• Child Abuse
• COVID-19
• Ethics
• Epidemiology

For children, the collateral damage of the COVID-19 pandemic response has been considerable: ‘nearly insurmountable’ educational losses,1 deteriorating mental health,2 low routine childhood vaccination rates,3 39 billion missed school meals by January 20214 and millions of estimated life-years lost among students in the USA alone.5 It is difficult to deny the harmful impact of lockdowns on children, who are society’s most vulnerable members. In this paper, we use the framework of evidence-based medicine to argue that child abuse is another negative side effect of COVID-19 lockdowns.

One of us serves as the American Academy of Pediatrics (AAP) Early Childhood Champion for the State of New Jersey, and we firmly stand by the AAP’s initial goal of having every student physically present in school during the pandemic.6 Yet, the potential reduction of COVID-19 transmission has been cited as justification for lockdowns, an intensive package of non-pharmaceutical interventions which include the prolonged use of general population restrictions and school closures.7 While it was certain that school closures would have profound social and economic costs, it remains uncertain whether they have any effect on COVID-19 transmission.8 One such cost is the negative effects on the detection, reporting and prevention of child abuse. Meanwhile, Sweden, which notably did not close primary schools, has emerged from the pandemic with one of the lowest overall excess mortality rates in Western Europe and finds no evidence of learning loss.9 10

There is emerging evidence that lockdowns significantly worsened child abuse on a global scale. Low-income and middle-income countries are particularly vulnerable to increases in child abuse. In Uganda, for example, there was a 1565% increase in the average number of calls per day to the Uganda Child Helpline in the first month of lockdown.11 Yet, even wealthy nations in the West did not escape unscathed. In the UK, there was a 1493% increase in cases of abusive head trauma at Great Ormond Street Hospital.12 In France, there was an 89% increase in national child abuse helpline calls, a 48% increase in home visits by law enforcement officers and a 50% increase in the relative frequency of child abuse hospitalisations.13 14 Furthermore, there appears to have been insidious changes with potentially long-term effects which are more difficult to measure. In the Netherlands, for example, there was a 32% increase in previously rare harsh parenting behaviours, including shaking and name calling.15

Agencies of the United Nations (UN) report that ‘the COVID-19 response’—school closures, movement restrictions, loss of income, isolation, overcrowding and stay-at-home measures—affected the frequency and intensity of risk factors for child abuse.16 First, child abuse tends to increase during public health emergencies. Second, the implementation of lockdowns were often followed by spikes in calls to child abuse helplines. Third, quarantines may be ‘the worst situation imaginable’ for vulnerable children who are pushed closer to their abusers. Fourth, lockdown-related disruptions imposed barriers to accessing community providers who recognise and report child abuse. Fifth, child abuse rates are likely to stabilise at a higher level than before the pandemic due to the persistence of risk factors, including unemployment and financial insecurity.

The best available external evidence from systematic research during the pandemic demonstrates an increase in the risk of child maltreatment, an increase in child maltreatment hospitalisations and a concerning decrease in official child maltreatment referrals.17 18 Given the lack of high-quality overall evidence, however, there is admittedly some uncertainty regarding the effect of lockdowns on child abuse. Despite an increase in the proportion of child abuse-related hospitalisation in the USA, for example, there was an initial transient decrease in child abuse reports.19 Some have therefore questioned whether lockdowns have anything to do with an increase in child abuse at all. Robert Sege and Allison Stephens describe child abuse during lockdowns as a so-called ‘missing epidemic’, hypothesizing that lockdowns prevented child abuse by strengthening families, community resources, and financial assistance.20

Yet, the Centers for Disease Control and Prevention found that more than 11% of surveyed adolescents experienced physical abuse and more than 55% of adolescents experienced emotional abuse during the first year of the COVID-19 pandemic alone, with socially vulnerable adolescents disproportionately harmed.21 These results were compared with a similar pre-lockdown survey which found 5.5% physical abuse and 13.9% emotional abuse in 2013.22 It is clear that child abuse continues to be a significant problem in the USA which has likely worsened during the COVID-19 pandemic. The high level of self-reported child abuse is consistent with under-reporting as a result of lockdown-related disruptions,and it is inconsistent with Sege and Stephens rather optimistic hypothesis. The paradoxical phenomenon of increased hospitalisations and decreased reports is therefore unlikely to be explained by a genuine decrease in child abuse.

We conclude that lockdowns have an unacceptably high risk of negative side effects for children, as evidenced by child abuse, the true extent of which appears to be masked by lockdown-related disruptions to schools and other surveillance systems. Rather than a ‘missing epidemic’, perhaps a more appropriate name for lockdown-related child abuse is an unseen pandemic—hidden in plain sight. More research on the short-term and long-term effects of lockdowns on child abuse, adverse childhood experiences and other social determinants of health is urgently needed to better understand the failures of the COVID-19 response and mitigate the collateral damage for children. Given the UN projection that child abuse will stabilise at a higher level, immediate steps must be taken to eliminate any remaining lockdown-related disruptions to the timely detection, reporting and prevention of further child abuse .

The desire for a sense of security may be a tempting bias towards emphasising the resilience of children, but it is ethically problematic to push children towards abuse in the name of public health. Suffering in silence is not resilience. In the face of uncertainty, protecting vulnerable children ought to be of the utmost priority. It is our view that the collateral damage of prolonged school closures for society’s most vulnerable members is a powerful ethical consideration against any pandemic response which involves their use.