Abstract
This study of children’s activity participation before and during the COVID-19 pandemic found that pandemic-related restrictions on activity participation unfavorably affected children’s mental health.
The coronavirus disease 2019 (COVID-19) pandemic has led some governments to implement disease containment measures, including school closures and social distancing, to curb the spread of the virus. These measures have unexpectedly altered children’s participation in daily activities for months. According to UNESCO (2020), schools were suspended nationwide in 194 countries in April 2020, and this suspension remained or recurred as a result of repeated waves of COVID-19 in 105 countries until or on August 3, 2020. Children mostly stayed at home and received either no schooling or online schooling during this period.
Researchers have found that as result of home confinement, children engaged in fewer physical or leisure-time activities and more sedentary or screen-time activities (Xiang et al., 2020). Prolonged changes in activity participation have raised health professionals’ concerns because these changes may exacerbate the risk of mental health problems among children (Wang et al., 2020). Although several resource websites are available to guide occupational therapy practice with children (e.g., American Occupational Therapy Association, n.d.; Occupational Therapy Australia, n.d.), little evidence is available to inform service development and policy decisions to help reduce the impact of pandemic-related restrictions on children’s mental health. Thus, this study aimed to examine the relationship between change in children’s activity participation and their mental health during the COVID-19 pandemic, which may provide information for intervention planning and policy-making.
Method
Participants
Parents of 388 children with and without disabilities ages 5–12 yr who took part in a child participation study in Hong Kong in 2017 (Chien et al., 2020) were invited to participate in a planned follow-up study between March and December 2019 (before schools were closed on January 25, 2020); 209 completed the first survey. The second follow-up survey was conducted, earlier than planned, from April to May 2020 (2–3 mo into school closures but before Hong Kong schools reopened on May 27, 2020). In the original study (Chien et al., 2020), parents of children from three primary schools and one special school for children with disabilities were recruited. The primary schools were located in three major geographical regions (Hong Kong Island, Kowloon, and New Territories), and the special school was located in Hong Kong Island. In the current study, children with disabilities were excluded to avoid the influence of disability on children’s activity participation patterns. The level of participation of the children with disabilities was low in the original study (Chien et al., 2020), and a limited number of parents participated in the follow-up study; hence, it was difficult to control for the confounding effect in the analysis. The original and present studies were approved by the Human Subjects Ethics Subcommittee at The Hong Kong Polytechnic University.
Procedures and Instrumentation
The follow-up surveys contained two questionnaires, completed by parents, that assessed children’s participation in a range of home, school, and community activities, in terms of frequency and involvement and their mental health: the Participation and Environment Measure for Children and Youth (PEM–CY; Coster et al., 2011) and the Strengths and Difficulties Questionnaire (SDQ; Lai et al., 2010), respectively. These questionnaires were selected because they can be completed by parents and are applicable to children both with and without disabilities across a wide age range. The PEM–CY has fair to high internal consistency (Cronbach’s α = .55–.85), moderate to high test–retest reliability (intraclass correlation coefficients [ICCs] = .70−.84), and acceptable construct validity, demonstrated by known-groups differences between children with and without disabilities and confirmatory factor analyses (Chien et al., 2020; Coster et al., 2011). The SDQ has a good internal consistency (Cronbach’s α = .70−.80), good test–retest reliability (ICCs = .78−.86), and good known-groups validity among children with and without disabilities (Lai et al., 2010). In addition, information about children’s demographics and disabilities was collected at baseline, at which point the children also completed the Children’s Depression Inventory (Chen, 2008).
Data Analysis
Paired t tests were applied to examine the differences in activity participation and mental health before and during the pandemic. Random-effects panel regressions were used to examine the time-varying relationship, adjusted for potential confounders (including child sex, age, and depressive symptoms at baseline). Results were analyzed with Stata (Version 16), and statistical significance was defined using p < .05.
The sample size was estimated using the formula proposed by Weichenthal et al. (2017) with a Type I error of .05, power of .80, and repeated measurement of two per child. On the basis of the findings of a similar longitudinal study investigating the relationship between the time spent on physical activities and mental health problems among children (Ahn et al., 2018), the minimal strength of association (slope) between activity participation and mental health was set at .044. In addition, the within-subject variance of .0237 and the mean squared distance of .4595 between individual participants and their mean were derived from the preexisting activity participation data collected in the original study and the first follow-up study. Hence, a minimal sample size of 105 participants was required to provide adequate power for the panel regression analysis of this study.
Results
Of the 209 original participants, 150 completed both follow-up surveys (71.7% response rate). After eliminating 10 surveys that were not completed by the same respondents and those for 26 children with disabilities, data for 114 children with typical development (60 boys [52.6%], 54 girls [47.4%]; mean age = 11.4 yr) were analyzed.
Table 1 shows the differences in children’s activity participation and mental health before and during the pandemic. Parents reported a significant increase in their children’s externalizing problems, t(113) = 2.333, p = .021, and a decrease in prosocial behaviors, t(113) = −2.108, p = .037. Children engaged in significantly more in-home activities involving electronic devices, t(111) = 5.074, p < .001, but engaged less in other home, school, and community activities in terms of both frequency and involvement (see Table 1).
Activity Participation and Mental Health of Children Before and During the COVID-19 Pandemic
Note. Each mental health variable was generated by summing the scores on items rated on a 3-point scale (0 = not true; 2 = certainly true). Participation frequency scores were generated by averaging the scores on items rated on an 8-point frequency scale (0 = never; 7 = daily, in the past 4 mo). Participation involvement scores were generated by averaging the scores on items rated on a 5-point involvement scale (1 = minimally involved; 5 = very involved), and no participation was coded as 0 (i.e., no involvement). COVID-19 = coronavirus disease 2019.
Internalizing problems consist of emotional and peer problems.
Externalizing problems consist of conduct and hyperactivity problems.
Electronically related home activities consisted of (1) playing computer and video games; (2) watching TV, videos, and DVDs; and (3) socializing using technology.
Other home activities consisted of (1) engaging in indoor play and games; (2) arts, crafts, music, and hobbies; (3) getting together with other people; (4) doing household chores; (5) personal care management; (6) school preparation; and (7) homework.
School activities consisted of (1) classroom activities; (2) field trips and school events; (3) school-sponsored teams, clubs, and organizations; (4) getting together with peers outside of class; and (5) special roles at school.
Community activities consisted of (1) neighborhood outings; (2) community events; (3) organized physical activities; (4) unstructured physical activities; (5) classes and lessons (not school sponsored); (6) organizations, groups, clubs, and volunteer or leadership activities; (7) religious or spiritual gatherings and activities; (8) getting together with other children in the community; (9) working for pay; and (10) overnight visits or trips.
Table 2 shows the associations between the children’s participation in home, school, and community activities and mental health, controlling for child sex, age, and depressive symptoms at baseline. No significant association was found between internalizing problems and participation frequency (or involvement) in home, school, and community activities (B = −.453 to .211, p > .05). However, more externalizing problems were significantly associated with less frequency (B = −.361, p < .05) and involvement (B = .435, p < .05) in school activities and less involvement (B = −.588, p < .01) in community activities. In addition, significant associations were found between prosocial behaviors and involvement (B = .425−.639, p < .01) in all types of activities, except for home activities involving electronic devices.
Associations Among Participation in Home, School, and Community Activities and Children’s Mental Health
p < .05.
p < .01.
p < .001.
Discussion
This study provides preliminary evidence that pandemic-related restrictions on children’s participation were unfavorably related to mental health. In particular, reduced involvement in daily activities, except electronically related home activities, was associated with more externalizing problems and fewer prosocial behaviors among children. This finding is consistent with those of two previous studies of children’s activity involvement and psychopathology (Monshouwer et al., 2013; Olivier et al., 2020). In one study, conducted by Monshouwer et al. (2013), social aspects, such as interaction with others and mutual support among team members during participation in organized sports, were found to influence the association between physical activity and mental health among school-age children. In the other study, conducted by Olivier et al. (2020), children’s overall (and behavioral) involvement in school activities was negatively associated with their externalizing behaviors. Given that involvement is characterized as an in-the-moment experience, it encompasses children’s motivation, persistence, and level of affect as well as their social interaction during activities (Imms et al., 2017). Therefore, it is not unexpected that as children’s involvement in activities declined in this study as a result of pandemic-related restrictions, they exhibited more uncooperative, overactive, or unhelpful behaviors. What is unique about these findings is that these behaviors, combined with the reduced involvement in activities, may negatively affect children’s mental health.
It is noteworthy that the current study excluded children with disabilities from the analysis. Therefore, the findings are applicable only to children with typical development who are not currently receiving occupational therapy. However, if mental health problems persist after the pandemic, these children would be vulnerable to behavioral problems that interfere with their learning and participation, and they may require occupational therapy intervention. In addition, the pandemic and social distancing measures have a significant impact on the daily lives of children with disabilities (Sakellariou et al., 2020). Compared with typically developing children, children with disabilities would be less involved in activities during the pandemic, which would in turn exacerbate their externalizing and antisocial behaviors. The increase in mental health problems among children with or without disabilities may subsequently result in an additional burden and stress on the family. In particular, some parents or caregivers may have limited knowledge and abilities to establish their child’s daily routine and deal with their child’s problematic behaviors; hence, timely assistance from health care professionals will be needed.
Limitations
This study had some limitations. First, it was conducted in Hong Kong, and the results cannot be generalized to children in other countries. Second, this study relied on parent reports of children’s activity participation and mental health, which limits the ability to identify these attributes from children’s perspectives. Third, because of the research burden for children and parents, apart from the change in activity participation, other factors that contribute in regard to children’s mental health—such as their understanding of the pandemic, social isolation, family’s financial condition, or parents’ and siblings’ mental well-being while dealing with the pandemic—were not included. To clarify the role of the additional factors in regard to children’s mental health, further studies are warranted. Last, this study used the PEM–CY, which asked parents to report their children’s frequency of participation in but not the duration of each activity. During the COVID-19 pandemic, it is possible that children may not frequently participate in specific activities, but they may spend a longer time on each activity they participate in. However, the extent of child involvement in activities was captured in the PEM–CY by emphasizing all aspects of participation (e.g., nonverbal behavior, focus of attention, and social interaction). There could be large variations in the duration of full involvement across different activities and different children, possibly confounding the findings of this study.
Implications for Occupational Therapy Practice
The findings of this study provide a possible direction for health promotion specific to integrative participation-focused elements in intervention planning and policy-making to decrease the risk of mental health problems among children during the COVID-19 pandemic. Because occupational therapists are experts who study occupations in which people participate, they can help facilitate children’s involvement in daily activities through a range of therapeutic strategies, adaptations, and interventions. Occupational therapy practitioners, especially school-based occupational therapists, can play an important role in mitigating the negative consequences of the pandemic on children’s mental health. For example, occupational therapists can help identify children who are relatively less involved in home, school, or community activities after school closure. The electronic version of the PEM–CY can be completed by parents or caregivers on their personal computers at home; hence, it may serve as a useful screening tool. Occupational therapists can also be involved in assisting school systems in planning for the transition back to in-person schooling when schools reopen. This could be done by putting in place mental health services and transition goals for all students, anticipating that the need for behavioral health supports will be greater for children both with and without disabilities.
Occupational therapists can inform parents of best-practice guidelines, such as setting limits for screen time (Guram & Heinz, 2018), and facilitate their involvement in other daily activities through telehealth platforms. Several evidence-based, participation-focused interventions have been developed, including occupational performance coaching (Graham et al., 2013), contextual interventions (Dunn et al., 2012), and participation-focused therapy (Palisano et al., 2012). These interventions can be used to promote activity participation among school-age children with or without disabilities.
Last, public health recommendations and policies pertaining to child mental health with respect to social distancing measures can be expanded with input from occupational therapists to provide activity guidance for children and their parents. For example, occupational therapists can contribute by providing health promotion videos or fact sheets that motivate children to have a balanced lifestyle at home by engaging in meaningful activities. Occupational therapy can be also included in a legislative sense in primary health care systems to provide parents with strategies to create stable, consistent routines that nurture the whole family and reduce the possibility of children developing mental health morbidities. Apart from these recommendations, other strategies or recommendations to promote child involvement in daily activities and prevent the impact of social distancing measures on their mental health during the COVID-19 pandemic are open for discussion.
Conclusion
COVID-19 pandemic-related restrictions on children’s participation were unfavorably related to their mental health. Children’s reduced involvement in daily activities might lead to more externalizing problems and fewer prosocial behaviors. Strategies and occupational therapy services that promote children’s involvement in daily activities are needed to decrease the risk of mental health problems during the COVID-19 pandemic.
Footnotes
Acknowledgments
I thank the families and children who participated in the original and present studies. I also express my appreciation to Pauline Cheung for her assistance in the preparation of the survey questionnaires, posting of research questionnaires, and data entry. The original and present studies were funded by The Hong Kong Polytechnic University (Grants 1-ZE4E, G-YBPC, and G-YBYP).