My presentation is part of the WASP-WPA Interorganizational Symposium for the WPA 21st Virtual World Congress of Psychiatry, Catragena, Colombia, October 16-21, 2021 Session Description At this time, the death toll from COVID-19 is approaching 3 million people worldwide. The full toll of COVID-19 far exceeds even this sobering number. Beyond the direct biological impacts of an infectious disease, the global impact of COVID-19 is revealing and magnifying pre-existing fractures in our social structures. COVID-19 has led to significant differential impacts among groups across age, health and socio-cultural variables, whether through increased direct illness morbidity and mortality in the elderly or those with mental illness, or through indirect impacts associated with widespread societal and health system changes, including youth impacted by confinement and social isolation impinging on development of prosocial skills, increased caregiver and family stresses ranging from financial distress to violence, and further disenfranchisement of already marginalized and vulnerable groups. At the same time, heightened public awareness and outcry about such disparities has the potential to fuel new alliances, challenging and perhaps dismantling some historical stereotypes of race, ethnicity, gender, sexual orientation, age, disability and illness. Rather than a pandemic, the global impacts reveal a syndemic – multiple pandemics along different lines, both the viral/biological pandemic, plus a social pandemic superimposed on pre-existing fault lines of inequity, poverty, mental illness, racism, sexism, ableism, ageism and other forms of stigma and discrimination. This session will include discussion of the varied impacts of COVID-19 and exploration of their root causes from a social psychiatry perspective.

1. CHILD AND FAMILY IMPACTS OF
THE CORONAVIRUS SYNDEMIC
DEVELOPMENTAL, FAMILY,
AND SOCIETAL HAZARDS
Prof. Vincenzo Di Nicola
21st World Congress of Psychiatry
World Psychiatric Association (WPA)
Cartagena, Colombia
October 18-21, 2021

2. COVID-19:
Far More Than an Infectious Disease
– A Social Psychiatry Perspective
AASP/CASP/WASP Symposium
KS Gaind (Chair), V Di Nicola, RR Gogineni

3. Child and Family Impacts
of the Coronavirus Syndemic:
Developmental, Family & Societal Hazards
Vincenzo Di Nicola
Founder & President, CASP
President-Elect, WASP

4. Vincenzo Di Nicola
MPhil, MD, PhD, FRCPC, DFAPA, FCPA, FCAHS
Professor of Psychiatry
University of Montreal & The George Washington University
Global Mental Health Teaching Faculty
Harvard Medical School
Honorary Chair & Professor of Social Psychiatry
Ambrosiana University

5. Declaration of Interests
Professor of Psychiatry
• University of Montreal (academic salary)
• The George Washington University
• Harvard Program in Refugee Trauma, HMS (stipend)
Offices
• AACAP, Diversity & Culture Committee
• APA, GMH Caucus, Assembly Rep, Assembly Awards Cmte.
• CASP, President; WASP, President-Elect (stipend)
• SSPC, Board Member
Publishing: Aeon/Psyche, Atropos, Durango,
Fordham, Oxford, Springer, WW Norton & Co.

6. 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 identify the pre-existing conditions of inequity, poverty,
mental illness, racism, ableism, ageism that create stigma and
discrimination and amplify the impacts of the syndemic.
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.

7. Our Premise
COVID-19 has led to significant differential impacts
among groups across age, health and socio-cultural
variables, whether through increased direct illness
morbidity and mortality in the elderly or those with
mental illness, or through indirect impacts associated
with widespread societal and health system changes,
including youth impacted by confinement and social
isolation impinging on development of prosocial skills,
increased caregiver and family stresses ranging from
financial distress to violence, and further
disenfranchisement of already marginalized and
vulnerable groups.

8. 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.

9. 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

10. Plato’s Cave
An Illustration of The Allegory of the Cave, from Plato’s Republic
Source: https://commons.wikimedia.org/w/index.php?curid=73850232

11. A group of prisoners is chained in a cave since childhood
where they cannot see each other, only shadows on the cave
wall ahead cast by a fire behind a parapet.
Puppeteers parade along the parapet with two-dimensional
objects poorly representing the real world outside the cave.
Sounds bouncing off the walls from beyond the cave are
attributed by the prisoners to the shadows, their only reality.
The philosopher who frees himself to seek the truth beyond
the cave is received with scorn when he returns to the cave to
inform his fellow prisoners who see illusions as their reality.
Ref: 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.
Plato’s Allegory of the Cave

12. Plato’s prisoners are in a situation of sensory
deprivation much like the subjects of Hebb’s
psychological experiments at McGill University
Hebb’s experiments demonstrate that Plato’s
prisoners would experience sensory deprivation and
begin to hallucinate to make up for the lack of
external stimuli
The brain lives – and only functions normally – in a
bath of stimuli which makes the brain grow
and the mind develop
How is COVID-19 making us like
the prisoners of Plato’s cave?

13. Chained since childhood, the prisoners have experienced
long-term sensory deprivation which impacts brain structure
Nobel-prize winning research by Hubel & Wiesel on cats
showed that blocking visual stimuli at a critical stage radically
alters their neurophysiology
COVID-19 is creating an “experimental childhood,” subjecting
billions of youth to confinement and social isolation casting a
deep shadow with potentially devastating life-long impacts (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.
How is COVID-19 making us like
the prisoners of Plato’s cave?

14. 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.

15. Image courtesy of V Di Nicola

16. “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

17. 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.

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

19. 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.

20. Antigone and Polynices (Nikiforos Lytras, 1865)

21. 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.

22. 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.

23. 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.

24. 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

25. 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.

26. Impacts

27. Royal College of Psychiatrists
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

28. Royal College of Psychiatrists

29. 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.

30. 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.

31. 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.

32. Acknowledgements
Candian Assoaciation of Social
Psychiatry Panelists
Dr. K. Sonu Gaind (Chair)
Dr. Vincenzo Di Nicola
American Association of Social
Psychiatry Panelist
Dr. Rama Rao Gogineni

33. 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.

34. 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.

35. 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.

36. 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

37. 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

38. Questions
&
Comments