Child protection in the time of COVID-19.

As the number of cases of coronavirus disease 2019 (COVID-19) caused by the virus SARS-CoV-2 rises exponentially in Australia with consequences for the health system and society at large, we need to remember that during this pandemic that necessary social distancing measures, effective school closures and rising unemployment levels may lead to an increased risk for child abuse and neglect.

As the number of cases of coronavirus disease 2019 (COVID‐19) caused by the virus SARS‐CoV‐2 rises exponentially in Australia, there have been immense efforts poured into preparing for our part in this global pandemic. The daily reports of the sheer number of people infected globally and succumbing to this disease are alarming, with news coverage from areas hardest hit by this pandemic being truly sobering. There are major concerns both locally and internationally about supplies of personal protective equipment, supporting clinical staff who are facing unprecedented challenges,2, 3 and the need for more ventilators and intensive care beds to cope with expected surges in the sickest of patients.2, 4 While initial reports suggest that children seem to be relatively spared, with fewer cases and a milder disease course,5, 6, 7 this does not by any stretch of the imagination mean that our paediatric patient population will go unscathed. In addition to the effects on the physical health of children, we can anticipate COVID‐19 to have negative impacts on their mental health and psychosocial functioning, and to increase many children's vulnerability to child abuse and neglect.

The social and economic effects of the COVID‐19 pandemic in Australia are far‐reaching and continue to evolve. The necessary social distancing measures undertaken have already dramatically changed how we live and interact, and many people are experiencing economic hardship. School‐aged children have been affected by these changes, with parents strongly encouraged to keep children at home where possible and a move to learning at home with no definitive end in sight.8, 9, 10 Children will lose out on peer social interaction and many will lose the benefits associated with the structure provided within the classroom and the school day. It has been hypothesised that the structure of the school day promotes children's physical health and fitness. Without conscious efforts at multiple levels, children will likely have reduced opportunity for physical activity during this pandemic with legally enforceable restrictions on physical proximity and social gatherings meaning playdates are out, playgrounds, play centres and swimming pools closed, and organised sport cancelled.12, 13 In Australia, this is likely to be compounded further as winter approaches when it has always been be harder to get children outside the home. We should prepare for the possibility of magnified negative impacts on children's physical health, and probably also on their emotional and mental health.

Social distancing measures and the economic consequences of the COVID‐19 pandemic have resulted in more parents being at home, either working from home or as the result of job loss, at the same time as their children being engaged in home‐based learning. There are opportunities for enhanced family closeness to be had but for many families the current circumstances will present increased stressors that are likely to negatively impact family functioning rather than bring them closer together. ‘Learning at home’ programmes often require significant input from the adults at home and are challenging enough for well‐resourced families. Home‐based schooling may be much more difficult to implement for families where, for example, there are insufficient suitable electronic devices, a limited home internet connection, or there are young children at home already requiring significant attention and insufficient adults available at home to help. There is likely to be increased stimulation in the home environment with impacts for children, parents and carers alike which could result in exacerbations of disruptive behaviour in children that families may struggle to manage. While it is known that child abuse and neglect can occur within all groups in society, children from lower socioeconomic groups15, 16 and those with a disability for example are already over‐represented within the child abuse statistics. The current changes occurring due to COVID‐19 are likely to be difficult for many families, however, those at social disadvantage and already under significant stress are likely to have the fewest resources available to manage.

The COVID‐19 pandemic has led to significant unemployment in Australia. Unemployment in Australian adults has been associated with anxiety and affective disorders ; moreover, negative parenting behaviours have been associated with economic hardship. In a recent Australian report, adult mental health disorders were a common theme in filicide. Domestic violence is well recognised to be intrinsically intertwined with child abuse ; it is concerning but perhaps not surprising that there are concerns of an increase in both in the current pandemic.

Additionally, school staff in Australia are of course mandatory reporters, and as such provide a valuable safety net to alert statutory agencies of concerns of possible harm as well as providing support to vulnerable children and their families. That valuable child protection system mechanism is currently significantly impaired.

It is not just in the home and school environments that this pandemic will impact on child abuse and neglect. The mother who might otherwise bring her child to the general practitioner or emergency department as a ‘cry for help’ might now desist due to fears about contracting COVID‐19, or be more likely to self‐discharge due to longer wait times. Clinical staff will quite understandably be focused on infectious and respiratory disease presentations. Sentinel injuries which are poorly explained and suspicious for child abuse may be missed by clinical staff who are various combinations of being inexperienced, overworked, tired, under‐resourced, under‐trained and generally stressed. Telehealth consultations may not support the same level of verbal and non‐verbal interaction as their face‐to‐face versions. Senior paediatric trainees and consultants may not be immune to stress and fatigue as junior staff are deployed to adult services and fellow senior paediatric colleagues are unable to work, either due to contracting COVID‐19 or the need to await a COVID‐19 test result. This scenario is particularly relevant to Child Protection Paediatricians who in Australia frequently work in small departments in tertiary settings or act as the sole repository of subspecialty expertise in peripheral settings.

Community services, often threadbare at the best of times, will be slowed down by ongoing changing guidelines around health and safety. Data from international conflicts and disasters have in fact suggested a paradoxical decrease in child protection reporting rates, possibly due to one or a combination of stresses on frontline child protection workers, the child protection reporting system and physical (e.g. telecommunication) infrastructure issues.

All these family, economic and societal changes during this pandemic period add up to a potential tinderbox for child abuse and neglect in Australia and health‐care professionals need to be as vigilant as possible. Whilst medical emergencies must continue to take precedence, we will still need to consult, report and respond to child abuse and neglect during the coming weeks and months. We need to be steadfast in advocating for the maintenance of the paediatric child protection workforce in this vital but oft‐neglected area, so as to not let this pandemic disproportionately affect an already vulnerable population of children and families.