key: cord-0956628-w8evcb65
authors: Chen, I-Hua; Chen, Chao-Ying; Pakpour, Amir H.; Griffiths, Mark D.; Lin, Chung-Ying
title: Internet-Related Behaviors and Psychological Distress Among Schoolchildren During COVID-19 School Suspension
date: 2020-06-29
journal: J Am Acad Child Adolesc Psychiatry
DOI: 10.1016/j.jaac.2020.06.007
sha: 60ae3fb91bdb6e68b77a235daf43db3f0430b819
doc_id: 956628
cord_uid: w8evcb65

The novel coronavirus disease 2019 (COVID-19) infection has rapidly grown worldwide,(1) and many governments have implemented policies to control the infection rate. For example, school suspension, self-quarantine, requirement of citizens to stay at home,(2) travel and border controls, and discouragement of outdoor activities(3) have been used. Although these actions emphasizing the importance of “spatial distancing” are based on the perspective of public health, they may result in health problems other than COVID-19 infection, such as psychological distress and fear.(4) Therefore, the present authors examined the potential predictors for psychological distress among schoolchildren during COVID-19 school suspension.

To the Editor: he novel coronavirus disease 2019 (COVID-19) infection has rapidly grown worldwide, 1 and many governments have implemented policies to control the infection rate. For example, school suspension, self-quarantine, requirement of citizens to stay at home, 2 travel and border controls, and discouragement of outdoor activities 3 have been used. Although these actions emphasizing the importance of "spatial distancing" are based on the perspective of public health, they may result in health problems other than COVID-19 infection, such as psychological distress and fear. 4 Therefore, the present authors examined the potential predictors for psychological distress among schoolchildren during COVID-19 school suspension.

Using of an ongoing longitudinal project approved by the Hong Kong Polytechnic University's ethics committee (ref: HSEARS20190718001), data from 2 waves of the project (ie, baseline [time 1] and 5 months after baseline [time 2]) were analyzed. The first-wave data (time 1) were collected from October 22, 2019, to November 1, 2019, and the COVID-19 outbreak in mainland China occurred around February 2020. Chinese primary school students ended their autumn semester on January 16, 2020, and had a winter vacation during the Chinese New Year (from January 17 to February 17, 2020). The students were then housebound from February 18, 2020, and received online teaching beginning March 5, 2020 (ie, a policy implemented by the Sichuan Province's education bureau). Online teaching included recorded video clips and homework designed according to the content of the video clip. Teachers sent out the homework using WeChat. The second-wave data (time 2) were collected from March 4 to 16, 2020: on average, 130.8 days after the data collection in the first wave (SD ¼ 5.42). In March 2020, mainland Chinese primary schoolchildren were still suspended from school because of the government's COVID-19 policy restrictions.

Data collections were performed with the assistance from teachers of three primary schools in Sichuan province. More specifically, the three primary schools were public schools and located in the suburban area of Qionglai city (population size, 0.65 million; approximately 60 km [37 miles] from downtown Chengdu city), which is a countrylevel city in the Sichuan province. Regarding the schoolchildren's parents in the three schools, approximately 85% of them had completed high school education, and 5% of them had a college degree or above. The parents' annual income was between 50,000 and 180,000 Renminbi (RMB; 1 USD z 7.05 RMB), with an average of 80,000 RMB.

In the baseline assessment (time 1), teachers first distributed the study information to schoolchildren and their parents. Their willingness to participate in the first wave was verified by written informed consent (signed by the children and one of their parents). For consent in the second wave, the survey was sent to parents' smartphone with the instruction that one of the parents was requested to accompany the children to complete the survey if they agreed to participate. Only those parents and children who agreed to participate in the second wave's survey could continue and complete the scales after providing online informed consent (ie, on the first page prior to the survey). If the parents or children did not hit the "agree" button on the first page, the survey ended directly. Several psychometric scales, together with a background information sheet, were then given to the students to complete in the classroom under the supervision of the schoolteachers. In the assessment during the COVID-19 outbreak (time 2), an online survey using the same psychometric scales and background information sheet as those at time 1 was generated by the researchers. Because schoolteachers were unable to have physical contact with the children in schools, the hyperlink of the online survey was sent to the students by their teachers. The study objectives and participants' rights (eg, withdrawal from the survey at any time without any consequence) were clearly stated on the survey's first page. Eligible schoolchildren fulfilled the following inclusion criteria: having the ability to read and understand written Chinese that enabled them to complete the online survey without difficulties, and their family possessing at least one smartphone with Internet access.

All the self-report measures were assessed using a pastweek timeframe. More specifically, schoolchildren's time spent on Internet-related activities, problematic use of Internet-related activities, and psychological distress were asked with the item stem of "in the past week." Participants' demographics and characteristics were collected, including their date of birth, grade, ethnicity, sex, health condition (using an dichotomous item "In the past week, were you ill [eg, having diarrhea or catching a cold]?"), perceived academic performance (using the question "How do you perceive your academic performance in the past week?" with a 5-point Likert scale [1 ¼ very good; 5 ¼ very poor]), and (using open-ended questions) time spent on gaming ("In the past week, how much time did you spent gaming per day?"), social media use ("In the past week, how much time did you spent on social media per day?"), and smartphone ("In the past week, how much time did you spent on smartphone per day?"). In addition, the Smartphone ApplicationÀBased Addiction Scale (SABAS), [5] [6] [7] Bergen Social Media Addiction Scale (BSMAS), [5] [6] [7] and Internet Gaming Disorder ScaleÀShort Form (IGDS-SF9) 5-7 were used to understand the problematic Internet-related behaviors among the schoolchildren. The Depression, Anxiety, Stress ScaleÀ21 (DASS-21) 8 Descriptive statistics were first used to report means and 95% confidence intervals to understand the time spent engaging in Internet-related behavior, problematic Internetrelated behavior use, and psychological distress for the participants. Paired t tests were then carried out to compare the differences in time spent engaging in Internet-related behavior, problematic Internet-related behavior use, and psychological distress between baseline and follow-up assessments. Three regression models were constructed to understand the factors associated with psychological distress during the COVID-19 outbreak period. The first regression model predicted the outcome of baseline psychological distress by age, sex, and baseline information on current illness status, perceived academic performance, time spent on Internet-related behaviors (time spent on smartphone, social media use, and gaming) and problematic Internetrelated behaviors (problematic smartphone-application use, problematic social media use, and problematic gaming). The second regression model predicted the outcome of follow-up psychological distress by age, sex, and follow-up information on current illness status, perceived academic performance, time spent on Internet-related behaviors, and problematic Internet-related behaviors. The third regression model predicted the outcome of psychological distress at follow-up by age, sex, and both baseline and follow-up information on current illness status, perceived academic performance, time spent on Internet-related behaviors, and problematic Internet-related behaviors.

Participants' characteristics for schoolchildren who completed the baseline survey, those who completed the follow-up survey, and those who completed both the baseline and follow-up surveys are presented in Table 1 . More specifically, the participation rates were 26% for baseline Note: a Longitudinal data were for participants who completed both baseline and follow-up assessments. b Participation rate was calculated using the denominator of the total number of students in the 3 primary schools: that is, 1,108/4,260 for baseline, 2,026/4,260 for follow-up, and 543/4,260 for those who attended both baseline and follow-up assessments. . Therefore, the present samples represented more senior primary schoolchildren. Moreover, Individualized Education Program Plans (IEPs) were implemented in the three schools (0.81%, 0.22%, and 0.38%, respectively). During the school suspension period, schoolteachers visited the homes of schoolchildren who required IEPs to provide additional support according to the Education Bureau's guidance.

The schoolchildren reported more time engaging in smartphone use and social media use. They further reported lower levels of problematic social media use and problematic gaming at follow-up assessment than at baseline assessment. However, the psychological distress was greater for the schoolchildren at follow-up assessment than at baseline assessment ( Table 2) . Table S1 , available online, additionally shows that problematic Internet-related behaviors were significant predictors for psychological distress at both baseline (standardized coefficient [b] ¼ 0.093 for problematic smartphone-application use; 0.081 for problematic social media use; and 0.437 for problematic gaming; n ¼ 1,108) and follow-up assessments (b ¼ 0.181 for problematic smartphone-application use; 0.152 for problematic social media use; 0.232 for problematic gaming; n ¼ 2,026). Follow-up illness status (reference group being healthy status; b ¼ 0.071) and perceived academic performance (b ¼ 0.099) were significant predictors for distress in the follow-up. Moreover, the regression on data from schoolchildren who completed both baseline and follow-up assessments (n ¼ 543) showed that problematic smartphone-application use at follow-up (b ¼ 0.304) and problematic gaming at follow-up (b ¼ 0.308) significantly predicted psychological distress at follow-up.

The higher association found between illness status and psychological distress during the COVID-19 outbreak period than before the COVID-19 outbreak may be explained by the fear of COVID-19 transmission and mortality rates. 1, 4 The associations between psychological distress and different types of problematic Internet-related behaviors found in the present study concur with prior research. 5, 6, 9, 10 Special attention should be paid to the greater associations between problematic smartphoneapplication use, problematic social media use, and psychological distress during the COVID-19 outbreak than before. Therefore, parents of primary school children are encouraged to understand and to monitor their children's smartphone and social media use during the COVID-19 outbreak. Subsequently, their children's psychological distress may not become as elevated during this period. here is considerable evidence that child maltreatment is associated with significant shortand long-term negative outcomes. 1 Protecting children from maltreatment should be a clear priority, and there is substantial opportunity for making improvements in child protective services (CPS) to better serve those they are tasked with protecting. Making progress in this effort requires a closer inspection of the processes in place to identify children in danger of being harmed and of the potential effectiveness of the current system. The article by Kim and Drake 2 published in the Journal examined CPS records to create US estimates for child maltreatment onset and recurrence for children from birth to age 11 years. More than one-third of children are estimated to have a screenedin report for investigation or assessment by CPS, and after an initial report is made regarding a child, the probability of a subsequent report is nearly 1 in 2. This alarming rate of maltreatment recurrence points to potential areas for improvement.

Given the high cost to each child whose maltreatment continues without effective intervention, the findings of recurrent reports made for children already brought to the attention of authorities is concerning. Most children remain in their homes even following substantiated maltreatment, and data presented by Kim and Drake 2 point to an unmet need to ensure the safety of children with CPS involvement. Strained budgets often limit the access to and availability of tailored mental health services, and training for mental health professionals working with families connected to CPS may not always be evidencebased.

Further, interventions for parents aimed to reduce reperpetration of maltreatment typically focus on providing behavioral techniques to replace or reduce physical discipline, rather than directly target the most common type of child maltreatment (ie, neglect). 2, 3 Given the links between neglect and poverty, such interventions may necessitate an T 

Coronavirus disease (COVID-2019): situation reportÀ72. Available at

Safer at home order for control of COVID-19. California Health and Safety Code §120295

Los Angeles County Code

COVID-19 concerns lead to unusual bans in Dallas County

Fear of COVID-19 Scale: development and initial validation

Time invariance of three ultra-brief Internetrelated instruments

Measurement invariance across young adults from Hong Kong and Taiwan among three Internet-related addiction scales: Bergen Social Media Addiction Scale (BSMAS)

Psychometric testing of three Chinese online-related addictive behavior instruments among Hong Kong university students

Cross-cultural validation of the Depression Anxiety Stress Scale-21 in China