“The Experimental Child”: Children and the COVID-19 Syndemic

zimmytws/AdobeStock

SECOND THOUGHTS

COVID-19 is not a pandemic.

– Richard Horton¹

COVID-19 syndemic is not global.

– Emily Mendenhall²

COVID-19: Pandemic or Syndemic?

Soon after the World Health Organization (WHO) officially declared COVID-19 a pandemic in 2020, Richard Horton’s¹ editorial in The Lancet convinced me to radically change my thinking about this socio-medical crisis. His message was blunt and direct: “COVID-19 is not a pandemic.” This crisis was more accurately seen as a syndemic, encompassing 2 different categories of disease—an infectious disease (COVID-19) spread by a virus (SARS-CoV-2) and an array of noncommunicable diseases (NCDs). Emily Mendenhall, a pioneer of syndemic studies went further: “COVID-19 syndemic is not global,” arguing that social context matters.²

Let us unpack this carefully and see what it means for the most vulnerable sector of every country—children and youth—and why an enlarged biosocial view of biomedicine is required to make sense of diseases and how to handle them.

Defining a Syndemic

A syndemic or synergistic epidemic is the aggregation of 2 or more concurrent or sequential epidemics or disease clusters from 2 different categories—communicable (infectious) and NCDs—occurring in a population with biological interactions, which exacerbate the prognosis and burden of disease. The term was developed by American medical anthropologist Merrill Singer in the mid-1990s.³ Syndemics develop under health disparity, caused by poverty, stress, or structural violence and are studied by epidemiologists and others concerned with public health, community health, and the social determinants of health.^1,3,4

Together, these conditions cluster within specific populations following deeply-embedded patterns of inequality and vulnerability.¹ And in all populations around the world, regardless of other risk factors, inequalities and vulnerabilities, children are the most affected population. Looking laterally at the humanities such as philosophy and literature (see my column on psychiatry and the humanities) and to our cognate fields of epidemiology and public health helps us understand why (see my column on the social determinants of health).

Plato’s Allegory of the Cave

In The Republic, written around 375 BCE, the ancient Greek philosopher Plato tells the story of a group of prisoners chained in a cave since childhood where they cannot see each other, only shadows on the cave wall ahead cast by a fire behind a parapet. Puppeteers parade along the parapet with 2-dimensional objects poorly representing the real world outside the cave.

Sounds bouncing off the walls from beyond the cave are attributed by the prisoners to the shadows, their only reality. One of the prisoners, a philosopher who courageously frees himself to seek the truth beyond the cave, is received with scorn when he returns to the cave to inform his fellow prisoners that what they have always believed is reality is in fact a shared illusion.⁵

How is COVID-19 making us like the prisoners of Plato’s cave?⁶ Plato’s prisoners are in a situation of sensory deprivation much like the subjects of D.O. Hebb’s psychological experiments at McGill University in the 1950s.⁷ Hebb’s experiments demonstrate that Plato’s prisoners would experience sensory deprivation and begin to hallucinate to make up for the lack of external stimuli. The brain lives—and only functions normally—in a bath of stimuli which makes the brain grow and the mind thrive.

Chained since childhood, the prisoners in Plato’s cave have experienced long-term sensory deprivation which impacts brain structure. Nobel-prize winning research by Hubel & Wiesel on cats showed that blocking visual stimuli at a critical stage radically alters their neurophysiology.⁶

“The Experimental Child”: A Cascade of Consequences

This exceptional set of circumstances—in response not only to the biomedical and populational health aspects of the COVID-19 syndemic but also in constructing policies for entire societies—has created an “experimental childhood” for billions of children and youth around the world. By subjecting billions of youth to confinement and social isolation, this syndemic has cast a deep shadow on these experimental subjects with potentially devastating life-long impacts.⁸

The impact of the COVID-19 syndemic triggers a cascade of consequences affecting societies at large, smaller communities, and the multigenerational family, all of which impinge on children and youth as the lowest and most vulnerable common denominator.⁸

Adverse Childhood Events

With its commitment to the social determinants of health9 (SDH; see my column), especially the adverse childhood experiences (ACE) studies,¹⁰ social psychiatry and the Global Mental Health movement in partnership with child and family psychiatry and allied professions must consider our roles for the future of these “experimental children” around the world.

The ACE studies have clearly demonstrated that early childhood adversity is associated with poorer health outcomes. Recall that a syndemic is not a single source of adversity but a cascade of connected and unfolding events. The structural vulnerabilities of class, cultural, gender, and all other differences significantly increase the risks for individuals in these groups.

The COVID-19 Syndemic as a Modern Morality Play¹¹

One of the cruelest aspects of our predicament with the COVID-19 syndemic was that family members were not allowed to accompany their loved ones during their dying days in hospital and were denied even the capacity to mourn together or to bury their dead. The only parallel I experienced in more than 40 years in medicine is from the early days of the HIV and AIDS epidemic even before it was named. In those early days, no one knew the routes of transmission for sure so we were made to don maximal personal protective equipment: masked, double-gloved in whole-body protective clothing doing consultations with terrified patients suffering from fatal diseases.

Consider these images from our recent history and from the arts¹¹:

1. The much-publicized photo in March of 2020 of army trucks hauling bodies out of Bergamo in Northern Italy because the cemeteries and crematoria were overwhelmed beyond capacity is a haunting one.
2. This brings to mind Sophocles’ tragedy of Antigone who was forbidden to publicly mourn or properly bury her dead brother Polynices because of his treason against the ruler Creon.
3. In a modern novel set in Brazil, Érico Veríssimo described the Incident at Antares (1971, filmed in 1994), the fictional town of Antares where the graveyard workers go on strike. As the bodies pile up, unburied, 7 corpses from a wide swathe of society rise up to claim their right to be buried. When they are unheeded, they disclose the sordid secrets of those in authority and the other townspeople.

In our contemporary tragedy, we became the unwitting actors of this modern morality play where not even death was a liberation and public mourning and a decent burial were forbidden.

At a loss for explanations and solutions, we turn to those whose imaginations have prepared us beforehand—artists and humanists.

“The State of Exception”: Protecting the Public or “Techno-medical Despotism”?

Italian philosopher Giorgio Agamben provoked a polemic at the beginning of the COVID-19 syndemic when he asked about the social impact of lockdowns, with governments reaching for power during a “state of exception,”¹² and raised even more disturbing questions about the value of the survival of “bare life”¹³ when all human interactions and dignity are denied by what he characterized as “techno-medical despotism.”¹⁴

Confinement and social isolation were imposed in the name of collective health, creating a “state of exception” which, as Agamben has powerfully shown in a series of historical studies from ancient Rome to Auschwitz, all too easily become the rule.^12,13 And the declared state of exception during the syndemic became the rule, not only for affected individuals or groups at risk which would have been prudent and necessary but entire societies. Tragically, this “techno-medical” and political overreach provoked critical questions, “vaccine hesitancy,” political resistance and popular mistrust in both medical expertise and government policy.

Impacts: Resilience vs Vulnerability

Historians have noted that pandemics are more disruptive and transformative of societies than wars or revolutions. After living through the full force of the syndemic, we are now working the ongoing impacts of that grim historical precedent.

In spite of that, there are naysayers, some of them outstanding scholars. Children should fare well, in fact, better than many people expect, Robin Dunbar of Oxford says.¹⁵ Dunbar is a British evolutionary psychologist, famous for his formulation of “Dunbar’s number,” a measure of the “cognitive limits” to the number of individuals with whom we can have stable relationships. Perhaps that insight blinded him to the fact that children only grow and thrive with attachments, friendships, mentors, and socialization.

“Children are designed to be very resilient and bounce back,” Dunbar asserted. “If they didn’t, they’d never survive. I am not convinced by any of the hysterical claims that children’s lives are being ruined by lockdown.”¹⁵

Count me among the hysterics. “Irksome it certainly is,” Dunbar allowed, “and it may exacerbate the condition of those already suffering from depression, or the like. But most will have forgotten all about it in a year or so.”¹⁵

My patients never got the memo. A disquieting proportion of the children and youth in my child psychiatric clinic never went back to school full time after the lockdown and social isolation of the syndemic. Too many of those who did still struggle with attending school full time and complain of mental and physical symptoms. Long COVID? The consequences of social isolation? Loss of prosocial skills? We need more research!

“Education-wise?” Dunbar asks, “In the long run, probably not a big deal either, unless education has sunk to the low of only being able to remember a handful of facts,” he adds.

“Something everyone seems to forget is that education is supposed to be about learning how to learn for oneself.”¹⁵ And yet for that to work, children have to actually show up for class.

Dunbar is hopeful. Using the language of evolutionary psychology that “children are designed to be resilient,” he is counting on their coping capacities. Even if it is true that such capacities are “built in” by evolution for the majority, there will still be those for whom the syndemic “piggy-backs” on latent or already expressed vulnerabilities or outright disorders.

Furthermore, even a small percentage of the billions affected by social isolation triggered by the syndemic will yield enormous numbers of cases to be evaluated and treated by school, health, and social care services. And that has overwhelmed those services in many jurisdictions.

Royal College of Psychiatrists Analysis

Our children and young people are bearing the brunt of the mental health crisis caused by the pandemic and are at risk of lifelong mental illness.

– Bernadka Dubicka, MD¹⁶

In Dunbar’s own backyard, Adrian James, MD, then president of the UK’s Royal College of Psychiatrists (RCP), said: “The extent of the mental health crisis is terrifying, but it will likely get a lot worse before it gets better. Services are at a very real risk of being overrun by the sheer volume of people needing help with their mental illness.”¹⁶ A year after the first lockdown and warnings from the mental health sector about the impact of the pandemic on the country’s mental health, NHS Digital data shows that while the crisis is affecting individuals of all ages, it is those who are under 18 that are suffering most.¹⁶

The RCP’s findings showed that there was a 28% increase of children and youth referred to mental health services (April-December 2020, compared with the previous year); 20% more treatment sessions were given to children and youth; and 18% more children and youth needed urgent or emergency crisis care—including assessments to see if someone needs to be hospitalized because they or others are at harm.¹⁶

Bernadka Dubicka, MD, Chair of the Child and Adolescent Faculty at the RCP, said, “As a frontline psychiatrist I’ve seen the devastating effect that school closures, disrupted friendships and the uncertainty caused by the pandemic have had on the mental health of our children and young people.” Dr Dubicka added that, “Services were already struggling to cope with the number of children needing help before the pandemic hit, and they risk being overrun unless government ensures the promised money reaches the frontline quickly.”¹⁶

Has this concern been borne out? A meta-analysis of the impact of the syndemic on children’s learning demonstrates that it has: “A meta-analysis of 42 studies across 15 countries to assess the magnitude of learning deficits during the pandemic found a substantial overall learning deficit which arose early in the pandemic and persists over time. Learning deficits are particularly large among children from low socio-economic backgrounds. They are also larger in maths than in reading and in middle-income countries relative to high-income countries.”¹⁷

Impacts: Confinement and Social Distancing

Children are vulnerable biologically and psychosocially to the impacts of the COVID-19 syndemic, with particular concern that the supposed prevention measures, especially confinement and social distancing, affected the development of prosocial skills longitudinally.⁸ In Canada, we have seen that in addition to a perceived deterioration in mental health, there are substantial mental health service disruptions and unmet support needs.^18,19

Social Psychiatric Implications

Recommendations for social psychiatric interventions include any and all measures that can mitigate the ACEs and the SDHs.²⁰ One example of social therapy is Brazilian social psychiatrist Adalberto Barreto’s integrative community therapy, which can be done with large groups at low cost and with measurable positive impacts.²¹

What was needed from the outset were longitudinal studies with parameters for observing the conditions of this COVID-induced syndemic in children, families, and society. Few such studies have been undertaken. Here is one Norwegian example²² and a scoping review of longitudinal effects of the COVID-19 pandemic on child and adolescent mental health which confirm our concerns.²³

Prospective interdisciplinary pediatric, psychological, family, community, and social studies are urgently needed as part of a suite of studies and interventions to translate populational studies to ground-level community, school, and clinical interventions.

Acknowledgments

I have expressed these concerns about the COVID-19 syndemic in national and international presentations including: SSPC Annual Meeting in Toronto, ON (April 2020), WASP Webinar (Sept 2020), WASP-WPA Interorganizational Symposium in Bangkok, Thailand (March 2021), the Ontario District Branch of the APA in Toronto, ON (April 2021), the Asia Pacific WASP Congress in New Delhi, India (Sept 2021), and the WPA World Congress in Cartagena, Colombia (Oct 2021); and in these publications: Global Mental Health & Psychiatry Review,^7,24,25 World Social Psychiatry,8 and the WASP E-Newsletter.¹¹

Resources

• Plato’s Allegory of the Cave from The Republic (“The School of Life” on YouTube, runtime 6:16): https://www.youtube.com/watch?v=SWlUKJIMge4
• American Academy for Child & Adolescent Psychiatry (AACAP): https://www.aacap.org/AACAP/Families_and_Youth/Resource_Libraries/covid-19/resources_helping_kids_parents_cope.aspx
• Canadian Psychiatric Association (CPA): https://www.cpa-apc.org/covid-19/
• WHO, “Considering the impact of COVID-19 on children”: https://www.who.int/europe/activities/considering-the-impact-of-covid-19-on-children

Dr Di Nicola is a child psychiatrist, family psychotherapist, and philosopher in Montreal, Quebec, Canada, where he is professor of psychiatry & addiction medicine at the University of Montreal and President of the World Association of Social Psychiatry (WASP). He has been recognized with numerous national and international awards, honorary professorships, and fellowships, and was recently elected a Fellow of the Canadian Academy of Health Sciences and given the Distinguished Service Award of the American Psychiatric Association. Dr Di Nicola’s work straddles psychiatry and psychotherapy on one side and philosophy and poetry on the other. Dr Di Nicola’s writing includes: A Stranger in the Family: Culture, Families and Therapy (WW Norton, 1997), Letters to a Young Therapist (Atropos Press, 2011, winner of a prize from the Quebec Psychiatric Association), and Psychiatry in Crisis: At the Crossroads of Social Sciences, the Humanities, and Neuroscience (with D. Stoyanov; Springer Nature, 2021); and, in the arts, his “Slow Thought Manifesto” (Aeon Magazine, 2018) and Two Kinds of People: Poems from Mile End (Delere Press, 2023, nominated for The Pushcart Prize).

References

1. Horton R. Offline: COVID-19 is not a pandemic. Lancet. 2020;396(10255):874.
2. Mendenhall E. "The COVID-19 syndemic is not global: context matters." Lancet. 2020;396(10264):1731.
3. Syndemic. Wikipedia. Accessed June 19, 2024. https://en.wikipedia.org/wiki/Syndemic
4. Mendenhall E. "Syndemics: a new path for global health research." Lancet. 2017;389(10072):889-891.
5. Allegory of the cave. Wikipedia. Accessed June 19, 2024. https://en.wikipedia.org/w/index.php?title=Allegory_of_the_cave&oldid=1228543784
6. Di Nicola V. From Plato’s cave to the Covid-19 pandemic: confinement, social distancing, and biopolitics. Global Mental Health & Psychiatry Review. 2021;2(2):8-9.
7. Rosner C. Isolation. Canada’s History. January 21, 2016. Accessed June 19, 2024. https://www.canadashistory.ca/explore/science-technology/isolation
8. Di Nicola V, Daly N. Growing up in a pandemic: Biomedical and psychosocial impacts of the COVID-19 crisis on children and families. World Social Psychiatry. 2020;2(2):148-151.
9. CSDH. Closing the Gap in a Generation: Health Equity Through Action On the Social Determinants of Health. Final Report of the Commission on Social Determinants of Health. World Health Organization; 2008.
10. Felitti VJ, Anda RF. The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders and sexual behavior: implications for health care. In: Lanius RA, Vermetten E, Pain C, eds. The Impact of Early Trauma on Health and Disease: The Hidden Epidemic. Cambridge University Press; 2010:77-87.
11. Di Nicola V. The Coronavirus epidemic as a modern morality play: challenges for social psychiatry. WASP E-Newsletter. 2020:3-5. Accessed June 19, 2024. https://waspsocialpsychiatry.org/newsletters/
12. Agamben G. State of Exception. Attell K, trans. University of Chicago Press; 2004.
13. Agamben G. Homo Sacer: Sovereign Power and Bare Life. Heller-Roazen D, trans. Stanford University Press; 1998.
14. Caldwell C. Meet the philosopher who is trying to explain the pandemic. Accessed June 19, 2024. https://www.nytimes.com/2020/08/21/opinion/sunday/giorgio-agamben-philosophy-coronavirus.html?smid=tw-share
15. Cimons M. Are we heading for a post-pandemic “Roaring Twenties,” with parties and excess? The Washington Post. March 27, 2021. Accessed June 19, 2024. https://www.washingtonpost.com/health/social-distance-covid-getting-closer/2021/03/26/61962630-8693-11eb-bfdf-4d36dab83a6d_story.html
16. Royal College of Psychiatrists. Country in the grip of a mental health crisis with children worst affected, new analysis finds. Accessed June 19, 2024. https://www.rcpsych.ac.uk/news-and-features/latest-news/detail/2021/04/08/country-in-the-grip-of-a-mental-health-crisis-with-children-worst-affected-new-analysis-finds
17. Betthäuser BA, Bach-Mortensen AM, Engzel P. A systematic review and meta-analysis of the evidence on learning during the COVID-19 pandemic. Nat Hum Behav. 2023;7:375-385.
18. Hawke LD, Barbic SP, Voineskos A, et al. Impacts of COVID-19 on youth mental health, substance use, and well-being: a rapid survey of clinical and community samples. Can J Psychiatry. 2020;65(10):701-709.
19. Hanafi S, Dufour M, Doré-Gauthier V, et al. Position Statement: Covid-19 and Canadian Psychiatry. Can Psychiatric Assoc. March 11, 2021. Accessed June 19, 2024. https://www.cpa-apc.org/wp-content/uploads/2020-CPA-Position-Statement-Covid-EN-web-Final.pdf
20. Di Nicola V. Family, psychosocial, and cultural determinants of health. In: E Sorel, ed. 21st Century Global Mental Health. Jones & Bartlett Learning; 2012:119-150.
21. Barreto AP, Filha MO, Silva MZ, Di Nicola V. Integrative community therapy in the time of the new coronavirus pandemic in Brazil and Latin America. Special Theme Issue: COVID-19 Pandemic and Social Psychiatry. World Social Psychiatry. 2020;2(2):103-105.
22. Larsen L, Schauber SK, Holt T, et al. Longitudinal Covid-19 effects on child mental health: vulnerability and age dependent trajectories. Child Adolesc Psychiatry Ment Health. 2023;17(104).
23. Wolf K, Schmitz J. Scoping review: longitudinal effects of the COVID-19 pandemic on child and adolescent mental health. Eur Child Adolesc Psychiatry. 2024;33(5):1257-1312.
24. Di Nicola V. A Canadian perspective on the biomedical and psychosocial impacts of the COVID-19 pandemic on children and families. Global Mental Health & Psychiatry Review. 2020;1(2):6-7.
25. Di Nicola V. “Tempest-Tost”: of tempests, boats, and lifesavers – the new language of the plague. Global Mental Health & Psychiatry Review. 2022;3(1):7-8.