Potential psychosocial impact of COVID-19 on children: a scoping review Potential psychosocial impact of COVID-19 on children: a scoping review of pandemics and epidemics of pandemics and epidemics

mandates, implemented to mitigate the transmission of COVID-19, will likely have far-reaching impacts on psychosocial health and well-being. We to examine on pandemics and to draw comparisons regarding COVID-19 on children’s psychosocial health and secondary outcomes, including nutritional, financial and child safety outcomes.

ing unanticipated income loss. Collectively, these experiences have caused substantial and unique change for families. To inform policies aimed toward protecting today, it is imperative to draw parallels to past pandemics. Concerns regarding the impact of the COVID-19 pandemic on mental health impacts, academic losses, malnutrition and child abuse have been raised. [3][4][5][6][7] An understanding of the potential impact of the COVID-19 pandemic on children is necessary to plan for the eventual return to socialized life, and to design programmes and policies that support families in the short-and long-term. The aim of this scoping review was to examine the impacts of previous and current pandemics/ epidemics on children's mental health, nutrition, academic performance, and recreational habits, as well as family wellness.

METHODS
The five-stage Arksey & O'Malley's (2005) methodological framework for scoping reviews was used. 8 Two avenues were implemented to identify existing literature: academic articles and grey literature searches.

ACADEMIC ARTICLES
Academic articles examining the relationship between child-and family-related outcomes during prior and current pandemics/epidemics were searched within the Medline, PsycINFO, Global Health, and CINAHL databases on June 11, 2020 (see Online Supplementary Document Online Supplementary Document, Appendix 1). Sixteen searches were completed within each database. Child, pandemic, and outcome of interest were present within the title, keywords, and/or abstract of all identified articles. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines 9 , articles were screened independently by KM and TW for eligibility. Articles were screened at the title and abstract level, and if deemed eligible, a full-text screening was completed. Any disagreements were discussed to consensus. When a consensus could not be reached, KJ reviewed the article and conflicts were resolved. Articles were deemed eligible if they: (a) included children between 0 to 18 years old, (b) involved a prior or current pandemic/epidemic [exceptions to this include: (1) the Zika virus because this virus is associated with severe cognitive impairment and/or fatality which is not observed in those with COVID-19 and (2) HIV/AIDS which, although classified as a pandemic, does not transmit to children the same as COVID -19] , (c) included a child-or family-related outcome of interest (e.g., nutritional, financial, and child safety outcomes) as specified in Online Supplementary Document Online Supplementary Document, Appendix 1, (d) were written in English, and (e) were original research with the exception of case studies. 10,11 No limits were placed on the year of publication to broadly identify the extent of available literature examining child outcomes in prior and current epidemics/pandemics. The reference lists of all eligible articles were screened for eligibly following the steps above.

in Online Supplementary Docu
Online Supplementary Docu-ment ment, Appendix 1 for specific searches). If the above terms were not found, the report was excluded; whereas if any of the above terms were found a full-text review was conducted. The full texts of all reports were screened independent-  ly by KM and TW to determine whether they met eligibility criteria. All disagreements were discussed to consensus. When a consensus was not reached, a third reviewer KJ reviewed the report to resolve the conflict. DATA

STUDY SELECTION
The literature searches yielded 17,352 academic articles and 320 grey literature documents. Ninety-five additional academic articles were included from the reference lists of eligible articles. In total, 9,435 duplicates were removed, leaving 8,332 articles and reports to be screened at the title and abstract level. After excluding 8,018 articles/reports which did not meet eligibility, 326 full-texts were assessed ( Figure 1). Collectively, 35 articles and 38 reports were included, which assessed child well-being during previous and current pandemics/epidemics. The characteristics of all studies included are in Tables 2-4.

ANXIETY
In total, 21% reported on symptoms of anxiety. Of these papers, one suggested minimal to no anxiety, one indicated increased levels of anxiety, and the remaining indicated prevalence rates. The lack of security and confusion regarding the changing environment during a pandemic can instill fear and panic in children. [13][14][15] Sprang et al., 2013 reported that generalized anxiety, which represented 20% of diagnoses, was the most commonly diagnosed disorder in youth during and after the H1N1 pandemic. 16 Elsewhere, most children were concerned about the pandemic, which resulted from them being uninformed, misinformed, and having unanswered questions about the nature and mode of transmission (Table 2). [17][18][19][20] Such concerns contributed to anxiety and feelings of guilt and responsibility if a family member fell ill. [13][14][15][16][20][21][22][23][24][25] In contrast, an Australian study found that 90% of children had minimal or no parent-reported anxiety due to school closure during the H1N1 pandemic. 26 The COVID-19 pandemic represents the first large-scale pandemic during which mass media is a major source of misinformation, defined as "incorrect or misleading information" by Merriam-Webster dictionary. 18,27,28 This misinformation could lead to unnecessary anxiety as illustrated above. One study reported that 36% of adolescent participants thought that mass media was alarming and caused wide distrust in social networks. 18 However, a 2011 hospital-based study reported reduced concern when the news, regarding the H1N1pandemic, was read alongside a healthcare worker. 17 Collectively, the literature highlights that anxiety has been a significant challenge during pandemics for children largely due to miscommunication and influence from the mass media.

LONELINESS/DEPRESSION
Overall, 12% of papers reported on depression and/or loneliness, of which one indicated an increase in depression, and the remaining indicated prevalence rates of depression symptomology. Due to confinement, physical distancing requirements, and stay-at-home orders during previous pandemics, children altered their way of play. 29 Qualitative data collected from children impacted by the Ebola epidemic suggest that they are "lonesome [and] no longer enjoy [their] childhood"-Boy, Sierra Leone. 29 Similarly, children hospitalised during the Severe Acute Respiratory Syndrome (SARS) pandemic were only allowed one visitor at a time which caused feelings of loneliness, fearfulness, and sadness, while parents could not be a source of comfort or support for their child. 20,30 Data from previous pandemics, and from the current COVID-19 pandemic, indicate that children experience depression. 25 Factors that correlated with higher levels of depression include living in a rural region, gender, school grade level, level of optimism, and location (Table 2). 15,[21][22][23][24]31 Pandemics and epidemics highlight how isolation can lead to feelings of loneliness, sadness, and symptoms of depression.

STRESS
Overall, 10 % of included papers reported on the influence of a pandemic or epidemic on stress-related disorders in children. Of these, 57% indicated the presence of post-traumatic stress disorder (PTSD), 29% on adjustment struggles, and 14% on acute stress disorder. Pandemics typically disrupted the structure and routine of children's lives, causing difficulties in adjustment, stress reactions, and trauma. [14][15][16][17]32 Stress may manifest in different ways for different age groups of children 14 (Table 2). However, schoolaged children tend to manifest symptoms of stress through behavioural issues, such as being withdrawal from friends and family, as well as decreased interest in daily activity. 14 Children affected by grief, such as orphaned children, often experience further isolation, have more nightmares about the death of their parents, and live in ongoing fear about what the future will hold. 29,33 Also, in an American study, 30% of children who isolated or quarantined during the H1N1 pandemic met criteria for a PTSD diagnosis, a stark contrast to the 1.1% of non-isolated children who met criteria. 16 Importantly, the intergenerational impacts of parental mental health is evident; in the same study, PTSD was diagnosed in 85.7% of children who had parents with PTSD resultant of the pandemic. 16 The extant literature demonstrates how sudden changes, such as, the disruption of routine or the death of a parent can lead to stress-related disorders, including PTSD. GRIEF In total, 7% of included articles reported on grief. Of these articles, 40% indicated there is a need for attention and counselling services for grieving children and adolescents, while 20% indicated physical distancing measures complicated matters. Whereas both children and adults grieve, the manifestations of grief change with age 34 (Table 4). The loss of a loved one during a time of physical distancing is a unique circumstance, in which standard processes of closure, such as funerals and family gatherings, are restricted. This poses a new threat to grieving children, in which feelings of isolation may be exacerbated. 35 The threat to the emotional well-being of children due to loss of peers, loved ones, or teachers is significant and has been well-documented. 14,29 Professionals in pediatrics and pandemic preparedness stressed the importance of involvement of children and families in pandemic planning, clear communication to the public, and accounting for missing plans and services, such as grief and bereavement counselling for children. 36 These findings demonstrate grief in children and adolescents can present itself through different manifestations and indicate that in times of physical distancing, the negative mental health impacts of grief can be exacerbated. STIGMA Overall, 12% of papers reported outcomes related to children experiencing stigma as a result of a pandemic or epidemic. The stigma surrounding infectious disease typically impacts those who are diagnosed with or have family infected by a disease (as reported in 86% the articles/reports presented here) and children of certain ethnic backgrounds, such as children from countries where a disease originated (as reported in 28% of the articles/reports presented here). 13,33,37-39 In a study focussed on Ebola survivors, in which 20% of the sample was children, 26% of participants were stigmatized by the public. 38 The isolation associated with stigma increases the risk of harm to a child's psychological well-being. 13,29,37,39,40 The psychological impact of stigma can lead to social rejection, complete isolation, and exclusion from social events. 29 Children may be discriminated against, especially those orphaned as a result of a pandemic. 22,33,37 During the Ebola epidemic, children's drawings of their peers who were orphaned due to Ebola were images of children who were ostracised, isolated, and discriminated. 40 Moreover, children orphaned due to Ebola, but who remain sero-negative, are less likely to be adopted by families. 41 In some of these cases, relatives, neighbours, or friends adopt the child, although over 20% of adults surveyed believe these children are not properly supervised or well-fed. 29 In summary, the findings suggest that stigma is mostly problematic for children who are associated with the disease, such as children who were infected, had family who was infected, or are from countries where the disease originated. NUTRITION A total of 33% articles provided evidence that pandemics and epidemics have a significant impact on children's nutritional status. 23,29,[42][43][44][45][46][47][48] Due to pandemic-related school closures, many families (one study reported 41% of participants) have lost access to subsidized meal programs, thereby finding themselves in a position where they must provide meals for their children. In many circumstances, these meals are less nutritious than those provided by the school. 42,43,47,49,50 Concurrently, pandemic-related increases in unemployment have also impacted the quality Potential psychosocial impact of COVID-19 on children: a scoping review of pandemics and epidemics Journal of Global Health Reports and volume of food that families can afford, thus having a further negative impact on children's nutrition. 22 One UNICEF report anticipates food insecurity will increase by 80% from last year in West and Central Africa, largely due to the COVID-19 pandemic. 51 These losses are further exacerbated by decreased food availability and increased food costs due to border closures, market closures, and quarantine requirements. These restrictions create obstacles to acquire nutritional foods for economically-disadvantaged families. 29,31,33,39,45,[52][53][54][55] Taken together, these obstacles lead to child malnutrition. 48,51,56-59 During the COVID-19 pandemic, Italian students' intake of potato chips, red meat, and sugary drinks increased significantly, whilst the number of meals per day increased by 1.15±1.56. 44 In contrast, during and immediately subsequent to the Ebola epidemic in Sierra Leone, diagnoses of both moderate-acute and severe-acute malnutrition doubled, from 3.6% to 8.2%, and 1.5% to 3.5%, respectively. 23 Due to COVID-19, an estimated 67,500 children in Mozambique alone will require treatment for malnutrition in the next 9 months. 60 Conclusively, the findings suggest that nutrition is often negatively impacted by pandemics either by over-eating inexpensive, unhealthy food, or by facing varying levels of starvation.

ACADEMICS
During pandemics and epidemics, 23% of the articles highlighted academic impacts on children. Twenty-three percent of these articles revealed unequal access to learning tools, such as radios, televisions, and power supply in rural regions. 22,50,61,62 During the Ebola epidemic, lectures were accessed through radio. Some lacked both access and finances to buy batteries for the radio. 29 This unequal access is also evidenced during the COVID-19 pandemic, as 1.6 billion children were crisis schooled at home. 53 Furthermore, a UNICEF COVID-19 report indicated that internet access for school children ranged from 1-2% in low income countries to < 50% in most countries. 53 These observations are now described as the "digital divide," resultant of differences in socioeconomic status and pre-existing vulnerabilities. 50,[63][64][65][66] During school closures children struggle to complete their schoolwork from home, causing learning delays in some and increasing the risk of dropout for others. 15,18,58,61,67 For example, Cui et al. indicated only 58% of children completed their school work online. 15 Females, those with ill caregivers, those who have a disability, or are in an economically-disadvantaged household were especially at-risk for learning challenges during pandemics/ epidemics. 22,33,50,53,57,61,68 School closures also disrupt the development of children socially and emotionally and also impact the development of coping skills. 13,63 These findings and reports indicate that school closure impacts child learning, widens the socioeconomic gap, and impacts child development. ENTERTAINMENT Twenty-one percent of articles discussed the nature of children's activity during a pandemic or epidemic. Play is critical for healthy development and self-confidence. 20,22,48 Yet, subsequent to home confinement, reduced access to group activities, playgrounds, team sports, and spaces for socialization, evidence from pandemics and epidemics point toward changes in the way children play. 15,43,44,48,49,[69][70][71] . One report indicated most children only played at home and did not play in groups (Table 4). 29 A unique consequence of the COVID-19 pandemic is significantly increased screen time due to confinement in a time where technology has greatly advanced. 31 Whereas online communities help to keep children socially connected, engage in play and education, risks for negative outcomes, including reduced online safety (i.e. sexual exploitation), privacy concerns, harmful marketing practices and cyberbullying, must also be acknowledged and monitored. 27,65,72,73 FAMILY CONFLICT Family conflict is on the rise during pandemics and epidemics, as indicated by 8% of articles. 13, 61 Pandemics and epidemics have demonstrated that increased stress due to confinement and economic pressures can lead to an increase in familial conflict and child exploitation. 63 These outcomes are often related to authoritarian parenting styles, a parenting style found to be ill-suited for pandemic situations. 15 During the Ebola epidemic, parents qualitatively described changes in parenting styles and disciplinary methods. Moreover, parents exposed to the virus reported significantly more household conflict and personal anxieties, as well as an increased preference for harsh punishment. In contrast, parents not exposed to the virus experienced decreased preferences for harsh punishment by 28.1%. 74 In addition to changes in parenting styles, parent-child relationships may suffer during quarantine due to altered communication and social interactions. 75 A new-found focus on responsibilities, such as household tasks, also had negative impacts on the parent-child relationship. 75 These findings suggest family conflict and relationships between parents and children are negatively impacted by quarantine resultant of pandemics and epidemics.

CHILD ABUSE
Heightened levels of stress and isolation for families in the home, coupled with reduced access to social supports for children during pandemics, creates opportunity for increased risk of child abuse as indicated by 25% of included articles. 49,62,65,[75][76][77] During the Ebola epidemic, 89% of reported cases of rape in Liberia were against children ages 0-17. The report further indicated rape and violence, specifically, were common amongst girls and increased during Ebola in West Africa. 78 Child abuse is often associated with a lack of effective coping strategies during periods of elevated stress. Child maltreatment reports during the COVID-19 pandemic include increased sexual assault, child trafficking, child marriage. Parental substance abuse also increases which is associated with greater levels of child maltreatment. 39,50,60,79,80 Physical distancing during COVID-19 has disrupted protective social networks and safe spaces for children, resulting in an elevated risk of child exploita-Potential psychosocial impact of COVID-19 on children: a scoping review of pandemics and epidemics Journal of Global Health Reports tion. 48,79,81,82 Extant literature suggests specific groups of children may experience more harm. For example, girls are more likely to experience gender-based violence, be sexually exploited, and suffer from increased rates of teenage pregnancy during a pandemic or epidemic. 50,68,78,80 Limited research to date during the COVID-19 pandemic points toward negative mental health outcomes associated with child abuse including anxiety, trauma, and psychological relapse. 13,54 In brief, the literature indicates increased instances of child abuse during pandemics and epidemics, especially for girls.

FAMILY ECONOMIC IMPACT
Twenty-five percent of articles described the socioeconomic impact on families during pandemics and epidemics. Pandemic-related closures place additional stress on caregivers to find childcare or provide childcare themselves at the expense of missing work. 15,26,43,70,71,75,83 After the 2009 H1N1 pandemic, 27% of parents reported work absenteeism and 18% lost wages. 83 In contrast, one study focused on the H1N1 pandemic found the majority of parents did not lose any time at work. However, this sample contained many "stay-at-home parents", thus influencing the number of missed work days. 69 Economic downturns caused by pandemics can also result in job loss, increased poverty, and price hikes for daily goods and services. 48,57,61,77,84,85 Those from a low socioeconomic background and those with pre-existing vulnerabilities face harsher economic impacts during economic downturns related to pandemics. 39,50,81 Notably, during 2008 Kentucky school closures consequent to an influenza outbreak, only 14.9% of parents had the opportunity to work from home. 49 This is alarming, given the acuity of work from home directives imposed on an unprecedented number of employees, many of whom are concurrently parenting from home, during the COVID-19 pandemic. 70,75,77 The majority of studies found that many parents lose income during pandemics, due to work absenteeism and job loss; low socioeconomic status households are disproportionately impacted.

DISCUSSION
The COVID-19 pandemic, and subsequent school closures, loss of social contact, impoverished diets, greater screen time, and reduced physical activity and outdoor time have adverse effects on child mental health. 31,44,53,63,71 Alarmingly, many families are facing greater food insecurity, due to losses to school lunch programs or household income, or because of decreased food availability, 45,47,59 and socioeconomic stress and confinement have contributed to increase familial conflict and child abuse. 53 Scoping reviews are intended to identify the extent of knowledge and gaps in an area of research. 8 One gap that was found herein was that mental health outcomes/diagnoses were lacking in specificity. Some studies did have the percentage of diagnoses, such as anxiety and depression, but most approached mental health outcomes from a general perspective, pointing toward a need for additional research on child mental health outcomes both now and after the pandemic. Of the research that did indicate prevalence of diagnoses, minimal studies had pre-pandemic data to compare to pandemic data, and much of the literature included short-term outcomes only. Thus, it is difficult to draw direct comparisons between pre-pandemic and during/post-pandemic data. Therefore, longitudinal studies are warranted to identify long-term sequelae of pandemic-related childhood mental health consequences. One unique aspect related to the COVID-19 pandemic is the increased amount of screen time for children. Although there are many positive outcomes to having access to these technologies, the long-term mental health effects are not currently well known, therefore, the impact of increased technology use on children should be monitored over time.
We acknowledge the limitations of this scoping review. Scoping reviews are not intended to analyze the quality of the included studies. Additionally, our search strategy covered a broad range of outcomes, thus necessitating a balance between breadth and depth. We also restricted our search to English-language publications only, raising the possibility that relevant studies in other language may have not been identified. Another limitation of the current study is that COVID-19 has had greater impacts on most individuals in some significant way. Therefore, one should keep this in mind as a limitation when making comparisons with epidemics or pandemics that may have a smaller scale impact (e.g. measles). Also, societal factors such as geographical location, culture, government, and socioeconomic status can pose a challenge for generalizing the results to the greater population (see Tables for identifying regions).
This scoping review also adds to the literature in several ways. A comprehensive search strategy, from both academic and grey literature databases, to identify relevant articles was comprehensive and included diverse child-related outcomes to ensure as much breadth and depth as was possible which would help guide the development of future research. This review may be viewed as a starting point toward creating programs and solutions for the many challenges children face during pandemics, including the prevention of long-term impacts subsequent to the COVID-19 pandemic, with particular emphasis on mental health services and resources, for children facing food insecurity, maltreatment, and economic disadvantage.

CONCLUSIONS
Insight gleaned from pandemics and epidemics provide evidence on the negative impacts, including psychosocial, nutritional, financial, and child safety outcomes, pandemics and epidemics can have on children and their families, which can help inform family-centered policies. Increased psychological supports for children and their families are essential both now and for years to come.     ) were less likely to have children participating in meal programs than school district A households (lower SES) (p<0.05) • 10.0% of households with children in meal programs had difficulty replacing school-provided meals • Adverse childhood experiences (maltreatment, poverty, food insecurity) are associated with mental health problems, obesity, cardiovascular disease • Adverse experiences are more common for children experiencing mandated social isolation, particularly for vulnerable populations • Closures increase food insecurity in those dependent on school meals • Pandemic-related financial loss has reduced food security, access to markets, preventative nutrition deficiency programs, and decreased access for treatments for nutritional deficiencies • These factors may result in the increase of children suffering with acute malnutrition • 2,426 children and adolescents (6-17 yr.) in China showed a reduction of 7.3 hours per week in physical activity during isolation • 30 hr/week increase in screen time compared to pre-pandemic • Prolonged screen time causes feelings of sadness, irritability, concentration difficulties, resulting in mood disorder in adolescents • Physical distancing is challenging for those with additional needs • Increase in family violence is expected, likely to be associated with greater nonaccidental injury and mental trauma in children • School supports are reduced due to school closures increasing social isolation felt by grieving children • Online communities important to children's learning/play • Increased cyberbullying, risky online behavior, exploitation • Lockdowns, school closures, loss of income, movement restrictions, overcrowding, and high levels of stress and anxiety increase the risk for maltreatment, gender-based violence, sexual exploitation • Refugees, migrants, those living without parental care, those with disabilities experience exacerbated risk for violence due to lack of access to supports such as teachers, friends, and social workers • Food supply disruptions, loss of livelihoods, remittances as a result of COVID-19 create barriers for accessing nutritious foods • Difficulties for low SES families to maintain healthy diets • Food insecurity levels rise on the West Bank (herders/farmers/fishers are particularly vulnerable) • Increased levels of violence in children, greater risks of anxiety, trauma, psychological relapse • 67,500 children will require treatment for malnutrition in the next 9 months in Mozambique • 3,000 children are being treated for SAM and 40,000 cases of pellagra since March 2019 • Negative coping mechanisms due to financial struggles; increased child marriage, transactional sex, reduced opportunities for schooling • Girls became heads of households during the Ebola pandemic • Girls who lost parents to Ebola forced to engage in transactional sex to afford food/housing • Children were afraid of rape shared these stories with each other • Most girls believed teenage pregnancy was rising and 10% stated that girls were being forced into prostitution due to loss of family members • Teenage pregnancy increased 65% from impacts of Ebola • Stigma faced by large number of children due to social isolation • Few children were completing studies during school closure • Data suggests girls are less likely to home study than boys • Many parents are uneducated and cannot help children with schoolwork, children are too hungry to focus/busy working • Sports such as football, volleyball, kickball etc. could not be played and places of socialization were closed • ∼ 70% of children in Sierra Leone and Liberia played at home • ~ 82 and ~ 85% in Sierra Leon and Liberia did not play in groups in groups, respectively. • Children grieving were unhappy, lonely, heartbroken • Interviews suggested that the emotional well-being of children was challenged by disrupted friendships, bereavement, a loss of hope in education, loss of care and intimacy with parents • Food availability/increased prices were problematic • Marginalized children may not have access to distanced education • Many low SES families rely on school-provided meals • Low SES families will reduce income further • Children who live in countries already in conflict situations face greater challenges • Girls more likely to drop out of school with school closures • Reduced access to schools for girls results in increased labour, forced marriage, early pregnancy, domestic/sexual violence • Teenage pregnancy doubled to 14,000 during Ebola, girls were attacked/raped in quarantined home • Disruption of routines difficult for children with disabilities who require stability • Closures put children with disabilities at a greater risk of abuse • School closures eliminate subsidized meals for low SES children • Quarantine has increased the trend of non-diversified diets, increased consumption of processed foods, decreased consumption of nutritious foods (whole fresh fruits and vegetables) • Food systems and supply chains are being disrupted by lockdowns and restrictions • Infants, young children, pregnant women, breastfeeding mothers face risks to nutritional status • School closures prevent children from accessing crucial school health and nutrition services, including nutritious school meals • Education of children has been disrupted, threatening continuity of education for children and the community • Reduction in employment, increased poverty and decreased food security • Strain on mental health of children and caregivers increased pressures and risk of violence against children, child marriage • Child protection is at risk due to lack of social services and family separation (child protection decreases by 25%) • Children with disabilities have an increased risk of violence, sexual abuse and exploitation • There is a marked increases in child poverty: 106 million children living in poor households by end of 2020 • Pandemic-related nutritional issues include: • Disruptions to food supply chains and local food markets • Increasing poverty reduces access to nutritious foods • Reduced access to essential nutrition services, including school meals (369 million children use) and services to prevent/treat stunting, wasting and micronutrient deficiencies • Vulnerable children may struggle in continuing education online: • Increased safety risks for vulnerable (e.g. child abuse in the home) • Neglect in children with disabilities • Greater isolation for girls and increased care for ill relatives and siblings • School closure results in ↓ social interactions crucial in developing social-emotional skills, normal development, and building coping skills • School closures will especially affect disabled, indigenous, refugee children, those in remote or rural areas, in countries with ongoing crisis, and those with limited access to family support networks or online education • Girls and children with disabilities are at a greater risk for violence • ↑ Gender inequalities, ↑ risk for child marriage and teenage pregnancies • Confinement and economic pressures in historic pandemics ↑stress ∴ increasing family conflict, violence against children and exploitation • ↑ Food insecurity results in undernutrition and poor feeding practices • Small farm holders are particularly at risk for food insecurity • Vitamin A access expected to ↓ due to reduced access to health care facilities • School closure, market disruptions, suspension of nutrition programs, and poverty is expected to↑nutrition deficiencies, obesity, and undernutrition ↓ quality, quantity, frequency and diversity of diet • Adolescent girls at risk for not having psychosocial support and ↑ GBV • School closures, lockdowns, curfews, and the worsened economic conditions↑ risk for violence, forced marriage, sexual exploitation, and reduced access to child protection • Children with disabilities are at risk for exclusion from education if remote learning is not accessible or they do not have assistive devices • Survey in Thailand showed youth spend a lot of time playing online games, watching movies, using Facebook or suffering the internet • Youth have ↑ exposure to harmful content such as violence, self-harm, inappropriate advertising to children, and misinformation about COVID 19 • Online communities allow play, and continued education but ↑online exposure ↑ risk of cyberbullying, sexual exploitation and risky behaviour • Children may talk more to strangers due to increased time online, and worry about what is happening in the world around them • Online platforms raise privacy concerns surrounding visible home environments and links can be misused for stealing information • School closure → learning loss and drop out to care for sick and work • Quarantine reduces safe spaces resulting in ↑ tensions, violence in homes • Quarantines ↑ GBV, sexual exploitation, forced early marriage, teenage pregnancy, separation from friends and caregivers, and ↓ protection • Adolescent girls are more affected by pandemics due to ↑ loss of education, loss of reproductive health services, and social networks • Fear of infection, violence and mistreatment by health workers prevents adolescent girls from seeking health services • Loss of family can ↑ risk of abuse of children, especially in adolescent girls • Discrimination of those suspected to be infected →violence against children • Marginalized adolescents (e.g. disability) are vulnerable to stigma and abuse • Young children are more affected by loss of livelihood, poverty, unemployment, disruption in skill building activity, loss of aspirations and empowerment • ↑ Depression, anxiety, isolation, uncertainty, worry, boredom, and rejection Low income has made access to quality food for children a challenge • Long periods from school ↓ chances marginalized children will return • Confinement ↑ risk for child abuse and being forced into crowded conditions • Children with reduced freedoms (e.g. detained) ↑ risk for violence, abuse, GBV • Vulnerable to abuse include children in poverty, with a disability, living on the streets, with underlying conditions, and with refugee status • Households may lose income or acquire debt due to TB • When child caregiver is occupied with caring for a relative with TB, the child may be neglected; become malnourished, or lose education • Child pre-existing mental/physical disabilities ↑ risk for discrimination • Young girls at ↑ risk for violence due to self-protection challenges • Orphaned children experienced stigma and rejection from the community • Stigma/discrimination → isolation of children putting them at ↑ risk for harm • Physical distancing has ↑ risk of intra-family violence and online abuse • Child abuse and witnessing of violence between parents/caregivers increased • Spikes in calls to helplines about child abuse and intimate partner violence • Declines in # of child abuse cases referred to child protection services • ↑ in online harms, including sexual exploitation and cyber-bullying due to ↑ internet use by children