Exploring the Association Between Comorbidity Status and Emotional and Behavioral Disorder Risk in Children Following COVID-19 Infection

Introduction: The COVID-19 pandemic had a substantial influence on various sides of global livelihoods. It is overbearing to recognize the relationship between short-term COVID-19 infections and ensuing emotional and behavioral symptoms. Nonetheless, the small number of research on long-term impacts of COVID-19 infections, coupled with deficient surveillance, raises concerns. This gap is particularly critical given the potential increase of depression and anxiety, with a 57% surge, and suicidal ideation, which has risen by 31%. Acknowledging the seriousness of the situation is utmost, necessitating combined efforts to address these issues effectively.

Methods: This study implements an observational analytical approach engaging a prospective cohort design, without of experimental interventions. Utilizing the Strength and Difficulties Questionnaire (SDQ) to measure the risk of emotional and behavioral disorders linked to comorbidity status. Twenty-nine children were selected as study participants. Data analysis involved chi-square tests and logistic regression, with statistical significance set at p < 0.05.

Results: Outcomes indicate that the overall prevalence of difficulties associated with emotional and behavioral risks stands at 48.3%. Emotional symptoms constitute 27.6%, behavioral issues 31%, hyperactivity and peer-related concerns 48.3%, while prosocial behavior is merely 6.9%. The study reveals a notable impact of comorbidity status on the likelihood of emotional problems, recorded at 54.5% (p=0.028, and C=0.426).

Conclusions: The presence of comorbidity status enhances the vulnerability to emotional and behavioral disorders among children post-COVID-19 infection. However, statistical significance is observed only in emotional problems.

Keywords: Adolescent, Behavior and Emotional problems, Child, Comorbidity.

Introduction

The COVID-19 pandemic began in December 2019 with the discovery of a highly transmissible coronavirus in China[1]. In response, numerous countries enforced lockdown measures, restricting travel in and out of their borders. Indonesia also implemented extensive social restrictions. Studies have indicated that these measures adversely affected the mental well-being of communities, including children[2].

Various factors contribute to mental health challenges in children during the pandemic. These include the transition to online learning, limited social interaction with peers, and constraints on visiting public spaces due to pandemic-related regulations. The adoption of hybrid schooling models as conditions stabilize post-pandemic can induce stress and anxiety among children[3],[4].

Empirical studies have explored the correlation between COVID-19 infection and mental health issues in adults[5],[6]. Children may experience anxiety due to insufficient emotional and psychological support from their parents during the pandemic[7]. The pandemic's disruption of children's social activities may elevate their risk of experiencing violence[8].

A study by Ludwig-Walz, et al[9]revealed increased depression among children in Europe during the pandemic, especially among girls. Another study suggests that loneliness resulting from social isolation and the loss of loved ones during the COVID-19 pandemic can precipitate long-term mental health issues, with effects persisting for up to nine years[10]. Additionally, children with comorbidities face worse mental health outcomes following the pandemic[11]. Tsankov, et al[12]found that children born with congenital diseases face a heightened risk of severe symptoms and mortality from COVID-19 compared to those without these conditions.

García-Fernández, et al.[13]reported a 31.1% rise in psychiatric ER cases related to suicide attempts or ideation in Spain in 2021, compared to 2018–2020. A study in China highlighted behavioral disorders, such as anxiety and irritability, among children aged 3 to 18[14]. In England, children aged 11 to 16 exhibit a lower level of anxiety compared to those aged 4 to 10[10].

Wiguna, et al.[15]examined the pandemic's impact and found increased risks of disrupted peer relationships (38.1%), diminished pro-social behavior (28.1%), and conduct issues (15%) during the initial and subsequent stages of the pandemic in Indonesia. in Indonesia. Indrawati, et al.[16]revealed the alarming prevalence of mental health disorders, with over half of children (57.6%) experiencing conditions like depression, fear, and anxiety. These findings highlight the need for timely intervention to protect children's mental well-being in the long term.

Studies have demonstrated that comorbid health conditions combined with COVID-19 infection in children has increased the prevalence of emotional and behavioral disorders. Consequently, longitudinal studies are needed to better understand these disorders in children affected by COVID-19. Failure to properly identify these disorders may lead to issues such as substance abuse and school dropout. These challenges stem not only from the virus itself but also from pandemic-related factors like bereavement, social isolation, and underlying health conditions.

METHODS

This study is part of a larger research initiative named LOCATE, carried out collaboratively by Gadjah Mada University, the University of Indonesia, and Airlangga University from 2021 to 2024. The main goal of this research is to ascertain the correlation between emotional and behavioral disorders and concurrent physical disorders in children who contracted COVID-19. The research was conducted over two visits to the children's polyclinic of RSUP Dr. Sardjito.

The study included pediatric patients aged 4 to 18 who had tested positive for COVID-19 and met specific inclusion criteria: confirmed diagnosis via real-time Polymerase Chain Reaction (RT-PCR) from a nasopharyngeal swab, discharge from a hospital or health center, and willingness to participate. The study excluded patients with severe cognitive impairments, such as mental retardation, rendering them unable to comprehend and complete the research questionnaire, as well as those intending to relocate to another city. A sample size of 26 respondents was obtained through purposive sampling techniques[17].

Two questionnaires were used to collect data concerning emotional and behavioral issues. The first questionnaire collected demographic data, medical history, COVID-19 background, clinical symptoms, vital signs, and lab results. The second questionnaire was the Strengths and Difficulties Questionnaire (SDQ), comprising 25 items rated on a likert scale, designed to evaluate emotional concerns, hyperactive behavior, peer relationship challenges, and behavioral difficulties. It also incorporated a domain assessing pro-social behavior to gauge strengths. The cumulative score for the difficulty domain ranged from 0 to 15 for normal, 16 to 19 for borderline or threshold, and 20 to 40 for an abnormal score.[15]. Participants were classified into two groups based on their risk level: individuals scoring 20 or higher were deemed at risk, while those scoring below 20 were categorized as normal. In community-based studies, child psychiatric screening tools often utilize the 90^thpercentile as the threshold for determining risk levels.

For individuals aged 11 to 17, emotional problems, hyperactivity, peer relationships, and behavioral issues are monitored across four domains. The risk level for each domain is determined by the total score. Specifically, for emotional problems, a total score below 6 is considered normal, whereas a score of 6 or higher indicates a risk. Similarly, for hyperactivity, a total score under 7 is categorized as normal, while a score of 7 or above signifies a risk. In the context of peer relationship problems, a total score below 5 is normal, whereas a score of 6 or higher indicates a risk. Finally, for conduct behavioral

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