Children experienced new or worsening tic issues when they were separated from their parents during the Italian COVID-19 lockdown.

Decades of research have confirmed that children develop best when they are in safe, supportive, nurturing relationships. Positive relationships with parents are essential for children's growth, health and well‐being, , as they protect them and help them to regulate their emotions during stressful times. If children are unnecessarily and traumatically removed from their parents, their physical and mental health and well‐being will suffer. ,

A systematic review and meta‐analysis covering the period up to 28 July 2020 suggested that the general impact of COVID‐19 on the physical health of children had been relatively mild up to that point. In fact, studies have suggested that children and adolescents have lower susceptibility to the virus than adults and play a lesser role in transmission, in marked contrast to influenza. However, they have indirectly suffered from the restrictions established to limit the spread of pandemic. , These include the mental and social health consequences of social distancing measures, such as closing schools and stopping recreational activities, which are important for the cultural, social and psychological growth of children and adolescents. , Some studies have reported that the impact of lockdown measures has caused more harm to them than the actual virus. ,

This paper focuses on the consequences of social distancing measures on child mental and social health. , It shares the experiences of staff at our Italian University Hospital in Rome and discusses the consequences of separating children from parents who test positive for the virus, in order to protect them from becoming infected.

In July 2020, our hospital evaluated two households where one or both parents tested positive for the virus, but the children were not affected. At that time, the World Health Organization criteria for discontinuing quarantine were no fever for three consecutive days, improvements in other symptoms and two negative test results 24 hours apart. In family one, nine‐year‐old twins were separated from their parents, who both tested positive, and they were quarantined with their grandparents. They returned home after 45 days. The single mother in family two was admitted to hospital with COVID‐19 for three weeks and separated from her 10‐year‐old son for two months, while he stayed with his grandparents.

In September 2020, our clinic saw a 10‐year‐old girl who had been forced to live apart from her parents for 45 days. In early March, she had gone to stay with her grandparents, who lived in another province some distance from her home, while her parents went on a business trip. On 8 March 2020, Italy declared a state of emergency, due to the COVID‐19 pandemic, and the country went into lockdown. The parents' trip was cancelled, but the police did not allow them to go and collect their daughter because of strict travel restrictions. Neither of the parents had COVID‐19.

The separation of these families was relatively short‐lived, but it had a considerable impact on the children's health, even though none of them developed COVID‐19.

About two weeks after they were separated from their parents, the twins and the child who normally lived with his single mother developed eye and mouth tic disorders and for this reason they started to attend our hospital.

After about 10 days of forced separation from her parents, the grandparents state that the girl in family three experienced serious worsening of her existing tics disorders. We were able to evaluate her later in September.

The frequency of the children's individual tics varied throughout the day and they benefitted from progressively longer tic‐free intervals after they were reunited with their parents.

Being separated from their parents is one of the most profound traumas a child can experience, because it undermines a pivotal foundation that they require for self‐regulation and resilience. , Some studied have also questioned whether a few weeks or months of forced separation can have enduring effects. However, we do know that brief traumatic events can have life‐long consequences. ,

Studies have associated separating children and adolescents of all ages from their parents with a high risk of posttraumatic stress disorder, anxiety disorder, depression, aggression, psychosomatic complaint and suicidal ideation. They have also showed a variety of age‐specific psychiatric and neurobiological effects. As we already know, the central nervous system undergoes profound maturational changes during all stages of childhood and various brain regions and pathways have their own unique sensitive periods. During these periods, experiences can shape and fine‐tune their synaptic structure and interconnections in a very dramatic way. ,

The appearance and, or, worsening of tics in our patients could have been due to a serious impact on the central nervous system, which was caused by the trauma of being separated from their parents. , We interpreted the appearance or worsening of tics as a sign or index of the psychic discomfort that these traumatised children experienced, in line with research that stress and neurobiological mechanisms affect the pathobiology of tic disorders and Tourette syndrome.

The question is whether developing COVID‐19 is more harmful for children than separating them from their parents. This also raises issues about when they should be separated from one or both parents and who should care for them if they are. It is clear that the time has come to provide specific guidelines for children living in the COVID‐19 era, in order to safeguard the rights and health of children and their entire families.

The guidelines would need to explore, and provide advice on, a number of key questions. Would the children be at risk if they got COVID‐19? Are one or both of the child's parents infected and are their lives at risk? Who can take care of the children? What harm could be caused by separating the children from one of both of their parents? Would the harm caused by separation be greater than the harm of being infected and developing COVID‐19?

Our experience suggests that, in general, the harm of separation is greater than the physical risk posed by COVID‐19. This view is backed up by studies that have demonstrated the effects of the pandemic on children's mental health , , and studies that have described how children are less susceptible to the virus and play a lesser role in virus transmission. However, all cases must be analysed before we can provide any evidence‐based answers.

What we do know is that some of the practices during the pandemic have affected child mental health , , and are no longer ethically acceptable. These are the routine and long‐lasting separation of children from their families, lengthy school closures and not being able to visit public outdoor spaces or play with other children.

At the same time, families should be actively educated on the importance and proper use of masks and hygiene practices. It is notable that studies have showed that newborn infants were not infected by mothers who tested positive for the virus if the mother practice proper hygiene and mask use, even if they remained in the same room and were breastfed.

The time has come to shift from social distancing to physical distancing with social inclusion, particularly for children, as the benefits for child health will be endless.

CONFLICT OF INTEREST

None.