The Covid-19 pandemic has imposed many unpreceded challenges on humanity. Unimaginable losses, grief, separations, lockdowns and interrupted lifestyles have caused collective impact on mental wellbeing. Children and adolescents are being deeply affected by the school closure extended nearly for two years and the struggles with adapting to online learning.  With the gradual reduction in the number of Covid-19 cases along with the successful vaccination drive, the schools are reopening in a stage-wise manner. This may be a challenging transition for most of the children with mixed feelings of excitement and anxiety. School teachers and parents are critical in supporting children’s transition back to in-person classroom learning, particularly after extended periods of school closure. Dr. Darshani Hettiarachchi, Consultant Child and Adolescent Psychiatrist at the Teaching Hospital Karapitiya shared her expertise on adapting to this transitional period.  Karapitiya Teaching Hospital Consultant Child and Adolescent psychiatrist Dr. Darshani Hettiarachchi    Following are the excerpts of the interview:  What are the psychological issues seen commonly among the children during the Covid-19 pandemic?  Children have experienced multiple physical, psychological and social adversities during this period. School closure has resulted in limited social interactions as they have separated from the routine associations with friends and teachers. Extra-curricular activities, which are essential for the mental wellbeing of children, were limited along with the school closure. Additionally, difficulties related to online education are seen among many students. Problems with understanding the learning materials, limited access and poor network coverage are the main problems related to online learning.  Issues that are directly related with the Covid-19, such as fear of getting infected, fear of being quarantined and the fear of getting subjected for PCR testing have instilled severe psychological impact on children. Further, the social stigma on being positive for Covid-19 has enhanced this fear. Unfortunately, a number of children have been victimised for child abuse and domestic violence. Financial constraints faced by the parents, loss of loved ones due to Covid-19 have obviously resulted in an increase of mental health issues and worsening of pre-existing mental health issues among children.  Considering all these factors, we can anticipate more mental health issues in children after the reopening of schools.  With the reopening of schools after a prolonged break, what are the psychological issues that can be anticipated in children and how can we identify such issues?  Development of psychological issues among children after commencement of schools can be vary and widely depends on multiple factors such as;

• Age and development of the child
• Level of intelligence 
• Child’s level of resilience and coping skills
• Direct impact of Covid-19 on the child and their family (getting infected, been quarantined, faced for PCR testing, loss of loved ones, financial impact on the family are the key factors) 
• How strong is the child’s support system? (The support of the family, relatives, friends, teachers, government organisations act as strengths)
• Impact on child’s education during online learning period 
• Having to prepare for a competitive exam such as scholarship, Ordinary Level or Advanced Level 

Younger children may present with anxiety with re-opening of schools due to the fear of infection. Some may be worried to leave the family with the worry of bringing the virus to home and infecting their family members. As the pre-schools also had been closed for a longer duration, pre-schoolers may commonly present with separation anxiety.  The expression of anxiety in children is quite different from that of adults. Medically unexplained physical symptoms have become a very common presentation among children presenting to hospitals these days. Excessive watching of Covid-19-related programmes on TV, excessive fear about the disease and over responsiveness of the parents and adults in front of children are the main triggering factors for this anxiety.  Children may also have difficulties in following health instructions such as wearing masks, washing hands and maintaining social distance. Younger children may also have difficulties in recognising their friends, behind the masks. Also, the teachers may find it difficult to see the children’s emotions through facial expressions and children may feel sad if teachers would not respond to their facial expressions appropriately. Generally, small kids expect hugs from teachers and may become disappointed when they do not get it due to health restrictions.  Many children may find it difficult to engage in studies as previously due to multiple reasons such as not being able to learn properly at home through online education, limited access to online education, difficulties in understanding the concepts, etc. This can lead to poor school performance, low self-esteem, anxiety and depression.  With these issues we have to anticipate school refusal of kids associated with excessive anxiety and difficulties in adjusting to school routines after a long period. Invariably, older children and children who are getting prepared for exams can present with exam stress, avoidance of learning, anxiety and depressive symptoms. During this period children may also disclose about their stories on victimisation for abuses at home, to their teachers.  What are the important aspects that should be considered by parents when considering the mental health of children at this transitional period?  Firstly, the parents and teachers themselves should focus on their mental wellbeing and look after their mental wellbeing. They should not overreact to Covid-19-related facts, news and incidents in front of children. It is important to always bear in mind that children learn to respond by looking at the behaviours of their parents and adults.  Always reassure the children and give correct information about Covid-19 in an age appropriate manner. Be flexible and have realistic expectations. We should not expect children to perform the way they have performed before Covid-19. Arrange time to spend with children, understand their worries, identify their issues and support them. It is also important to support teachers and not to put too much pressure on them.  Have you seen any mental health issues among children and adolescents that can be related to exclusive online learning?  Exclusive online education has resulted in multiple physical, psychological and social problems among children in all age groups.  Limited social interactions can affect personality development in the long run, as it results in poor communication skills, deficits in developing empathy, sympathy, learning to respect others, sharing, problem-solving skills, etc. Boredom and loneliness due to less interactive learning is commonly seen with online learning.  Difficulties in controlling emotions, victimisation of cyber bullying, difficulty in maintaining attention and lack of interest in school work leading to poor academic performance, screen addiction, reversal of sleep-wake cycle and sleep problems  resulting poor attention and  concentration, poor memory, anger and irritability are the commonest out of many issues related to exclusive online learning.  What is your advice to overcome internet addiction in children?  Once the child gets addicted to internet or online gaming it will be extremely difficult to get the child out of it. Therefore what is important is preventing the child from getting addicted.  Firstly, parents should be aware about the condition, about the bad consequences and how to support children before they fall into addiction. Parents themselves should avoid excessive device use in front of children and the children should be made aware of screen addiction and its harmful effects. Adequate adult supervision at home is essential when children are working with devices. Strict boundaries at home on internet use is essential and limiting the internet and device use only for academic work is the key to prevent addiction. Never introduce devices and the internet as a method of recreation.  By introducing a flexible time table at home and spending time with children with alternative pleasurable activities such as music, playing, dancing, creative work will be basically helpful in preventing screen addiction.  If the child is already addicted to the internet or online gaming, they may need the support of a doctor.  If your child is displaying the following behaviour, they are already addicted to screens/internet or gaming and needs immediate attention on it; 

• Spending more and more time on internet, gradually increasing of the time spending on internet 
• Internet becomes the most important thing in the life and tend to ignore other important things in life 
• Cannot control the behaviour while having the knowledge on its harmful effects 
• Neglect sleep, eating, self-care, social interactions and relationships 
• Become secretive about time spending on internet 
• Become aggressive, irritable when someone tries to take the device away 

Children in urban and rural areas may have different types of psychological issues. What are the differences you have noticed among these two categories?  Rural children were more affected in online education due to poverty, not having devices, poor internet coverage, poor knowledge on technology, limited parental capacity to support them in online studies and parental illiteracy. However they were less affected by social restrictions than urban children. Hence, rural children still had the opportunity to spend time in the environment and explore unlike the children in urban areas. Unfortunately, many rural children are looking for alternative options for earning and have left the schools due to financial constraints in their families.  Apart from these factors there are no significant differences in common mental health issues like medically unexplained somatic symptoms, anxiety and depression among rural and urban kids.  What is your message to teachers related to the mental health of children during this transitional period?  Children may have gone through multiple physical, psychological and social adversities during this period. Due to all these factors they may present with many psychosocial issues. You may not see the same child you saw during the pre-Covid-19 times and do not expect to see the same normal child.  Firstly look after your psychological wellbeing since you cannot pour from an empty cup. Be flexible and have realistic expectations. Be observant, predict, understand and support the children to pass through this transitional period.  (The writer is a Medical Officer at the Directorate of Healthcare Quality and Safety of the Ministry of Health)