Effects of Covid-19 con�nement on the mental health of children and adolescents in Spain

In Spain, in order to control COVID-19 transmission, one of the strictest con�nement measures in the world for children and teenagers has been implemented. From 14 March to 26 April 2020 underage Spaniards were not allowed to leave their homes, except for reasons of force majeure. This could have consequences on their mental health in both the short and the long term. Thus, the aim of the present study was to explore the consequences of con�nement on the mental health of Spanish children and teenagers, at the time when minors had been locked down in their homes between 8 and 10 days. The sample was composed of 590 con�ned Spanish children and teenagers between 8 and 18 years old. The scales of Depression, Self-esteem, Anxiety, Problems with Emotional Regulation, Rage Control Problems, Integration and Social Competence, Somatic Complaints, Rebellious Behaviour, as well as Awareness of the Problems of the Assessment System for Children and Adolescents (SENA) were used. The results revealed that, during con�nement, children and adolescents showed emotional and behavioural alterations. This study, as far as we know, is the �rst one to explore the psychological consequences of lockdown in minors while it was taking place, with them being the ones directly assessed.


Introduction
In order to control the contagion of the COVID-19 disease, the Spanish government implemented strict domestic quarantine policies.On 14 March 2020 the State of Alarm and con nement for the entire population, including children, was decreed.When more than 7500 people had tested positive for COVID-19, 293 were admitted to the ICU and 136 people died 1 .
In relation to con nement measures, Spain has been one of the most restrictive countries, concerning permission for minors to leave their house.From 14 March to 26 April 2020 minors in Spain were not allowed to do this.This meant they were in lockdown at home for six uninterrupted weeks, when the adverse psychological effects on children and teenagers are yet to be determined.
In this regard, the data in China indicate that the consequences on the levels of depression during quarantine were greater in teenagers than in adults 2,3 .
It is hoped that even after such disasters, most people are resilient and do not develop psychopathological problems.However, some groups can be more vulnerable to the psychosocial effects of pandemics 4 .In children at key stages, the interruption of social and educational activities for many months can have a higher impact on their development.Recent investigations on the consequences of stressful situations in the mental health of small children show that anxiety, depression, lethargy, damaged social interaction and poor appetite are the most usual psychological manifestations, while at the physiological level a weakened immune system can be observed [5][6][7][8] .
Regarding the emotional consequences of events linked to health, Sprang and Sigman 9 , analysed the effects of pandemics on 398 families, discovering that children who were isolated or in quarantine during pandemic illnesses were more likely to develop acute stress disorder, adjustment disorder and mourning.Thirty percent of the children that were isolated or in quarantine met the clinical criteria for post-traumatic stress disorder.Recently, a preliminary study conducted in the province of Shaanxi during the second week of February 2020 10 , in which the Chinese population were con ned, showed that the most common psychological and behavioural disorders of 320 children and teenagers between 3 and 18 years old were: bonding problems, distraction, irritability and being afraid to ask questions about the epidemic.Regarding differences according to age, the youngest, between 3 and 6 years old, were more likely to develop bonding problems and fear that the members of the family could contract the illness, while children between 6 and 18 years old showed more attention problems and persistent inquiry 10 .Also in China, Zhou et al. 3 conducted an investigation on teenagers between 12 and 18 years old, discovering a high prevalence of anxiety (43.7%) and depression (37.4%) during the COVID-19 outbreak, especially in females.Along the same line, Pisano et al. 11 conducted a study in Italy in which they evaluated, through the parents, the impact of the con nement in minors between 4 and 10 years old, in the form of a questionnaire created ad-hoc.The results showed regressive behaviour, such as the wish to sleep with their parents; enuresis episodes; a worsening in their vocabulary; and fears that were inexistent before.In regard to emotional or behavioural changes, 53.5% of the children showed more irritability: 21.2% showed continuous mood changes; 20% revealed trouble sleeping; and 34.3% were more nervous.
Even though, as shown, it is expected that a few of the children and teenagers react in a resilient way to this crisis, the risk is real and needs attention 12 .Minors, in addition to the aforementioned, can experience fear of the virus, frustration, boredom, lack of socialization with friends and teachers and lack of room at home, leading to problematic consequences that can go beyond the quarantine period 13 .In Spain, children and adolescents stopped attending school from the beginning of the con nement (March 14 th ) to (predictably) the beginning of the next school year in September 2020.If also, we add to this that the mental health services for minors must face the new challenges that the COVID epidemic has brought, and without guidelines adapted to the new circumstances or that are restricted to the worst cases, addressing these consequences is even more uncertain 13,14 .
In this context, the main goal of the present report is to analyse the consequences of strict con nement on the mental health of children and teenagers, at the time when the minors had been con ned to their homes between 8 and 10 days .This research is, as far as we know, the rst one exploring the psychological consequences of con nement on minors in Europe, being the ones directly evaluated, and while it was taking place.All of this has occurred in one of the countries with the most restrictive con nement measures and which has met all the restrictions of movement in a stricter way, according to the mobility data of Google and Apple [15][16][17] .Furthermore, a bigger number of variables linked to the mental health of minors is depicted, in comparison to the reports on anxiety and depression that have been published in recent studies of children and teenagers conducted in China 3,18 .In this way, rst prevalence rates are gathered and compared to data from minors in quarantine with the scales of the technical manual of the SENA 19 (Assessment System for Children and Adolescents), which is the resource used in the present study to evaluate the state of mental health of minors.
The second goal is to investigate if con nement has affected the levels of anxiety, depression, self-esteem, rebellious behavior, somatic complaints integration and social competence, rage control problems, as well as greater emotional regulation problems in children or teenagers.Lastly, the third goal is to differentiate between the mental health of children and adolescents based on gender and level of education, since these were some of the main risk factors for anxiety and depression in Chinese adolescents 3 .

Participants
The sample consisted of 788 minors, 440 of whom were between 8 and 12 years old and 348 between 13 and 18 years old.After removing the participants that had not answered 100% of the raised items, 590 minors were left, 325 between 8 and 12 years old and 265 between 13 and 18 years old (teenagers).It is an incidental sample, instead of a random one.The selection of participants was carried out through an anonymous survey conducted on the Internet, social networks and the press.
In the case of the children (between 8 and 12 years old) 158 were girls (51.7%) and the average age was 9.95 years old (SD= 1.40).
Regarding the place of residence, they were from all the Spanish communities; the most represented was Castilla y León, where more than half of the participants lived (71.75%), followed by The Basque Country (7.7%) and Madrid (6.5%).
In the sample of the teenagers (between 13 and 18 years old), 168 were female (63.4%), with an average age of 15.42 years old (SD= 1.70).They also came from all the Spanish communities, being Castilla y León the most represented again (55.8%), followed by Andalusia (10.9%) and Madrid (6%).

Instruments
Assessment System for Children and Adolescents 19,20 (SENA).is a resource focused on the detection of a wide range of emotional and behavioural disorders from 3 to 18 years old.It allows one to detect areas of vulnerability that predispose people to develop psychopathological problems and the presence of psychological resources that can act as protective factors to different problems.In our study, self-reporting questionnaires aimed at Elementary (6-12 years old) and High School (13-18 years old) students were used, and some of them were chosen so that they did not take too much time, keeping in mind the state in which the minors were.They were the following nine: Depression, Self-esteem, Anxiety, Problems with Emotional Regulation, Rage Control Problems, Integration and Social Competence, Somatic Complaints, Rebellious Behaviour, and Awareness of Problems.It shows a response format of a 5-point Likert-type scale.Both children and teenager scales were reliable, producing a Cronbach internal consistency rates between .754 and .914.They present scores in their technical manual on both normal population and clinical samples (anxiety, depression, learning di culties, ADHD, etc).SENA has shown suitable psychometric traits referring to evidence of validity, as well as test-retest reliability and internal consistency on both normal and clinical population 20 .None of the variables show relevant in uence of gender, age, socioeconomic status of the family or the educational level of the parents 19 .
Despite the fact that the evaluation tool is validated from 3 years old on up, in the present work the sample for 8 years old on up has been chosen, so that the children were able to adequately answer the questions asked them on their own, without adult collaboration.

Procedure
A cross-sectional study was conducted through surveys between 22 and 25 of March 2020 (after between 8 and 10 days of con nement at home) by means of an anonymous survey carried out on the Internet, social networks and press, using the onlineencuesta platform (https://www.onlineencuesta.com/),which took approximately 15 minutes.The investigation was sanctioned by the Research Ethics Committee of the University of Burgos.All parents or legal guardians gave voluntary informed consent to the participation in the study, which was explained to them as an investigation of the effects of con nement on the physical and emotional condition of minors.

Prevalence
The correction criteria of the technical manual of SENA 19 are used in the study of prevalence.Table 1 presents the number and percentage of Spanish children and teenagers in strict con nement who are between 1 and 2 standard deviations above average, more than 2 standard deviations above average, and the ones that scored higher than the clinical sample of SENA scales.In the aspects of self-esteem, integration and social competence and awareness of the problems, the distance in standard deviations is below average, and those participants who score lower than the SENA clinical sample are also shown.Following, the results of the consequences of con nement are described rst on children (8 to 12 years old) and then on the teenager sample (13 to 18 years old).
Consequences of COVID con nement in children between 8 and 12 years old First of all, Student t-tests are carried out as a sample in which the one of our study is compared with the technical standards of each of the SENA scales (Table 2).
As can be seen, once the con nement week is over, there are already signi cant differences concerning the scales in every dimension besides self-esteem.In all of them, apart from somatic complaints, the clinical situation of children between 8 and 12 years old is signi cantly worse than the sample of the scales.They show more anxiety, depression, rage control and problems with emotional regulation, rebellious behaviour and worse integration, besides social competence.
The effect sizes found here are bigger than the ones published in the technical manual of SENA 19 regarding the differences between the scores of normal population and the clinical sample in rage control problems and rebellious behaviour.Consequences of COVID con nement in teenagers from 13 to 18 years old As can be seen in Table 2, after being con ned for a week, teenagers show signi cant differences regarding the scales in all nine evaluated scales.In all of them, besides awareness of the problems, the clinical condition of teenagers between 13 and 18 years old is signi cantly worse.
The effect sizes of the present study are greater than the ones published in the technical manual of SENA 19 regarding the differences between the scores of the normal sample and the clinical one.

Differences between children and in Covid-19 con nement
In relation to the goal, in order to compare children and teenager data, the scores of all the evaluated dimensions were standardised taking the average and standard deviation of the SENA scales for children (8 to 12 years old) and teenagers (13 to 18 years old).Then, a MANOVA was carried out with all the mental health variables set out in the study and shared with both groups, that is, all of them except for awareness of the problems.
The differences turned out to be signi cant (Pillai's trace=.157,F=13.551, p=.0001, h 2 =.157).The inter subject tests can be seen in Table 3. Teenagers show higher levels of anxiety, depression, problems with emotional regulation and somatic complaints, as well as lower self-esteem and integration and social competence levels than children.As for children, their sample reaches higher scores in rebellious behaviour than teenagers.Note.The middle level comprises 3 rd and 4 th elementary (8 to 10 years old).The upper level 5 th and 6 th elementary (10 to 12 years).
Differences by gender and level of education in teenagers between 13 and 18 years old Regarding gender, results show that there are signi cant differences between teenagers (Table 5), with females presenting higher levels of anxiety, less self-esteem, more problems with emotional regulation and more somatic complaints than their masculine counterparts.Then again, males show a signi cantly lower score on integration and social competence than females.
Table 5. Differences by gender and education in the mental health of teenagers between 13 and 18 years old during con nement SENA Female Regarding the level of education, there are signi cant differences among anxiety, depression, self-esteem, problems with emotional regulation, somatic complaints and awareness of the problems.In all of them, teenagers who study in ESO show a better clinical condition that the ones who study in high school and professional training, except for the scale of awareness of the problems (Table 6).

Conclusions
The results of the present report show that the strict con nement situation of children and teenagers already reveal, from 8 to 10 days, signi cant consequences on the mental health of both of them, although we still do not know the long-term effect.
It appears that the consequences of con nement on children are mostly in the affective area, this also being re ected at the behavioural level.They show problems of rebellious behaviour (t d =.75), rage control (t d = .61)and emotional regulation (t d =.27) to a greater extent.As opposed to adults, children do not clearly identify these altered conditions in themselves, and it is frequent that symptoms like irritability or aggression appear as a warning sign of more chronic disorders for this age group.We have also discovered that during con nement they showed higher levels of anxiety (t d =.14), depression (t d =18), and less integration and social competence (t d =16), although with lower effect sizes.However, it should be pointed out that such high percentages as 33.2% and the 22.8% of the children in con nement score higher than the clinical sample of SENA on anxiety and depression respectively.
The only variable that revealed improvement in children during con nement was somatic complaints (t=-5.571,gl=324, p=.0001, d z =-.31).One possible explanation is that somatic complaints usually appear as an involuntary expression of psychological discomfort that children use to seek attention or affection from their parents.Franco, Pérez and de Dios 21 discover differences between parenting styles and the somatization of their children, proving that parents with less disciplined educational behaviour or situations in which one of the parents takes fewer caring tasks, increase the somatization in children.Thus, in our investigation, parents who are also in a con nement situation, and who, as a result, are nearer now, and spend more time with their children, should try reprimanding their children less.
In the case of teenagers, there are signi cant differences regarding the scales of every evaluated variable (anxiety, depression, rebellious behaviour, somatic complaint problems with emotional regulation and rage control) being the effect size average except in awareness of the problems and somatic complaints, which is low.
In all the dimensions, the results show a worse clinical situation than in teenagers after being between 8 and 10 days in con nement, except in awareness of the problems (t=3.50,gl=264, p=.001, d z =.21), that is, they were more aware during con nement that some things were not going well, that they were having a di cult time, so could have needed help.
Regarding gender, the results point in the same direction as the ones found by Zhou et al. 3 in Chinese teenagers: Spanish girls between 13 and 18 years old have been more affected by con nement than boys.They show more anxiety, less self-esteem, more problems with emotional regulation and more somatic complaints.As for male teenagers, they show lower levels of integration and social competence.Because of this, it seems they have greater di culty being accepted and loved by others than females through the methods which social interaction in con nement allow (video calls, chats, phones, etc).This might well be because teenage girls tend to use on-line means of socialization more, give more importance to them than boys do, and they affect their well-being more.Consequently, they are more used to this socializing agent than boys, who use digital media more often for gaming 22 .Nevertheless, con nement does not seem to have a differential impact based on gender in children between 8 and 12 years old.
Regarding the school year, Zhou et al. 3 discovered that teenagers during years with more academic pressure in students showed more anxiety and depression, since the COVID-19 outbreak interrupted their normal learning process.In our study the results are similar.Teenagers in high school (prior to examinations for University admission) showed lower levels of self-esteem and more anxiety, depression and somatic complaints than middle-school students.Professional training students also showed worse symptomatology (more anxiety, depression, problems with emotional regulation and less self-esteem) than the ones in middle school.Professional training students noticed how their internship came to a halt due to coronavirus, perhaps the part of their studies which they consider the most important and the one they value the most in this kind of education.Without a doubt, this meant a period of uncertainty to them since they did not know the terms and conditions in which they could carry out their studies.
In short, the differences in teenagers' mental health took into account high school and professional training students, as well as those in middle school, a school age that does not imply great academic pressure in Spain.
In children between 8 and 12 years old, there were only differences in problems with emotional regulation, where middle-school students reached a higher score than the ones in high school.This coincides with the study that indicates that emotional control grows with age and that not until they are 10 years old, are children mature enough to understand states such as emotional ambivalence (experimenting contradictory emotions in the same situation) 23,24 .This would doubtlessly make emotional understanding and the ability to adequately face the con nement situation di cult for young children.
The present report represents a rst approach to the consequences of con nement on Spanish children and teenagers, which, nevertheless, must be interpreted in the light of some limitations.First of all, the selection of the sample was for the sake of convenience and following snowball sampling.In future con nement situations, a probability sampling should be obtained.
Besides, the evaluation was transversal, which prevents establishing causal relationships.It should also be noted that the results displayed here only comprise the consequences of the rst 8 to 10 days of con nement, still needing to be established what its long-term evolution will be.
In conclusion, looking at these results, it seems clear that strict con nement situations affect the mental health of children and teenagers between 8 and 18 years old.It is expected that most minors overcome this situation without long-term consequences, but in future pandemic situations in the local con nements which are taking place and are foreseen in the near future, they should be weighed, especially in those minors with risk pro les. Declarations

Table 1 .
Prevalence in mental health problems of children and teenagers in Spain during con nement Note: SD are the ones from the normal population of SENA technical manual.CS= The clinical sample score of the technical manual.*The distance in standard deviations is below average.

Table 2 .
Differences between the study sample and SENA scales for children (between 8 and 12 years old) and adolescents (13 to 18 years old)

Table 3 .
Differences in the state of mental health between children and adolescents during con nementDifferences by gender and level of education in children between 8 and 12 years old Regarding the third goal, ANOVAs of a factor with SENA dimensions based on gender and educational cycle were carried out (Table4).There are not signi cant differences regarding gender in any of the nine evaluated variables in children in quarantine.According to the educational level, the youngest of the middle elementary level revealed greater problems of emotional adjustment than those of the upper level (F=9.061,p=.003, h 2 =.028).

Table 4 .
Differences by gender and level in the mental health of children between 8 and 12 years old during con nement

Table 6 .
Signi cance of the post-hoc differences (DMS test) between pair averages depending on the teenagers'school course during con nement