The Impact of Covid-19 on Children and Young People’s Mental Health.

                         S Foster BA hons. PGDip Play & Creative Arts Therapy, LandPlay Outdoor Play Therapist and PCAP Practitioner Feb 2021

                Click Here for PDF

 “During the UK lockdown, children’s depression symptoms have increased substantially, relative to before lockdown. The scale of this effect has direct relevance for the continuation of different elements of lockdown policy, such as complete or partial school closures”.  Bignardi et al. (2020, p. 1).

Findings show that children and families with poorer economic backgrounds,  those from black and ethnic minorities,  families with existing mental health problems, those with safeguarding issues and those with disabilities already face adverse challenges and these groups have been found to be the most disadvantaged, Bibby et al. (2020), Gov of Scotland (2020), MHS (2020), OECD (2020) and Save the Children (2020).

Up until December 2020, it was not widely thought that children were at a high risk of biological harm of the Covid-19 virus. (In light of the recent Government and media reports, this opinion is changing). But what we do know is that children have been, and continue to be disproportionately affected by the virus’s  “hidden” impacts  (Save the Children, 2020, pp.1-67).

What can be gleaned from a smaller selection of the many studies on children’s mental health during Covid-19, is the consensus that the UK population, families and children are living with constant and unsettling changes during extraordinary times. And, as yet,  there is no end in sight. Across the globe countries have implemented unprecedented levels and scales of quarantine, physical and social distancing and lock downs. Children and adults alike are feeling anxious, fragile and fragmented, disconnected from the work place, colleagues, family, neighbours, peers, schools and education, clubs and communities, the environment, and medical services and support. Unsurprisingly key findings of the NHS survey: Mental Health of Children and Young People in England 2020,  show an evident increase in the mental health of both boys and girls aged 5 to 16 years. Up from one in nine, in 2017, to one in six during 2020. (NHS Digital 2020).

Meanwhile, access to services for children with existing mental health issues have been notoriously precarious prior to 2020, but as things stand now, waiting times are very uncertain.  Children from rural areas of the UK, notably Cornwall, (where the writer originates) are having to wait 12 weeks for a follow appointment, write reporters, Church and Aru (Cornwall Live, Jan 2021, n.p.). With many forms of intervention and health services seeing huge rises in referrals, (see below)  postponements, deferments and delays,  some appointments now run online due to the need for social distancing.

From the closure of playgroups, community centres, to delayed and cancelled medical appointments and treatment, to steep declines in mental health, children and young people are experiencing loss of normality, routine and familiarity. Families and children are disadvantaged greatly, the physical disconnection of much needed medical, mental health and community services, may well compound increasingly common feelings of abandonment and isolation.

Studies carried out during the Covid-19 pandemic show varying rates of increased depression.  Researchers talk about the effects of the pandemic being likened to adverse life experience outcomes, and effects from natural disasters and terrorist attacks. Symptoms can include insomnia, loss of appetite, anxiety, trauma and post-traumatic stress disorder (Jacob et al., 2020). What is increasingly being spoken about in current studies is that anxiety and trauma have a direct effect on physical, mental and psychological well-being, and link to poor health symptoms, and outcomes later in life.

Loneliness, Confinement and Social Isolation

In the throes of the third lockdown and with social distancing having been in place for over 10 months,  loneliness is a pressing and worrying issue for families and professionals who are seeing the consequences.  A review of 63 studies  (Loades et al., 2020, p.1234) found “clear evidence” of loneliness and mental health issues in children and young people. This is becoming more evident across all ages and backgrounds in children and adolescents, not helped at all by the reduction of access to peers,  play and activities (which may, in normal circumstances help to regulate mood, wellbeing and physiological health.)

Authors, Tso and Park (2020) indicate that social isolation disconnection, sedentary behaviours and loneliness have been independently linked to premature death from stroke and cardio vascular diseases, (and altered expression of genes involved in inflammation and antiviral response). It was also noted that social isolation was linked to increased depression, generalized anxiety disorder, suicide risk and psychosis.

The physical and psychological consequences of social isolation  are also discussed at length by López-Bueno et al. (2020) in their review: Potential health-related behaviors for pre-school and school-aged children during COVID-19 lockdown, they highlight: “Social isolation may worsen several health-related behaviors” and that “Insufficient physical activity and too much screen exposure could be among the main consequences of COVID-19 lockdown”.

Research shows that we are seeing today, an increased risk of a build-up of toxic stress and post-traumatic stress disorder in a “post disaster” context,  McDermott et al. (2012, cited in López-Bueno et al., 2020, p.2).  Social isolation has been linked to higher levels of inflammation, while early social deprivation has been linked to  “higher cellular aging,”  Drury et al. (2012, cited in López-Bueno et al., 2020, p.2 ) and profound effects over social cognition, and emotional development.  (Bick et al., 2017; Young et al., 2017, cited in López-Bueno et al., 2020, p.2).  Children and adolescents confinement at home is associated with uncertainty and anxiety, which is attributable to disruption in their education, physical activities and opportunities for socialization in the future. Jiao et al. (2020, cited in Singh et al., 2020 n.pag).

The Organisation for Economic Co-operation and Development (OECD) in their policy response Combatting COVID-19s effect on children (OECD, 2020 p.15) states that: “Previous pandemic episodes show that steps taken to control the outbreak, notably quarantine measures and school closures, especially when prolonged, can reduce children’s mental wellbeing”. It cites (Sprang and Silman, 2013: Hawryluck et al., 2004, Brooks et al., 2020) who say that previous findings from the SARS 2003 outbreak in Canada and China, show evidence of increased anxiety, depression and PTSD including for children in  confinement. (OECD, 2020, p.15).

With children, teenagers and young adults, turning to technology to ease confinement, boredom and isolation,  they can freely access entertainment, news, information, socialising/social media, gaming, face time and video calling and, increasingly now, education and school work during lockdown, all from the comfort of their bedrooms.

The increased social connectedness of screen and social media time, may in some cases, help mitigate some of the negative effects of social distancing, confinement and isolation.  However the following are considerations that need to be taken seriously:

Tech:  A Solution or A Problem?

Researchers have noted that due to prolonged confinement at home, screen time is increasing and becoming heavily relied on, the increased use is predisposing children and young people to use the internet impulsively, addictively and “problematically” (Chen et al, 2020).  These authors warn that: “Special attention should be paid to the greater associations between problematic smartphone application use, problematic social media use, and psychological distress during the Covid-19 outbreak than before.” (Chen et al., 2020, p.1101). Counsellors and doctors, who have advocated cutting down teenagers’ screen time for years, recognise this as a “contradiction of the lockdown,” writes Suvarna in an article in the Deccan Herald April 18, (2020, n.pag).  Children’s screen addiction is now being  compared to adults with drug and alcohol dependency. The addictive appeal of technology, caused by the neurotransmitter dopamine “hit”, can limit capacity to make healthy choices due to cognitive muscle use falling by the wayside, affecting the brain’s frontal lobe, (involved in decoding and comprehending social interactions), hindering social cohesion (Margalit, 2016, n.pag).  The fact that this has been known about for some time is surprising, but by 2017 the World Health Organisation were concerned enough to included Gaming Disorder in the revision of International Classification of Diseases. Yet few Doctors would know how to address this mounting issue!

Dunckley, author, child, adolescent and adult psychiatrist, in an article for Psychology Today:  (Dunckley, 2015, n.pag) discusses how “both hyper arousal and addiction pathways suppress the brain’s frontal lobe, the area where mood regulation actually takes place”.  Her opinion is that children or teens over-using screens can get “revved up“ and “prone to rages” or alternatively “depressed and apathetic”.  She continues that children who overuse technology can seem “wired and tired”, “agitated but exhausted”, with high arousal levels impacting on memory, cognitive functioning, and the ability to relate to and empathise with others. Dunckley claims that is these children, whose use of screen time has been left unregulated, who are likely to “struggle academically and socially.”

Her professional opinion is that children and young teenagers who over-use screen time, gadgets and electronic games, can often be misdiagnosed as having major depression, bipolar disorder or ADHD and offered treatments that won’t often work.  Her suggestion for mood regulation is to implement an “electronic fast” to  enable the nervous system to “reset” as it reverses much of the “physiological dysfunction” produced by daily screen use. She reports that these “fasts” improve sleep, and encourage more “face to face contact” with others. (Dunckley, 2015, n.pag).  At the moment with the pandemic lockdown in process, it would seem prudent  to enable  these children and young people access to schools, colleges and clubs and to reduce their screen time as soon as feasibly possible to enable them to reintegrate and socialise with peers, back in the three dimensional world.

Her article goes on to say that daily screen time affects children and adults, but due to children’s brains being more pliable and  sensitive, it may only take minimal electronic stimulation to knock a developing brain “off track”.  She outlines  six of the “physiological mechanisms that explain electronics’ tendency to produce mood disturbance” below:

Screen time;

  1. Disrupts sleep and desynchronises the body clock. The blue light emitted suppresses melatonin after only a few. minutes of screen stimulation, preventing deep sleep, destabilising the body clock, (Sutherland, 2013) and encouraging hormone imbalance and worryingly: brain inflammation.
  2. Gaming and online activities release dopamine, but when reward pathways are overused, more stimulation is needed to experience pleasure. Focus and motivation can be impaired (two important functions of dopamine) and even small changes in dopamine sensitivity can affect; “how well a child feels and functions”.
  3. Light at night from electronics have been linked to depression and suicide in various studies. and she advises that parents should be aware that removing light at night is protective. (Dunckley, 2014).
  4. Induces stress reactions. Both acute stress (fight or flight) and chronic stress produce changes in brain chemistry and hormones that can increase irritability. Cortisol, the chronic stress hormone, seems to be both a cause and an effect of depression – creating a vicious cycle. Additionally both hyper arousal and addiction pathways suppress the brain’s frontal lobe, the area where mood regulation actually takes place.
  5. Overloads the sensory system, fractures attention and depletes mental reserves, promoting anger and melt-downs which become a coping mechanism.
  6. Reduces physical activity levels and exposure to healthier, “restorative” time outdoors (Kaplan, 1995) in “green spaces.”                                     Wentworth and Clarke (2016).

Rowan (2017) author and speaker, in his post published in the HuffPost Online, writes that the impact of technology on the developing child reveals that “vestibular, proprioceptive, tactile and attachment systems are under stimulated”, and the “visual and auditory sensory systems are in “overload”. The consequences are that there will be issues in neurological development with chemistry and pathways becoming “altered and impaired”.  Younger children are now relying on technology for play activities which “grossly” limit the “challenges” that aid a child develop and reach “optimal sensory and motor development”. He goes on to say that children are “hard-wired” for high speed and struggle to navigate through school with poor self-regulation and attention,  skills essential for learning. (See Fig 1.) The lack of which becomes problematic for behaviour management. (Rowan, 2017, p. 1-6). Figure 1 (Rowan 2017 Negative  Impacts of Technology) HuffPost

Indication of poor and inadequate sleep regimes, a decrease in outdoor activities, and an increase in sedentary behaviours with the over use of electric and technological devices, are adverse changes which have intensified over the periods of lockdown and social isolation.  There has been a tendency for the social areas of the brain to be ignored since the start of Covid. The learning of facial expressions, (communication, empathy and language skills), along with impairment in cognitive and behavioural  skills, are impeded by the mandatory use of masks and social restrictions, and excessive screen use. These will all have a detrimental effect on children, and can “prevent child development from reaching its full potential.” (Arantes de Araújo et al., 2020, p. 6).   

Neurologist Manfred Spitzer, author of Demencia Digital, asked whether children are now suffering impairment from digital dementia.  Spitzer, like Dunckley and Rowan, recognised that prolonged use of digital technology can lead to over-development in the rational, more logical and linear left side of the brain. Consequently he saw this as being to the detriment of the more imaginative, creative intuitive and emotional right side of the brain, causing an imbalance, leading to a number of deficits i.e.:   Difficulty in concentrating • Short Attention Span • Short term memory loss • Emotional disturbances – leading to depression .  (Spitzer, 2012)                                              Wireless Technology

Some of the issues with the over-use of screens have been outlined, but It is also known that wireless technology, also referred to as microwave radiation (available commercially since the late 1990’s) can affect child development through the effects of the signals on the brain.

Wireless (Wi-Fi) is a type of electromagnetic radiation and uses radio frequencies to send signals between devices.

Most adults and children across the world have access to Wi-Fi via routers in homes, at work and at school, additionally via 3g and 4g masts emitting internet and mobile data, and through wireless hotspots in towns, cities and public places. (Philips, 2020. n.pag.).

Looking at what is known about wireless technology and exposure to radio frequency radiation (RFR), microwave radiation (MWR), and electromagnetic frequencies (EMFs), there are in fact databases with thousands of studies showing evidence of the neurological, cellular and biological harm to health to animals, plants and humans. The largest database has approximately 28 thousand studies, with 23-24  thousand of these showing evidence of harm to biological systems and can be found at the Oceania Radiofrequency Scientific Advisory Association Inc. (ORSAA).

Taken from The Environmental Health Trust (EHTrust) website:  Children and Wireless Radiation:

“Wi-Fi and all radio frequency radiation has been on the World Health Organisation’s Class 2B list of Possible Human Carcinogens since May 2011, based on research showing increased brain cancer in heavy users (30 mins a day) with over 10 years of use.  Lead and DDT are also included on this list. Recent research suggests that cancer is only the “tip of the iceberg” and low level wireless microwave radiation is now associated with a host of other concerning biological effects”.  The EHTrust warns that there are no studies showing that microwave radiation exposure in children is safe and no studies show that continuous exposure from mobile phones, phone masts, antennas, radio/TV  towers, radar, cordless phones, Wi-Fi routers, baby monitors are safe.”

They continue;                                                                                                                                                                                                                “Children are not little adults. Children’s skulls are thinner and certain tissues of a child’s head, including the bone marrow and the eye absorb significantly more  energy than those in an adult head. It is scientifically accepted that children are more vulnerable to the biological effects of microwave exposure than adults due to their rapidly developing body systems. Stem cells are more active in children and stem cells are known to be more affected by microwave, [wireless EMF and RF] radiation”.

And;                                                                                                                                                                                                                         “That due to their unique vulnerabilities, children are thought to be at increased risk. Current research provides evidence”….while “experimental studies are showing significant neurological changes from exposure to microwave radiation levels which meet (Fcc) guidelines”.                   

Concluding that;                                                                                                                                      “                                                          Environmental exposure at critical periods can have profound effects of foetal and childhood development.”                                 (Environmental Health Trust, 2015)

Brain Exposure in Young Adults

A Swiss study (Foerster et al., 2018) found that mobile phone radiation (RFR-EMF) may cause memory loss and harm brain performance in teens. The study, conducted over the length of a year with young teens, found that there was a negative and more “pronounced”  effect on the development of figural memory performance (mainly located in the right brain hemisphere, where a mobile phone is typically used) in adolescence, confirming prior results in a study by Roser et al. (2015).

A study by Morgan, Desari and Davis (2014) shows how MWR exposure can result in degeneration of the protective myelin sheath that surrounds brain neurons and additionally how digital dementia has been reported in school age children. Studies have been carried out from 1996 onwards, showing that MWR penetrated proportionally deeper into the brain of children age 5 and 10 – compared to adult’s brains.  Gandhi et al. (1996, cited in Morgan et al., 2014, p.198) .Figure 2 Microwave Absorption in the Brain According to Age. Gandhi et al (1996)

Wiart et al. (2008, cited in Morgan et al., 2014, p.198) described how  a senior researcher for French telecoms and Orange, reported that: “the brain tissue of children absorbed about two times more MWR than adults’ tissue”.  Christ et al. (2010, cited in Morgan et al., 2014, p.198) stated that “children’s hippocampus and hypothalamus absorbs 1.6-3.1 times higher and the cerebellum absorbs 2.5 times higher MWR compared to adults.” These are very worrying facts.

In Professor Tom Butler’s  paper: On the Clear Evidence of the Risks to Children from Smartphone and Wi-Fi Radio Frequency Radiation, published by the University of Cork (2019), he speaks of why children’s health and wellbeing is under threat from Radio Frequency Radiation (RFR) and Microwave Radiation (MWR). He strongly disputes the argument put forward by telecommunications companies who state that there is no danger in using Wi Fi technology or mobile phones.  Insisting that their view is outdated and based on the obsolete belief that non-ionizing radiation such as microwaves are not strong enough to cause biological damage, Professor Butler, a former satellite and microwave communications engineer  and IT professional, is a staunch proponent for RFR and MWR awareness.

Pall (2015) in his review of Microwave Frequency Electromagnetic Fields concludes that “Low intensity microwave EMFs cause widespread changes in the nervous system, including elevated VGCC activity and high sensitivity to non-thermal and lower frequency EMFs causing in turn, diverse neuropsychiatric effects, including depression”. Worrying findings, especially as the home environment today is saturated with electromagnetic pollution.

A report from Sage and Burgio (2018) discusses neurodevelopmental and neurobehavioral changes due to exposure to wireless technologies, they list: impeded  memory, learning cognition, attention and behavioural issues along with autism and attention deficit hyperactivity disorders, as  symptoms of EMF and RFR exposure, and continue…..that the benefits of technology can be realised when substituting Wi-Fi  for hard-wired devices to avoid health risk and to promote academic attainment.

Along with Dr Sarah Starkey’s evidence given to Parliament of the effects of technology on children Starkey (2018), experts: Alasdair Phillips, Olle Johansson, Martin Pall, those from the EMF Scientists organisation and countless researchers, engineers and technical professionals, are raising their voices. Public concern across the UK and beyond is growing and people are calling for access to EMF/RFR and MWR free areas.

In February this year,  the writer corresponded with Debra Fry whose teenage daughter, Jenny  committed suicide in 2015. Her mother cited Jenny’s sensitivity to EMFs (a condition known as electro sensitivity – ES) as being the major reason for her death.  Jenny exhibited agitation, challenging behaviour, and other symptoms of ES: headaches, fuzzy head, problems with recall etc. and it was later found that she had been looking at suicide forums.  Debra, has called for:

“Children struggling with mental health, to be encouraged to only use shielded, hard- wired Ethernet adapted tech which will aid their recovery. A phone should only be used for emergency or absolute essential purposes .”   (See EMF-at-Home-Checklist-7)

 She believes that in the current climate where children have faced unprecedented social isolation and restrictions, it is more important than ever that “pre-cautionary advice should be given to parents and children on blue light, screen time, non-ionising radiation, electrosensitivity (ES) [also known as] electro hypersensitivity (EHS), suicide, mental health and sleep issues, as well as anti-social media’s many risks which includes pro anorexia and suicide groups,…..  additionally,  bullying, addiction, grooming  and porn.”

Debra  has spoken about how if she had been given access to the tools to have helped her, help her daughter, or that the school had been more sympathetic with Jenny’s physical and psychological needs, the outcome may have been different. There are many issues surrounding Jenny’s death.  To add to the complexity,  it was later found that Jenny had also been viewing suicide sites during difficult spells at school.

Sobering thoughts. She is more upbeat of the news arriving of some countries banning the use of Wi-Fi and phones in schools, nursery’s and hospitals etc. (in France, China and Cyprus.) Her parting sentence: “When will this be acknowledged worldwide?”  is a question that remains woefully unanswered for now.

Online Sessions: Telehealth/Tele-therapy

Those concerned with the over use of screens and its effects on children’s brain development, the down turn of mental health and coping abilities, Bahamonde (2019, cited in Lopez-Bueno et al., 2020) and those who are aware of the effects of RFR, MWR and EMFs, are in agreement that screen time should be reduced, and that wireless technology must be hard-wired (i.e. easily and cheaply, with an Ethernet cable.  See HERE).

While we drag our feet over the hard-wiring the of internet, the issue arises how do we help those who over-use technology and/ or whose mental health may be suffering?  Suggestion is that there is a need for telehealth/online therapy compatibility in place of in-person assessment and intervention,  to be utilised to help those who need accessible support  (Singh et al., 2020).  Their solution is to use a digital collaboration of networks from psychiatrists, psychologist, paediatrics and community volunteers to provide online support. This on one hand may have some advantages,  but may hold some contention for Therapists who see it as essential for safe practice to use face to face contact with clients in a private, therapeutic space. They claim that the therapeutic relationship and its effectiveness can be hindered by social disengagement, and that non-verbal clues will not be picked up, and that major privacy, confidentiality and safeguarding issues can occur if conversations are overheard. The current idea of therapeutic “check-ins” with clients should also perhaps be debated in detail as the concern is that a client may begin to internalise and  to “process,” and the therapist may not be able to therapeutically ”hold” or support  the client safely.

More will need to be looked into using telehealth sessions for medical needs and appointments, although this article does not focus on medical or disability-online help and support, any benefits will need to be thoroughly weighed up against risks.   It is the writer’s view that a 2 dimensional screen appointment (medical or therapeutic session) should not replace “real time“- face to face interaction as it can inhibit and restrict the relationship with practitioner and child, and impact on the child’s social skills, ultimately preventing thorough, and successful treatment.

Additionally, Loades et al. (2020, p.1237)  note that where mobile applications for mental health have been acceptable to children and adolescents, there has been a “lack of convincing  evidence of effectiveness on intended  mental health outcomes” and that “computerized therapy” tended to be “less effective than face to face therapies”.

Good Enough Parenting?

Parents more than ever during lockdowns are having to manage their children’s time, their schooling, their behaviours, at times, indoor entertainment, and are struggling to oversee and keep to appropriate  bedtime and screen time boundaries, all while managing their own anxiety, worries and their own mental health.  In terms of help and intervention for children, parent responses to the Covid-19 situation are important, they are their children’s role models.  “Healthy parenting, engaging in interactive play activities, practising mental health hygiene, maintain consistent routine, [promote] healthy behavior”  state Singh et al. (2020, Tbl.1.).

In times of paramount stress and uncertainty, parents providing a secure family environment will be a strong protective factor, Schofield at al. (2013, cited in Singh et al., 2020). Evidence to show that parental practices and coping measures affect children’s post disaster mental health, are mentioned by Cobham et al. (2016) and Jiao et al. (2020).  The survey by NHS Digital (2020, p.17) has pointed out that children who had a parent showing signs of “psychological distress” were more likely to be exhibiting signs of their own psychological issues, in comparison to those whose parents were not showing distress. (See Appendix 2.) This raises questions: are parents equipped to be good role models at the moment? If not, how can they be supported?

Erika Christakis, for Atlantic Magazine, writes that parent and child relationships, hindered by the adults’ own screen distraction, is now common place. She claims that technology expert Linda Stone coined the term “continuous partial attention” over twenty years ago, to describe the modern predicament of being constantly attuned to everything without fully concentrating on anything (Christakis, 2018., n.pag). In an earlier interview with James Fallows, for The Atlantic magazine, Stone claims “What we’re doing now is modelling a primary relationship with screens, and a lack of eye contact with people. It ultimately can feed the development of a kind of sociopathy and psychopathy”. (Stone, 2013, n.pag).   Authors of  Technoference: Parent Distraction With Technology and Associations With Child Behavior Problems McDaniel and Radesky (2017) indicate parent digital technology use (especially involving the mother)  can hinder parent–child relationships and can be linked to challenging behaviours. Ongoing research into  problematic mobile phone use and has shown strong associations with “impaired psychological well-being, impaired parent  and school relationships, and more behavioural problems”. (Roser et al., 2015, The evidence is that parent-child communication, relationships and child well-being, conduct and developmental stages are being hindered by technology, and are becoming increasingly more apparent and should be urgently addressed

A child seeing a parent fascinated and distracted by technology will grow up to believe that they need to try/do the same, instead of mirroring each other in playful games, that child mirrors the parent’s use of phones and technology. Other research has reported of children feeling “unimportant” when parents checked their phones and devices says Annabelle Timsit, for Quartz (2019, n.pag.) and likewise,  McDaniel and Radesky (2017). Chronic distraction and additionally impaired relationships have been associated with being a familiar sign of technology and phone addiction (for both parents and children) and Christakis recommendation is for parents to put down their phones when spending time with their children.

For parents to switch off their own devices and engage, and play with their children is incredibly important as this may well be the key to helping their children’s mental health. Parents and carer’s are well equipped to be positive regulators of their child’s mental health and well-being. Play’s importance to children has been recognised in “What is play and why is it important” (Play Wales, 2014, n.p.), while a team from the Play in Education, Development and Learning (PEDAL) are looking at what effects a global pandemic has on children’s play and what is the role of play in protecting children’s well-being amidst restrictive circumstances.

All play is beneficial, however play used therapeutically (for example Play Therapy) can be very beneficial for children suffering from poor mental health, life changes, loss, behavioural and emotional issues, anxiety, stress and depression, anger, hopelessness  and attachment issues. Active play helps to overcome sedentary pastimes, and when engaged in “free play” this enables the child to play-out scenarios and to try out new experiences before attempting them in the real world, experimenting and at times playing out their troubles symbolically and literally, Webb (2007), learning all the while.

How can Parents and Practitioners Tap into the Benefits of Play?

Parent Child Attachment Play (PCAP) a course developed by Debi Maskell-Graham, now delivered by Clear-Sky, is grounded in Attachment research. (Clear-Sky, 2020, n.d.,  It offers child and family practitioners working with parents/carers and children/teens, an early intervention programme. The course enables the practitioner to give parents and carers (delivered 1:1 or in groups) the tools to build and develop more positive relationships with their children through regular, short  play sessions. Methods such as “reflective functioning”, the ability to understand feelings, desires, beliefs, and intentions in the self and others, originate from positive,  parent-child early interactions, as seen in  Bowlby’s work, (Bowlby, 1969) and are taught, with age-appropriate activities and adaptations for teens. The PCAP course spends an amount of time focusing on, and learning to understand the child or young person’s internal world and mind-set through play and role play scenarios. Often there are significant improvements in the parent-child relationship by helping to nurture and improve connection and healthy attachment. The course training ensures the parent is supported by the practitioner while they (the parent) learn to support  their child/teen. Although the course was designed to improve the parent-child relationship, there would likely be other positive changes which would warrant further investigation. The writer believes it would be wise to suggest more research is done on this type of intervention to gauge changes and/or improvements  in screen addiction and children/young person’s mental health.

The Importance of a Connection with Nature

While screen time is so prevalent, and at an all-time high,  tactile and sensory experiences are limited. Play and leisure activities, if any, tend to be inside the home, Araujo et al. (2020).  The three dimensional world is being replaced with a 2d screen and the risk is that fundamental childhood experiences are missed out on. Figure 3 (Rowan, 2017)  Positive Impact Multi-sensory, Natural Environment. Why jump in a puddle, and get wet, or make dens and shelters,  when you can simulate it all on screen?! We are facing an “Extinction of Experience,” say Soga and Gaston (2016).  Access to the outdoors and to nature has been severely restricted during the initial weeks of the lockdowns, however it has been noted that children’s access to nature has in fact been declining over the last few decades.                                                                                    

Time outdoors immersed in nature lays critical foundations, (see fig 3.) essential for a healthy developing brain. Physical activity strengthens the mind and body connection, there are even significant impacts on learning while also supporting social and emotional intelligence “EQ.” (Mirrahimi et al., 2011).                                            

Due to children’s access to nature today being so woefully small, we need to seriously ask ourselves what repercussions this might have on physical and mental health and wellbeing in the rising digital age. The rising acknowledgement is that a sensitivity and connection to the unhurried natural cycles of nature is being lost, and is being replaced by addictive electronic stimulation and virtual experience. Figure 4 Reduced Roaming Radius of 8yr olds   (Robb et al. 2015 p. 13) Authors and journalists are keen to inform us of children’s lack of time outdoors, Carrington (2016) reported back then that children are nature deficit and spend less time outdoors than prisoners!)  Further claims that “unsupervised” time outdoors has declined by almost 90% is illustrated in figure 4,  Gaster, (1991, cited by Robb et al., 2015 pp. 13-15.)  Today, during the lockdown, the Government requirement is that children and families in the UK should only venture outside for exercise, or when absolutely necessary, in sharp juxtaposition to two major report findings:

Major Reports

The Monitor of Engagement with the Natural Environment (MENE ) provides data on how people experience the natural environment in England. The findings in their latest report: contact with nature is reported to be good for health and well-being, concludes that connectedness with nature has a positive relationship with “eudaimonic” well-being and positive environmental behaviours. (MENE, 2020, p.p.5, 18.)  Additionally the Government have also acknowledged the importance of “Green and Blue Spaces” in the report: Green Space and Health, (Wentworth and Clarke, 2016). The following are key findings:

  • Physical and mental illnesses associated with sedentary urban lifestyles are an increasing economic and social cost.
  • Areas with more accessible green space are associated with better mental and physical health.
  • The risk of mortality caused by cardiovascular disease is lower in residential areas that have higher levels of ‘greenness’.
  • There is evidence that exposure to nature could be used as part of the treatment for some conditions. Wentworth and Clarke (2016)

However, children’s access to parks, and green spaces (if open, and if permissible during the lockdown restrictions),  can be dependent on parents who may have understandable fears about Covid transmission and allowing children free access to the outdoors with transmission  risks.  With virus transmissions known to be a lesser risk outdoors, and with the health benefits of being outside being so prolific, it would seem especially important  for all children (especially those from ethnic and black communities who spend less time in nature,  those with screen addictions and those with poor mental health) to spend more time outside once the lockdown period has ended.  Re-introducing risk-adverse children who lack resilience and who disengage from actual experience, into sensory immersive outdoor experiences has, in fact been happening for some time in areas around the UK. Evidence is showing successful results which will looked at.

Anxiety and the Brain

During times of stress and trauma, when overwhelmed or in emotional shut-down, there is a loss of access to the medial prefrontal cortex (MPFC) and the frontal lobes, (the thinking logical parts of the brain accessed during learning). The more stressed out a child is, the further back in the brain they go, enabling the limbic system, involved in behaviour and emotional responses to be in charge. The amygdala is activated and the threat detection systems come in causing the fight, flight (increased arousal, reactions and chemical reactions, cortisol, fear, anxiety, physical and emotional sensations) or alternatively: reaction, freeze/collapse/disassociation/shutdown.

Over time the exposure of cortisol, its impact on the immune system, and the hippocampus (responsible for learning) can lead to “chronic cell damage” and ill health throughout adulthood. (Cozolino, 2006, p.86, Gerhardt, 2015, p.p. 89-93) and (Hughes et al., 2017). Withdrawal, disassociation and depersonalisation are further reactions that can occur if the threat is prolonged and the body’s reactors remain permanently on. (Van der Kolk, 2014.)

How the Outdoors can Bring Calm and Reduction of  Stress 

Reducing children’s time indoors and enabling a frequent and ongoing digital detox, while tapping into the benefits of the outdoors, would be highly beneficial for children’s mental health.

There are two ways of changing the body’s threat detection system to affect the capacity for stress regulations; either from the top down, via messages from the (MPFC), strengthening the frontal lobes, monitoring the body’s sensations with the use of mindfulness, meditation, visualisation and relaxing in nature/ imagining being in nature, or from the bottom up, via the autonomic nervous system (ANS) and the reptilian, survival brain, through breathing, movement, rhythm and touch, using nature’s multi-sensory, freely available creative tool kit. (Van der Kolk, 2014, p.63).     Figure 5. The two ways of Changing the Threat Detection System (Van der Kolk, 2014, p.63)                                                                   

Breathing and relaxation methods, both top down, and bottom up exercises can be applied outdoors or inside, but are more beneficial carried out, in “green” or “blue spaces”: Slow, deep breathing into the diaphragm and stomach, encouraged by being in the fresh air stimulates the body’s parasympathetic reaction, which calms us by preventing the body’s stress response (cortisol and adrenaline) and releases opioids and dopamine in the brain. (Macairt, 2018).

Taking  breaths in outdoor, green spaces draws in cleaner oxygen and with it immune boosting phytoncide from trees and all manner of fragrant mood-enhancing aromas from flora and fauna.  By adding in the benefits of Vitamin D, and serotonin from sunlight, Scaccia (2019), and additionally  the effects of negative ions (found wherever water collides or plants grow), we can see that natural immune boosters and mood enhancers are abundant in nature.  In fact, the review and meta-analysis findings by Perez et al., (2013) show that there is a “notable” [positive] “effect” from negative ions, on people with depression.

Nature by fulfilling both top down, and bottom up methods of finding calm, provides far more rich and varied sensory experiences than can be found indoors. Sensory inputs have had an influence on us from birth and have built up our perceptions of the world, our relationship to it, and to others. Becoming more mindful of the effects on the body outdoors, we naturally become more mindful of our environment, this awareness brings an understanding that, in the here and now, we are safe.

Outdoor  Interventions –  1. LandPlay

LandPlay, was developed by Play Therapist, Ex teacher, and Forest School supporter, Kate Macairt, Co-founder of the Collaboration of Outdoor Play Therapists (COOPT).  Put simply, LandPlay is child-led Play Therapy taken outside,  with its roots in Forest School principles. it can be one to one, or a group intervention.  By being outside with others, using play and natures sensory tools, it develops  and enhances children’s ability to relate to others, to feel empathy, to connect, care, cooperate with others and additionally problem solve, explain, reflect, learn, vocalise and reason. (Bento and Dias, 2017, and Mirrahimi, 2011).  Trained Practioners can facilitate outdoor nurture groups using LandPlay principles which use Attachment techniques or “reflective functioning” methods similar to those used in PCAP training. These methods would ideally suit those who are resistant to returning to school, or who find social situations difficult after social isolation. In addition, this natural, creative, low cost intervention, uses practice based evidence using measured outcomes that show successful results. Suiting a variety of children, especially those with mental health needs and those dysregulated through screen and tech addiction, LandPlay sits alongside indoor Play Therapy, seamlessly

Applying Grounding Techniques Outdoors

LandPlay, uses the grounding aspects of Jennings’s Embodiment Stage, working with water, clay, sand, soil, natural materials and textures. It incorporates: messy play, body awareness, rhythmical movements, stretching, pulling, dancing, singing, walking and barefoot connects directly with the soil. (Macairt, 2018, n.pag).  Sitting or lying on the earth or grass ensures self-regulation and has the additional benefits of direct contact with the earth’s health-enhancing, natural frequencies.  It also enables children to take a break from using digital devices.  Neurologist Spitzer, (2012) regarded it as essential that children take an active role in rebalancing their brains, his findings support Macairt,  and those attempting to re-engage screen saturated children, with sensory, rhythmical and creative play, in all its forms and modalities.

Using visualisation and mindfulness brings an awareness of the body, the sounds, smells, sensations, textures and temperatures enabling the child to become more present. This can strengthen and develop the safety circuitry of the brain: the insula which in turn increases capacity for empathy and compassion. (Siegel, 2007).   Bringing the child into the present moment, and back in control can be a much needed comfort when under stress. Once grounding has occurred, and the child more regulated, the therapeutic space becomes the multi-cultural playground and the Projection and Role stages (Jennings, n.d. n.pag) can be explored, and nature’s ready-made materials utilised.

Games and activities such as these  illustrated above can be applied with a group of children in LandPlay, although group dynamics and ensuring children have similar needs must be some of the main  considerations.

Activities can be social distanced if necessary and the LandPlay model can be developed and adapted for groups of parents and children, aiding and enhancing parent-child attachment relationships and family resiliency. This would introduce parents, carers and key support workers to simple play techniques and mindful games, relying on creative communication (non-verbal and reflective language) and skill sharing.  It is clear that well-being and learning opportunities are numerous in these sensory rich environments.

Marina Robb, co-author of Learning with Nature, (Robb et al., 2015) recently spoke of how children and adults alike do not value play as the key driver to learning, and so often will not give [play] the time it needs. She is adamant that enhancing parenting knowledge and skills in play can make a difference and points to the “Play it Out” document,  a comprehensive guide championing the importance of children taking part in daily, active outdoor play experiences for their “health, wellbeing, and physical and cognitive development.” (Scottish Government, 2018, p.1 ).

She will be working alongside Macairt and other outdoor practitioners to deliver “Nature Gateway Training “for practitioners to take their practice (education or health) into nature on a wider scale.

Outdoor Learning – Forest School

Outdoor learning via Forest Schools has become steadily popular throughout the UK over the last 30 years with many schools sending staff for Forest School training.  Forest School is an “outdoor education delivery model based on Scandinavian culture and philosophies in which students visit natural spaces to learn personal, social and technical skills”. For children primary age and upwards, the Forest School programme support child-led play, exploration and supported risk taking which children and teens are lacking in today. (FSA, 2020, The practical skills that children learn (knife and equipment handling, carving, whittling etc., fire and safety, cooking, foraging, creative work, shelter and den building – team building …. all require an amount of careful management, focus and risk taking, and enable the child to feel a sense of achievement, developing confidence, self-esteem and resilience through hands-on experiences.  Newer group sessions for mothers, toddlers and babies with an emphasis on outdoor sensory play are beginning to emerge, introducing children to “healthier” experiences at earlier ages.

Outdoor Intervention and Learning – BootUp

Based on Forest School principles, the small team are skilled in dealing with children and young people with social and emotional and relational needs.  One to one sessions for individuals and small groups are created for young people referred from outside agencies: Children & Families Services, Social Services, youth workers and youth offending team and other educational teams. The organisation works with Personal Education Plans or Pathway Plans that have been created for the young person. The centre, tucked away off a main road is a hive of activity and learning. Here primary and secondary age children work in short sessions, with projects and challenges making use of the rich and varied outdoor space. The centre hosts volunteers and paid staff.  Those who work at BootUp bring with them diverse skills, (from Art and Design to Engineering, the latest staff addition being a Chef) but importantly these are people who the children and young people feel at ease with, resulting in a very unique and naturally supportive base for those who attend who have adverse backgrounds.

New Findings: Outdoor Sports and  Increased Perception of Resilience

A new study published by Cornwall Children’s Research Service in association with Exeter University, reveals sailing builds resilience in children. Findings by research commissioned by the Roseland Youth Sailing Trust (RYST) have shown that children learn to cope with a host of challenges, stresses and worries …by learning to sail.  The benefit in using physical activity while learning and implementing new skills is very evident.  The research compares children’s estimation of their ability to cope in a variety of stressful situations before and after a sailing course, with findings demonstrating a significant enhancement in self–confidence.  The study, the first to look at perceived future coping ability in the participant, concludes that there is strong evidence that participants believe that that they can cope with life’s ups and downs, future setbacks and uncertainties etc.. The perception of coping, being an essential foundation to resilience.  The organisation has said that extensive research will be needed to substantiate the results but that the findings were especially relevant during the pandemic.  (Barnard, 2020).  The organisation is aware that sailing is not the most accessible of activities for all but they hope to access more funding to enable more children and young people to take part. The writer is currently assisting the trust, looking into the positive, social and wellbeing aspects of spending time on water.


Key implications from studies have been clear that the negative associations between lock down and mental health should be addressed and incorporated in the decision making process of policy makers. (Bignardi et al., 2020).

To understand the full implications for the present state of children’s mental health during the Covid-19 pandemic, we need to understand that children and young people’s mental health has been declining throughout the past few decades, with little being done to address this. Inequality in all its guises still exist, the problems have not gone away, but have likely intensified under  the restrictions and lockdowns. The consensus is that children’s mental health is suffering, depression is increasing. The interventions that should be deemed as essential during these times, cannot function in the way they were intended to during lockdown. Many low Covid risk outdoor interventions have had to halt and to remain closed even when these are clearly a sorely needed part of the solution.

We need to be working with children, teens and their families in order to fully support  those who work with or care for children whose mental health is failing. Specific recommendations would be for teachers, early years and health practitioners, to receive training in the benefits of the outdoors, for mental health to support other strands of their work – and for parents/carers to access training in mental health awareness which can happen outdoors in local green spaces.

To transfer health and mental health services to (telehealth/online appointments) cannot be the solution, and will only create further issues of disconnection and inflame screen addiction, confidentiality and safeguarding.  All schools, surgeries and services should have  access to fully trained professionals with therapeutic skills. From this point forward,  policy makers should look into, and engage with, the many good practices that exist, in order to gage whether these are suitable for use on a wider scale. The Government commissioned its own report into “Green Spaces” (Wentworth and Clarke, 2016.)  and there is a strong need for the findings to be acknowledged and applied.  Right action needs to be taken so that the effects of the pandemic on children and young people are not continuing to unravel in the decades to come.