Abstract Not only is the coronavirus crisis a natural laboratory of stress offering social psychiatrists a unique historical opportunity to observe its impact on entire populations around the world, but the responses to the crisis by international health authorities, such as the WHO, along with national and local educational institutions and health care and social services, are creating an unprecedented and unpredictable environment for children and youth. This hostile new environment for growth and development is marked by the sudden and unpredictable imposition of confinement and social isolation, cutting off or limiting opportunities for the development of cognitive abilities, peer relationships, and social skills, while exposing vulnerable children and youth to depriving, negligent, or even abusive home environments. For this reason, this crisis has been renamed a syndemic, encompassing two different categories of disease—an infectious disease (SARS-CoV-2) and an array of non-communicable diseases (NCDs). Together, these conditions cluster within specific populations following deeply-embedded patterns of inequality and vulnerability (Horton, 2020). And children are the most vulnerable population around the world. The impact on children is part of a cascade of consequences affecting societies at large, smaller communities, and the multigenerational family, all of which impinge on children and youth as the lowest common denominator (Di Nicola & Daly, 2020). This exceptional set of circumstances—in response not only to the biomedical and populational health aspects but also in constructing policies for entire societies—is creating an “experimental childhood” for billions of children and youth around the world. With its commitment to the social determinants of health and mental health, notably in light of the monumental Adverse Childhood Events (ACE) studies (Felitti & Anda, 2010), social psychiatry and global mental health in partner with child and family psychiatry and allied professions must now consider their roles for the future of these “experimental children” around the world. The parameters for observing the conditions of this coronavirus-induced syndemic in the family and in society, along with recommendations for social psychiatric interventions, and prospective paediatric, psychological, and social studies will be outlined. Keywords: children & families, coronavirus syndemic, ACE Study, confinement, social isolation

1. THE EXPERIMENTAL CHILD:
MENTAL & SOCIAL CONSEQUENCES
FOR CHILDREN AND FAMILIES OF
THE CORONAVIRUS SYNDEMIC
Vincenzo Di Nicola
MPhil, MD, PhD, FRCPC, DFAPA, FCPA, FCAHS

2. Prof. Vincenzo Di Nicola, MPhil, MD, PhD
Licentia Docendi atque Magisterium ad Honorem
Honorary Chair and Professor of Social Psychiatry
Scuola Medica di Milano
Founder & President
Canadian Association of Social Psychiatry
President-Elect
World Association of Social Psychiatry

3. Conflict of Interests
The presenter declares no financial conflicts
of interest.

4. Learning Objectives
To offer a comprehensive model for the coronavirus crisis as a
syndemic, integrating both the infectious disease (SARS-CoV-2)
and the related non-communicable diseases (NCDs).
To describe the cascade of consequences impacting on children
and families during a major crisis such as the coronavirus
syndemic, using the Adverse Childhood Events (ACE) model.
To outline psychosocial and community interventions and the
need for prospective interdisciplinary studies.

5. Pandemic or Syndemic?
This crisis has been renamed a syndemic, encompassing
two different categories of disease—an infectious
disease (SARS-CoV-2) and an array of non-
communicable diseases (NCDs) *
* Note: SARS-CoV-2 is the virus, COVID-19 is the disease
Together, these conditions cluster within specific
populations following deeply-embedded patterns of
inequality and vulnerability (Horton, 2020)
And children are the most vulnerable population
around the world
Ref: Horton R. Offline: COVID-19 is not a pandemic.
Lancet 2020; 396: 874.

6. Defining a Syndemic
A syndemic or synergistic epidemic is the aggregation of two or
more concurrent or sequential epidemics or disease clusters in a
population with biological interactions, which exacerbate the
prognosis and burden of disease
The term was developed by medical anthropologist Merrill Singer
in the mid-1990s
Syndemics develop under health disparity, caused by poverty,
stress, or structural violence and are studied by epidemiologists
and others concerned with public health, community health, and
the social determinants of health
Ref: Syndemic (n.d.). In Wikipedia. Retrieved March 27, 2021, from
https://en.wikipedia.org/wiki/Syndemic

7. Cascade of Consequences
The impact on children is part of a cascade of
consequences affecting societies at large, smaller
communities, and the multigenerational family,
all of which impinge on children and youth as the
lowest common denominator (Di Nicola & Daly,
2020)
Ref: Di Nicola V, Daly N. Growing up in a pandemic: Biomedical and psychosocial
impacts of the COVID-19 crisis on children and families. World Social Psychiatry, 2020,
2(2): 148-151.

8. “The Experimental Child”
This exceptional set of circumstances—
in response not only to the biomedical and
populational health aspects but also in
constructing policies for entire societies—
is creating an “experimental childhood” for
billions of children and youth
around the world

9. Adverse Childhood Events (ACE)
With its commitment to the Social Determinants of
Health and Mental Health (CSDH, 2008), especially the
Adverse Childhood Events (ACE) studies (Felitti & Anda,
2010), Social Psychiatry and Global Mental Health
(GMH) in partner with child and family psychiatry and
allied professions must consider our roles for the future
of these “experimental children” around the world
Ref: CSDH. Closing the Gap in a Generation: Health Equity Through Action On the Social
Determinants of Health. Final Report of the Commission on Social Determinants of Health.
Geneva, Switzerland: World Health Organization; 2008.
Felitti VJ, Anda RF. The relationship of adverse childhood experiences to adult medical disease,
psychiatric disorders and sexual behavior: implications for health care. In: Lanius RA, Vermetten
E, Pain C, eds., The Impact of Early Trauma on Health and Disease: The Hidden Epidemic.
Cambridge, UK: Cambridge University Press; 2010:77-87.

10. Impacts
Social distancing
Class and cultural differences
Confinement
Impact on vulnerable groups, relationships
Adverse Child Events (ACE)
Associated with poorer health outcomes

11. Army trucks in Bergamo, Italy (Reuters – March 19, 2020)

12. The Coronavirus Pandemic as
a Modern Morality Play
One of the cruelest aspects of our current
predicament with the Covid-19 pandemic is that
family members cannot accompany their loved ones
during their dying days in hospital and are denied
even the capacity to mourn together or to bury their
dead.
This image from March of this year of army trucks
hauling bodies out of Bergamo in Italy because the
cemeteries and crematoria are overwhelmed beyond
capacity is a haunting one.

13. Antigone and Polynices (Nikiforos Lytras, 1865)

14. The Coronavirus Pandemic as
a Modern Morality Play
This brings to mind Sophocles’ tragedy of
Antigone who was forbidden to publicly
mourn or properly bury her dead brother
Polynices because of his treason against the
ruler Creon.

15. Incident at Antares
Érico Veríssimo
(Novel, 1971)
Carlos Manga
(Film, 1994)

16. The Coronavirus Pandemic as
a Modern Morality Play
In a modern novel set in Brazil, Érico Veríssimo
described the “Incident at Antares” (1971,
filmed in 1994), the fictional town of Antares
where the graveyard workers go on strike.
As the bodies pile up, unburied, seven corpses
from a wide swathe of society, rise up to claim
their right to be buried.
When they are unheeded, they disclose the
sordid secrets of those in authority and the
other townspeople.

17. The Coronavirus Pandemic as
a Modern Morality Play
In our contemporary tragedy, we are the
unwitting actors of this modern morality play
where not even death is a liberation and
public mourning and a decent burial are
forbidden.

18. The Coronavirus Pandemic as
a Modern Morality Play
At a loss for explanations and solutions, we
turn to those whose imaginations have
prepared us beforehand – artists and
humanists.

19. The Coronavirus Pandemic as
a Modern Morality Play
Italian philosopher Giorgio Agamben provoked a
polemic this year when he asked about the social
impact of lockdowns, with governments reaching for
power during a state of exception, and raised even
more disturbing questions about the value of the
survival of “bare life” when all human interactions and
dignity are denied by what he characterized as
“techno-medical despotism” (Caldwell, 2020).
Ref: Caldwell C. Meet the Philosopher Who Is Trying to Explain the
Pandemic.https://www.nytimes.com/2020/08/21/opinion/sunday/giorgio-
agamben-philosophy-coronavirus.html?smid=tw-share

20. Impacts
Historians have noted that pandemics are
more disruptive and transformative of
societies than wars or revolutions.
With this pandemic still in full force, we are
living the first impacts of that grim historical
precedent.

21. Impacts
Children should fare well, in fact, better than many
people expect, Robin Dunbar of Oxford says.
“Children are designed to be very resilient and
bounce back … If they didn’t, they’d never survive. I
am not convinced by any of the hysterical claims that
children’s lives are being ruined by lockdown.”
“Irksome it certainly is, and it may exacerbate the
condition of those already suffering from depression,
or the like. But most will have forgotten all about it in
a year or so.”
Ref: Cimons, M. Are we heading for a post-pandemic “Roaring Twenties,”
with parties and excess? The Washington Post, March 27, 2021.

22. Impacts
“Education-wise? In the long run, probably not a big
deal either, unless education has sunk to the low of
only being able to remember a handful of facts,” he
adds.
“Something everyone seems to forget is that
education is supposed to be about learning how to
learn for oneself.”
Ref: Cimons, M. Are we heading for a post-pandemic “Roaring Twenties,”
with parties and excess? The Washington Post, March 27, 2021.

23. Royal College of Psychiatrists Analysis
Royal College of Psychiatrists (2021) analysis :
Children & young people are bearing the brunt of the mental
health crisis caused by the pandemic
A year on from the first lockdown and after warnings from the
mental health sector about the impact of the pandemic on the
country’s mental health, NHS Digital data shows that while the
crisis is affecting people of all ages, it is under-18s who are
suffering most
Ref: Royal College of Psychiatrists (UK). Country in the grip of a mental health crisis with children worst
affected, new analysis finds. Available online: https://www.rcpsych.ac.uk/news-and-features/latest-
news/detail/2021/04/08/country-in-the-grip-of-a-mental-health-crisis-with-children-worst-affected-new-
analysis-finds

24. 24
trauma
Image courtesy of V Di Nicola

25. Royal College of Psychiatrists
Royal College of Psychiatrists’ findings:
80,226 more children and young people were referred to CYP
mental health services April-December 2020 - up by 28% on
2019 to 372,438
600,628 more treatment sessions were given to children and
young people - up by 20% on 2019 to 3.58 million
18,269 children and young people needed urgent or
emergency crisis care - including assessments to see if
someone needs to be sectioned because they or others are at
harm - an increase of 18% on 2019, to 18,269.

26. Royal College of Psychiatrists
Dr Bernadka Dubicka, chair of the child and adolescent faculty
at the Royal College of Psychiatrists, said:
“Our children and young people are bearing the brunt of the
mental health crisis caused by the pandemic and are at risk of
lifelong mental illness.”
“As a frontline psychiatrist I’ve seen the devastating effect that
school closures, disrupted friendships and the uncertainty
caused by the pandemic have had on the mental health of our
children and young people.
“Services were already struggling to cope with the number of
children needing help before the pandemic hit, and they risk
being overrun unless government ensures the promised
money reaches the frontline quickly.”

27. Royal College of Psychiatrists
Dr Adrian James, president of the Royal College of
Psychiatrists, said:
“The extent of the mental health crisis is terrifying, but it will
likely get a lot worse before it gets better.
“Services are at a very real risk of being overrun by the sheer
volume of people needing help with their mental illness.

28. Impacts
Children are felt to be vulnerable biologically and
psychosocially to the impacts of the pandemic, with particular
concern that measures may affect the development of
prosocial skills longitudinally (Di Nicola & Daly, 2020)
In addition to a perceived deterioration in mental health,
there are substantial mental health service disruptions and
unmet support needs (Hawke, et al., 2020)
Refs: Di Nicola V, Daly N. Growing up in a pandemic: Biomedical and psychosocial impacts of the COVID-19
crisis on children and families. World Social Psychiatry, 2020, 2(2): 148-151.
Hawke LD, Barbic SP, Voineskos A, et al. Impacts of COVID-19 on youth mental health, substance use, and
well-being: a rapid survey of clinical and community samples. Can J Psychiatry 2020;65:701–9.
Hanafi S, Dufour M, Doré-Gauthier V, et al. Position Statement: Covid-19 and Canadian Psychiatry. Can
Psychiatric Assoc March 11, 2021.

29. Social Psychiatric Interventions
Parameters for observing the conditions of this
coronavirus-induced syndemic in the family and in
society
Recommendations for social psychiatric interventions:
Based on SDH (Di Nicola, 2012)
Integrative Community Therapy (Barreto, et al., 2020)
Prospective paediatric, psychological, and social studies
need to be addressed
Refs: Di Nicola V. Family, psychosocial, and cultural determinants of health. In: E Sorel (Ed), 21st
Century Global Mental Health. Burlington, MA: Jones & Bartlett Learning; 2012, pp. 119-150.
Barreto AP, Filha MO, Silva MZ, Di Nicola V. Integrative Community Therapy in the Time of the
New Coronavirus Pandemic in Brazil and Latin America. Special Theme Issue: COVID-19
Pandemic and Social Psychiatry. World Social Psychiatry, 2020, 2(2): 103-5.

30. References
Barreto AP, Filha MO, Silva MZ, Di Nicola V. Integrative Community Therapy in
the Time of the New Coronavirus Pandemic in Brazil and Latin America.
Special Theme Issue: COVID-19 Pandemic and Social Psychiatry. World Social
Psychiatry, 2020, 2(2): 103-5.
Caldwell C. Meet the Philosopher Who Is Trying to Explain the
Pandemic.https://www.nytimes.com/2020/08/21/opinion/sunday/giorgio-
agamben-philosophy-coronavirus.html?smid=tw-share
Cimons, M. Are we heading for a post-pandemic “Roaring Twenties,” with
parties and excess? The Washington Post, March 27, 2021.
CSDH. Closing the Gap in a Generation: Health Equity Through Action On the
Social Determinants of Health. Final Report of the Commission on Social
Determinants of Health. Geneva, Switzerland: World Health Organization;
2008.

31. References
Di Nicola V. Family, psychosocial, and cultural determinants of
health. In: E Sorel (Ed), 21st Century Global Mental Health.
Burlington, MA: Jones & Bartlett Learning; 2012, pp. 119-150.
Di Nicola, V. From Plato’s cave to the Covid-19 pandemic:
Confinement, social distancing, and biopolitics. Global Mental
Health & Psychiatry Review, Spring 2021, 2(2): in press.
Di Nicola V, Daly N. Growing up in a pandemic: Biomedical and
psychosocial impacts of the COVID-19 crisis on children and
families. Special Theme Issue: COVID-19 Pandemic and Social
Psychiatry. World Social Psychiatry, 2020, 2(2): 148-151.

32. References
Felitti VJ, Anda RF. The relationship of adverse childhood
experiences to adult medical disease, psychiatric disorders and
sexual behavior: implications for health care. In: Lanius RA,
Vermetten E, Pain C, eds. The Impact of Early Trauma on Health
and Disease: The Hidden Epidemic. Cambridge, UK: Cambridge
University Press; 2010:77-87.
Hawke LD, Barbic SP, Voineskos A, et al. Impacts of COVID-19 on
youth mental health, substance use, and well-being: a rapid survey
of clinical and community samples. Can J Psychiatry 2020;65:701–
9.
Hanafi S, Dufour M, Doré-Gauthier V, et al. Position Statement:
Covid-19 and Canadian Psychiatry. Can Psychiatric Assoc, March
11, 2021.

33. References
Horton R. Offline: COVID-19 is not a pandemic. Lancet 2020; 396:
874.
Royal College of Psychiatrists (UK). Country in the grip of a mental
health crisis with children worst affected, new analysis finds.
Available online: https://www.rcpsych.ac.uk/news-and-
features/latest-news/detail/2021/04/08/country-in-the-grip-of-a-
mental-health-crisis-with-children-worst-affected-new-analysis-
finds
Syndemic (n.d.). In Wikipedia. Retrieved March 27, 2021, from
https://en.wikipedia.org/wiki/Syndemic

34. Resources
American Academy for Child & Adolescent Psychiatry (AACAP)
– www.aacap.org
Canadian Psychiatric Association – https://www.cpa-
apc.org/covid-19/
Resources for Helping Kids and Parents Cope Amidst COVID-19
https://www.aacap.org/AACAP/Families_and_Youth/Resource
_Libraries/covid-
19/resources_helping_kids_parents_cope.aspx?utm_source=I
nformz&utm_medium=email&utm_campaign=Annual%20Me
eting

35. Questions
&
Comments