and 1077 were included in the study. We excluded 27 children and adolescents who had been receiving treatment for any mental problem before the pandemic. In addition, participants with missing data for any of the variables were excluded from the study (2%). As table 1 shows, the study participants comprised 513 females (47.63%) and 564 males (52.37%), and 68.99% were less than 11 years old. Most of the caregivers lived in urban areas (81.06%), had university studies (75.02%) and had a partner (74.28%). The children belonged primarily to nuclear families (74.09%). More than half of the families lived in a house (60.91%) and most of the families had three or fewer children in the household (94.06%). The percentage of families earning less than two minimum wages was 38.90%.

    View this table:
    Table 1

    Bivariate analysis of the association between children and caregiver’s characteristics and psychosocial dysfunction in children and adolescents, Ecuador, 2020 (N=1077)

    Table 2 shows the descriptive analysis of the PSC score by sex and age. The mean of the total score was 18.40 (SD: 10.57) and the highest mean was for attention symptoms (3.60, SD: 2.10). When the data were examined for female and male children separately, we found statistically significant differences in mean values of PSC internalising symptoms (p<0.005). The highest mean of externalising and attention scores was observed in children between 4 and 7 years old (3.64, SD: 2.83 and 3.84, SD: 2.15, respectively). On the other hand, the mean of the internalising score was higher in children between 8 and 10 years old (2.58, SD: 2.09).

    View this table:
    Table 2

    Mean scores of the Pediatric Symptom Checklist for all children separated by age and sex, Ecuador, 2020 (N=1077)

    Psychosocial functioning of children and adolescents and associated factors

    Psychosocial dysfunction was present in 20.8% of the children (21.8% in females and 19.9% in males) and the lowest proportion (18.9%) was observed in children between 11 and 16 years of age (figure 1). However, no statistically significant differences were observed by sex and age. Internalising symptoms were the most prevalent (30.73%), followed by externalising symptoms (14.30%) and attention symptoms (9.56%).

    Figure 1
    Figure 1

    Prevalence of psychosocial dysfunction by age groups during the COVID-19 lockdown in Ecuador, 2020.

    Table 3 shows the bivariate association between independent variables and psychosocial dysfunction. The prevalence of psychosocial dysfunction in children and adolescents was higher in families who reported a poor family relationship during lockdown (PR 2.44; 95% CI 1.47 to 4.06), children who used electronic devices for 4 or more hours/day (PR 1.68; 95% CI 1.09 to 2.58) and children who never helped with housework (PR 3.11; 95% CI 1.43 to 6.73). Children who never, sometimes or often played video games (VG) had a 55%, 48% and 58% lower prevalence of psychosocial dysfunction than children who always played.

    View this table:
    Table 3

    Bivariate association between lockdown variables and psychosocial dysfunction in children and adolescents, Ecuador, 2020 (N=1077)

    Regarding attitudes towards COVID-19, children who were afraid of COVID-19 had a 1.56 (95% CI 1.23 to 1.97) times higher prevalence of psychosocial dysfunction than children who were not afraid. The highest prevalence of psychosocial problems occurred in children whose caregivers were worried about the need for (a) psychological aid (PR 3.04; 95% CI 2.21 to 4.16), (b) medication (PR 1.82; 95% CI 1.30 to 2.55), (c) emotional therapy (PR 3.58; 95% CI 2.64 to 4.85) and/or (d) inability to return to normal life (PR 2.94; 95% CI 2.17 to 4.00).

    After the multivariable analysis was performed (table 4), psychosocial dysfunction was positively associated with good (PR 1.98; 95% CI 1.44 to 2.72) or poor (PR 2.23; 95% CI 1.22 to 4.07) family relationships during lockdown compared with those with excellent relationships. In addition, the prevalence of psychosocial dysfunction was three times higher in children who never (PR 2.63; 95% CI 1.13 to 6.14), sometimes (PR 2.76; 95% CI 1.44 to 4.29) or often (PR 2.68; 95% CI 1.39 to 5.17) helped with housework compared with those who always helped. The highest prevalence of psychosocial problems occurred in children whose caregivers were very worried (PR 2.86; 95% CI 1.97 to 4.15) and a bit worried (PR 2.37; 95% CI 1.75 to 3.21) that their children may need emotional therapy after lockdown compared with those who were not worried at all. Finally, not having played VGs (PR 0.34; 95% CI 0.17 to 0.69) or having played them infrequently (PR 0.39; 95% CI 0.20 to 0.79) was associated with a lower probability of psychosocial problems in children and adolescents.

    View this table:
    Table 4

    Multivariate regression of the association between independent variables and psychosocial dysfunction in children and adolescents, Ecuador, 2020 (N=1077)

    Discussion

    The results obtained in this study show that 20.8% of the children suffered psychosocial dysfunction during the COVID-19 lockdown in Ecuador, and internalising symptoms were the most common. The prevalence of psychosocial dysfunction was higher in children who had a poor family relationship during confinement, children who never helped with housework and those whose caregivers were worried about the need for emotional therapy for their children. Never playing VGs or playing VGs infrequently was a protective factor against the psychosocial problems of children and adolescents.

    Our study showed a higher prevalence of psychosocial dysfunction in children and adolescents compared with a study carried out in Mexico from February to May 2021 that showed a prevalence of 12% using the same evaluation instrument; attention symptoms were the most common, followed by internalising/anxiety/depression and externalising/conduct symptoms.21 The differences in prevalence could be partially related to the period of the pandemic being studied. A study performed in Ecuador showed moderate to severe emotional distress levels (anxiety-depressive symptoms and stress) in adolescents.1 Specifically, 40.6% of the adolescents suffered from severe or very severe symptoms of anxiety, 36.4% from depressive symptoms and 28.2% from stress 6 months after the beginning of the COVID-19 pandemic.1 In addition, a study of Ecuadorian high school students (14–18 years old) showed a 16% occurrence of mental health problems during the COVID-19 quarantine.14 In studies done before the COVID-19, it was found that 6.2% of Ecuadorian college students met the criteria for diagnosis of a major depressive episode22; this level of depression is substantially lower than the 30.7% rate of internalising symptoms reported in our study, suggesting that depression rates have increased as a consequence of the COVID-19 lockdown. Finally, the most common mental health issues reported in a review of 35 survey studies with 65 508 participants, ranging from 4 to 19 years of age, were anxiety (28%), depression (23%), loneliness (5%), stress (5%), fear (5%), tension (3%), anger (3%), fatigue (3%), confusion (3%) and worry (3%) as a result of the COVID-19 pandemic.7 In our study, internalising/anxiety/depression symptoms were also the most prevalent.

    Our results indicate that the presence of psychosocial problems was higher in children who did not have a good family relationship during confinement and in children who did not share family activities like housework. Previous studies showed that family characteristics, particularly parent–child interactions, were directly associated with children’s mental health in situations when bad life events such as hurricanes, earthquakes, migrations and terrorist attacks occurred.23 24A study in Northwest China reported that frequent parent–child communication and better parent–child relationships improve children’s psychological status associated with children’s home isolation.25 A study conducted by Liu et al on 5000 Chinese children found that a poor parent–child relationship resulted in depression and anxiety in children during quarantine.26 While confined together, families have more time to work through difficulties, which may result in better and more meaningful relationships. Contrarily, family conflicts might also easily occur when families are isolated in their homes for an extended period of time.27 In those circumstances, the stressful confined environment may exacerbate pre-existing issues or perhaps lead to the development of new ones. A study in the USA reported a high level of closeness between parents and children during the pandemic as well as increased conflicts, discipline and harsh words.28 Research in Australia found a decrease in positive family expressiveness during the pandemic.29 Families can reduce stress during a pandemic by keeping open lines of communication, participating in common activities, seeking out social support and cultivating thankfulness.30

    Considering the family factors, our study found a higher prevalence of psychosocial problems in those children whose caregivers were concerned about the children’s mental health. In a Canadian study, parents with children <18 at home reported unique pressures, including worrying about their children’s health, mental health and education, and being stressed about looking after their children while continuing to work.27 Higher parent stress has been associated with elevated child anxiety during the COVID-19 pandemic.31 In addition, higher levels of parenting stress have been associated with an increased use of harsh parenting practices.32 Therefore, interventions should also be focused on the mental health of parents since they affect the well-being of their children.

    In our study, children who sometimes or never played VGs showed a reduced prevalence of psychological deterioration during COVID-19. Playing VGs for prolonged periods of time is a major risk factor for the emergence of pathological behavioural signs.33 Some studies support suggestions that the COVID-19 pandemic will lead children and adolescents to be more engaged in playing VGs because of their decreased access to social activities.34 35 A longitudinal study showed that VG use and internet gaming disorder severity increased significantly among adolescents during the COVID-19 pandemic.35 Theoretically, during home confinement, children and teens spent more time playing VGs to prevent boredom and loneliness, which led to an increase in use and, ultimately, pathological gaming. Effective monitoring techniques that can assist in preventing the emergence of VG addiction should be rapidly adopted by parents of children and teenagers.

    Our research has some limitations. The cross-sectional study design restricts the ability to demonstrate causality. The study represents a short time-lapse of exploration during the strict COVID-19 lockdown in Ecuador; therefore, the results could have been influenced by situational factors. We did not conduct a more detailed analysis of the risk factors for psychosocial problems across different age groups. Understanding the impacts on different age cohorts can provide valuable insights for age-specific interventions and policies. Another potential limitation is that our data only include a proxy report of the child/adolescent’s psychosocial problems, as the PSC was completed by caregivers. Using the PSC-Youth self-report version for adolescents aged 11–18 could enhance sensitivity in detecting psychosocial problems within this age group. In addition, parents who were more concerned about their children’s mental health were more motivated to participate, which could have influenced the symptoms that were reported. Finally, the use of social networks may lead to a bias in selection and the lack of representation of vulnerable groups.

    Conclusion

    Prolonged school closures and confinement during the COVID-19 pandemic had a remarkable impact on children and adolescents’ mental well-being in Ecuador. There is a need to further explore the long-term consequences of the lockdown on the mental health of these vulnerable groups and to develop structured strategies that focus on parent–child relationships when facing adverse events such as pandemics. To better maximise these efforts, future studies should investigate how services, such as virtual mental health support, may be implemented.

    Data availability statement

    Data are available upon reasonable request. Data are available upon reasonable request through the corresponding author.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants and was approved by the Ethics Board of the College of Medicine, Pontificia Universidad Católica del Ecuador (SB-CEISH-POS-458). Participants gave informed consent to participate in the study before taking part.

    Acknowledgments

    We are appreciative of the support of the Pontificia Universidad Católica del Ecuador. We thank the caregivers of the children for their participation.

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    Footnotes

    • Twitter @mateoaam29

    • Contributors ALM is the guarantor. CVE, ALM and FGC contributed to the conception and study design. CVE, ALM and JDC-G conducted the statistical analysis. CVE, ALM and MA interpreted the results and drafted the manuscript. The methodology and data collection were completed by ACC and AMN. All authors read and approved the final manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.