Drawing the COVID-19 pandemic: how do children incorporate the health crisis and its consequences into their everyday thinking?

Drawing the COVID-19 pandemic: How do children incorporate the health crisis and its consequences into their everyday thinking? Nahia Idoiaga Mondragon(1), Naiara Berasategi Sancho (2), Amaia Eiguren Munitis(23, & Naiara Ozamiz Echevarria(4) (1)Department of Evolutionary and Educational Psychology, University of the Basque Country UPV/EHU, Spain. [email protected] (2) Department Didactics and School Organisation, University of the Basque Country UPV/EHU, Spain. [email protected] (3) Department Didactics and School Organisation, University of the Basque Country UPV/EHU, Spain. [email protected] (4) Department of Evolutionary and Educational Psychology, University of the Basque Country UPV/EHU, Spain. [email protected] Abstract Objective: The general objective of this research was to listen explore how children understand and represent COVID-19 health crisis in their everyday thinking. Design: This research is based on a qualitative interpretive research methodology that uses children's drawings to collect data. This technique allows children for visualizing how they face this situation through a tool that promotes expression of their feelings and representations. Results: A total of 345 drawings were collected, and 949 elements related to the different categories were coded. The themes that have arisen were related to symbols of the pandemic (n= 307, 32.34%), emotions (n= 290, 30.55%), actions carried out (n = 258, 27.18% ) and socialization (n= 94, 9.90%). Conclusions: Children have a realistic representation of the COVID-19 virus and its consequences, which closely resembles the representation shown by the media and society. The children show a good understanding of the new measures and social rules Idoiaga Mondragon, N., Eiguren Munitis, A., Berasategi Sancho, N., & Ozamiz Etxebarria, N. (2022). Drawing the COVID-19 pandemic: how do children incorporate the health crisis and its consequences into their everyday thinking? Psychology & Health, 39(3), 379–398. This is an Accepted Manuscript of an article published by Taylor & Francis in Psychology & Health on 19 Apr 2022, available at: https://doi.org/10.1080/08870446.2022.2066103. It is deposited under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. associated with the pandemic. They are also very aware of the need to support their emotions by different spheres (family, educational and social context). Alternative play activities and art-based education must be promoted, avoiding the abuse of screens 1o reinforce their well-being. KEYWORDS: children; COVID-19; drawing; post-lockdown; emotions; representation Introduction Coronavirus disease (COVID-19) emerged in Wuhan, China, in early December 2019. The World Health Organisation (WHO) declared COVID-19 a pandemic on March 11, 2020 (Sohrabi et al., 2020), and on March 13, 2020, WHO proclaimed Europe as the center of the pandemic (Jakovljevic et al., 2020). This pandemic has had worldwide effects at multiple levels including medical, social, psychological, political, economic, religious, cultural, and civilizational spheres (da Silva & Neto, 2021; Deng et al., 2021; Wu et al., 2021). On a global scale, it has been crucial to implement strong social distancing and containment measures to stop the spread of the virus (Smith & Lim, 2020). Each country has taken its own measures, and during the first months of the pandemic, Spain was one of the countries in the world with the most rigid restrictions, especially with children. From March 13 to April 26, Spanish children were locked in their homes (Garcia, 2020). From April 26 to May 25, many children were allowed to go out, but only for one hour each day and always near their homes (Gorriaran, 2020). From May 25 onwards, children were allowed to go out as much as they wanted in most Spanish territories, but they were required to comply with the same mobility restrictions as the elderly. As far as schools were concerned, most schools (from nurseries to universities) remained closed until September 2020. Only a few high schools were opened in June 2020 to prepare for final exams, while a few nurseries and summer daily camps also opened in June or July to allow for work-life balance (Torres, 2020). In July, at the end of the first wave of COVID-19 in northern Spain, this research was carried out in the Basque Autonomous Community. At this time, the mandatory measures to deal with the pandemic were that anyone with symptoms of COVID-19 should selfisolate and report to their health service. The widespread use of masks was already mandatory regardless of the interpersonal distance, including all children over six years of age, both on public roads and in open spaces and enclosed spaces for public use. The use of masks was not required at beaches and swimming pools during bathing as long as the interpersonal safety distance between people could be respected (Basque Government 2020). Pediatricians, psychologists, and educators have warned of the threats that this pandemic may pose to children from a global health perspective, where physical, emotional, and social aspects should be integrated (Ghosh et al., 2020; Shingh et al., 2020; Walker & Tolentino 2020). These professionals have also emphasized that it is essential to investigate how children understand this pandemic to mitigate the harm this may cause (Dalton, Rapa, & Stein, 2020; Wang et al., 2020a). During the 1980s and 1990s, a considerable body of research focused on children’s understanding of illness (Myant & Williams, 2005). Most of this research was based on Piaget’s theory of development, essentially demonstrating that children have different perceptions of the disease depending on their age and stage of development (Bibace & Walsh, 1980; Banks, 1990; Gillis, 1990; Hergenrather & Rabinowitz, 1991; Carson et al., 1992; Simeonsson et al., 1993; Kury and Rodrique, 1995; Moss-Morris & Paterson, 1995). However, these cognitive studies, even in their most modern versions (Vacik et al., 2001; Koopman et al., 2004; Myant & Williams, 2005; Piko & Bak, 2006), have failed to address how children understand specific diseases from a common-sense standpoint or how they deal with illnesses on an emotional level. In the COVID-19 pandemic, research aimed at analyzing how children understand and cope emotionally with this health emergency has found that the children have understood perfectly well that the COVID-19 virus is a contagious disease, and it is something negative that they view as an enemy. In addition to understanding the concept of the virus, they have experienced emotions such as fear, worry, sadness, and nervousness about the virus, while also feeling guilt due to fear of infecting their loved ones (Idoiaga et al., 2020). In addition to these emotions experienced due to the virus itself, the collateral effects that the lockdown has had, for example, have led them to feel emotions (Brooks et al., 2020; Jiao et al., 2020; Jiloha, 2020), such as boredom, anger, overwhelm, tiredness and loneliness. Moreover, emotions such as fear and sadness are related to lockdown and the perception of the virus itself (Idoiaga et al., 2021). However, little research has yet been conducted to explore how children understand and integrate the COVID-19 pandemic from their perspective using active methodologies such as drawing. Drawing is a natural and perhaps the most fundamental form of human expression and can be used to explore concepts and experience, promote self-analysis and dialogue, and as [NI1] an investigative tool (Lyon 2020, Reiss et al., 2002). Moreover, it has been demonstrated that through drawing, children can understand and express complex concepts (Hämeen-Anttila et al., 2004) and emotions that they cannot express through words (Brechet et al., 2020). In fact, during the current pandemic, illustrations of the coronavirus have been used for children and adults for education and outreach programs so that the entire population knows what the virus is (Goodsell et al., 2020). In the same vein, in recent years, a growing movement driven by the United Nations Convention on the Rights of the Child (UN, 1989) has promoted the importance of listening to children's voices first-hand regarding matters that affect their lives (Robinson, 2014). For years, research has regarded children as passive subjects, focusing on aspects "about" children without considering their voices as protagonists in the process. However, recent research highlights the need for research "with and for" children as active subjects in the research process (Urbina-Garcia, 2019) to develop inclusive research (Berasategi et al., 2020). Given these considerations, it is critical to identify how children understand this health crisis to develop strategies and tools that, by taking into account their concerns, will ultimately help them to overcome these unprecedented circumstances. Therefore, the general objective of this research was to listen to the voices of children during the postlockdown period of the COVID-19 pandemic in the summer of 2020 using a childsensitive approach to data collection to explore how they understand and represent this health crisis. Design Sample A total of 345 children participated in this study. Of the sample, 57.13% were girls, and 42.87% were boys. The mean age of the participants was 8.65 years (SD = 2.05) with an age range of 6-12 years. All the drawings were collected in the city of San Sebastian (a city of 188,240 inhabitants located in the Basque Country of northern Spain). The drawings were collected in July during the summer camps organized by the city council. The aim of the Municipal Service that organized that summer camp was to offer children the possibility of enjoying their free time in Basque. In the summer of 2020, the camps were held mainly on school grounds and took place from Monday to Friday from 9:30 am to 1:30 pm in July. The groups consisted of 8-9 participants between 6 and 12 years old. Procedure To collect the drawings, each camp monitor asked them to draw whatever they wanted relating to the health epidemic they were experiencing. Then it was explained to them that this drawing was going to be sent to another child in the city, allowing for an exchange of drawings to know how other children were experiencing the situation. Before sending the drawing to another child, the municipal services of San Sebastian and the Tabakalera organization collected and scanned all the drawings that were later analyzed in this research. Throughout the process, permissions were sought from the children's guardians, and this research also has the approval of the Ethics Committee of the UPV/EHU [M10/2020/055]. Data analysis method This research is based on a qualitative interpretive research methodology that uses children's drawings to collect data. Through children's drawings, children are given a voice so that their thoughts are visible beyond the vision and interpretation of adults (Robertson, 2000). Taking children's drawing as a discursive act, children create representations of the world around them (Dockett & Perry, 2005). The drawings were analyzed with the Nvivo 12, QRS International Software, using visual content analysis procedures (Rose, 2007). Visual content analysis forces the researcher to delve deeper into the images, discovering elements and patterns that often escape casual observation (Schnettler & Raab, 2012), taking as basic premises the identification of visual elements through categories that two researchers have reviewed to ensure the consistency of the categorization generated. Likewise, the focus has been placed on the frequencies of appearance of the elements for their subsequent analysis (Kalvaitis & Monhardt, 2012). Results A total of 345 drawings were collected, and 949 elements related to the different categories were coded. In particular, the most frequently drawn categories were the COVID-19 pandemic symbols ( n= 307, 32.34%) and emotions experienced during the pandemic (n= 290, 30.55%). Following these main categories, the other main categories were actions carried out by children during the pandemic (n = 258, 27.18% ) and the impact of the pandemic on social relations (n= 94, 9.90%). Pandemic symbols: Table 1 Elements o f the drawin g s g rouped into di ff erent cate g ories. n % COVID-19 virus representations 131 42.26 Protection measures 94 30.61 The COVID-19 crisis has created a new collective imaginary regarding the meaning of the pandemic. This category has been the most represented and describes both the virus itself and its consequences (confinement, deaths), as well as the measures to deal with it (see Table 1) The participating children show a very graphic and precise representation of COVID-19 since 42.28% of the items in this category are graphic representations of the COVID-19 virus. These representations are primarily in line with the images disseminated in the media (Figure 1). Masks 74 24.10 Gel, soap, hand cleaning 11 3.58 Social distance 7 2.28 De-escalation measures 2 0.65 Lockdown 28 9.20 Home as protective space 24 7.81 House + balconies 4 1.30 Health-related elements 26 8.46 Vaccines 16 5.21 Health workers 10 3.25 Hope-Rainbow 16 5.21 Mortality 12 3.90 Virus-death 7 2.28 Death 5 1.62 TOTAL 307 100.0 Figure 1: Examples of COVID19 graphic representations This indicates a recognition of the Covid-19 virus at different ages, incorporating animism into the virus and drawing smiley faces in some of the cases, crowns on others, along with forbidden signs. There are even some children who paint the virus next to representations of feces. It is also significant that several children painted the COVID-19 virus attacking a sick world, thus clearly representing the globalization of the pandemic (Figure 2). Figure 2: Example of COVID-19 as a disease affecting the world as a whole Another of the categories most frequently reproduced by the children (30.61%) was related to protective measures, particularly mask use, social distancing, and hand Impact on social relations: In the last category, the children highlighted that they missed both their families (8.51%) and their friends (26.31%). Likewise, although they emphasized that the confinement helped them to be with their immediate family (parents, brothers, and sisters) (14.89%), they also emphasized that they were delighted to meet up with their friends again (17.89%). In this sense, the summer camps were a space where they could play with their friends again (29.79%) (See Table 4) (Figure 10) Table 4 Elements cate g orized in the drawin g s related to social relationships. n % Family 22 23.40 Missin g famil y 8 8.51 Bein g with Famil y 14 14.89 Friends 44 46.31 Missin g friends 25 26.31 Happ y with friends 17 17.89 Wantin g to celebrate birthda y parties 2 2.11 Summer camps 28 29.79 TOTAL 94 100.00 Figure 10: Examples of representations of social relations Discussion The findings of this research offer important clues for identifying how children integrate COVID-19 into their everyday thinking. From the children's drawings, the issues that have arisen can be classified into the following four main categories: COVID-19 itself and the symbols of the pandemic, the emotional burden placed on children, actions they carry out, and the repercussions for children's socialization. First, the main contribution of this work is that it allows us to visualize very clearly how children have integrated the concept of the virus and its representation, as well as its symbols and consequences in their everyday thinking. It is remarkable how they draw the virus with a characterization that accurately mirrors that reported in the media. Such a realistic representation of the virus itself made by children is a new feature of this pandemic and has not previously been detected with other diseases (Byrne, 2011, Martinerie et al., 2021). However, there are also notable signs of animism (Bruce, 1941), as some viruses have crowns or faces and even express happy, sad, or frightening emotions. It is also very noteworthy that sometimes the virus is drawn both with the "forbidden" sign and next to a pile of feces, indicating that it is something that the children dislike. The children had already used the expression "the virus is shit" in previous research (Idoiaga, Berasategi, Eiguren & Dosil, 2020), but this time they draw it literally. It is also very striking how they represent the world as threatened by the virus. In other words, the global conception of the crisis has also been internalized and expressed (Cucinotta & Vanelli, 2020). Aside from the virus itself, the paintings appeared to represent the rules and norms associated with preventing the spread of the virus. The latter suggests that the children have assumed the impact of this virus and represent it well. Further, they know that to protect themselves and others, it is necessary to adapt their routines and apply the different rules that have been imposed, including the use of masks, gels, and social distancing (Wang et al., 2020b). Other studies also point out that children — although sometimes regarded as irresponsible or incapable of following the rules — have in fact adapted well to the new rules, and they promote them knowing that this is important for protecting the health of the whole population (Berasategi et al.,2020; Council of Europe, 2020). Another significant aspect of this symbolization was that they also created drawings that depict their house as a protective space where the virus could not enter and where they felt safe during the lockdown. That expression of the lockdown image where there was no one in the street, and everyone was at home and went out to the balconies to applaud is also an image that is often depicted. Other studies conducted during confinement found that some children were even afraid to leave their homes after the lockdown period (Idoiaga et al., 2020; Loades et al., 2020; Sánchez, 2021), and this is something that even several associations of families, psychologists, and educators have detected (Williams, 2020). Among the symbols of the pandemic, children also drew images of doctors, health workers, or vaccines represented as the heroes who are going to solve the situation, along with the image of death itself. First of all, depicting a health epidemic in terms of heroes and villains is quite common, even for adults (Wagner-Egger et al., 2011). Moreover, in this pandemic, this pattern of identifying health professionals as heroes has already been reported (Idoiaga, Berasategi, Eiguren & Picaza, 2020), and the images of vaccines that were already depicted in July 2020, many months before they became a reality, are also striking. Nevertheless, at the same time, children are well aware that this pandemic has led to many deaths; at that time, 28.443 people had already died from COVID-19 in Spain (Spanish Government, 2020). Finally, hope symbols through rainbows that symbolize the slogan "Everything will be all right" were also very frequently drawn, creating leisure narratives that are responding directly to this lockdown. This trend to draw rainbows started in Italy — the first country in Europe to go into lockdown — where children drew rainbows and put them in windows and on balconies for others to see (Otte, 2020). This trend was repeated in many other countries, such as the UK (National Health Service, 2020), and some authors even pointed out that the rainbow was increasingly being portrayed in the media as harbingers of “hope” and “positivity” that helped to "raise spirits of passers-by” (Mukherjee, 2020) or that this rainbow supported children's participation in adapting to COVID-19 (Larkins, 2020). Second, the emotional response was the other theme most represented through the paintings; children drew pictures of themselves and how they had felt both during the lockdown and in the new post-lockdown reality. Ambivalent emotions appear, such as sadness, anger, and loneliness, along with emotions such as happiness, hope, encouragement, love, or sense of care. Some of this whirlwind of emotions had previously been identified in children during the COVID-19 pandemic, such as fear, sadness, anger, loneliness, happiness, and even hope (Imran et al., 2020; Lambrese, 2020; Larkins, 2020; Mukherjee, 2020; Yeasmin et al., 2020). However, the emotions of caring or love, which are related to compliance with restrictive measures, are notable for their novelty, together with feeling down or sad. That is to say, even if wearing the mask or distancing themselves from their loved ones makes them feel "bad" and sad, the children decide to do so because of their love and sense of responsibility toward others, thus showing a high level of empathy (Miguel et al., 2021). Another notable point on the emotional side is that many children write about feeling "bad" without putting a name to those emotions. It is therefore essential to educate the whole population (especially youngsters) in emotional expression. Educating children in emotions will also be crucial to promote their well-being, particularly in times of crisis, when taking care of their emotions will be paramount, that is, knowing how to recognize, listen, and express themselves assertively (Cao et al., 2020; Ghosh et al., 2020; Patric et al., 2020). Third, actions carried out by children in the lockdown and those that they were willing to perform were represented through the paintings, along with activities carried out during post-confinement periods where more time is still spent at home. Many children drew themselves indoors as "just being," that is, without carrying out any activity, which contrasts with other studies showing that many children engaged in creative activities such as painting, dancing, cooking, and playing with their families. Nonetheless, these studies also noted that younger children with less schoolwork were more likely to engage in these activities (Berasategi, Idoiaga, Dosil & Eiguren, 2021; Idoiaga, Eiguren, Berasategi, Dosil & Picaza, 2021). On the other hand, and similar to other previous studies, abusive use of screens (watching TV, playing video games, using social networks such as Facebook, Instagram, or Tick Tock) was also represented in the drawings. Without ignoring the vital contribution that new technology makes to society and also to the children (particularly during these times), the excess consumption of such devices is worrying, as noted by several studies conducted in different countries (de Miranda et al., 2020; Imran et al., 2020). Other studies have also revealed that sedentary lifestyles that have become routine in lockdown have also led to the increased time spent in front of screens (Chambonniere et al., 2021). Another noteworthy aspect of this section is that the children drew many outdoor and natural spaces (mountains, beaches), reflecting their need to connect with the outdoor environment (Berasategi, Idoiaga, Eiguren, Dosil, Picaza & Ozamiz, 2020; Martínez et al., 2020). It should be borne in mind that children in Spain spent more than six weeks without leaving their homes at any time, and some even mentioned that they were struggling to breathe indoors (Idoiaga, Berasategi, Dosil & Eiguren, 2020), so their perceived need for outdoor space is a fact that should be taken into consideration (Cifuentes-Faura, 2020). Finally, drawings express the impact that the pandemic has had on the way they socialize. Although they emphasized that the lockdown helped them spend more time with their immediate family, they also expressed the need to connect with other familiar people, along with the fact that they miss friends and classmates. On a social level, school closures and the lack of outdoor activity have disrupted children's everyday lifestyles (Ghosh et al., 2020). The latter has had a significant impact on the children's social relations, as they have not been able to relate to their peers, leading to isolation. Playing with peers is very important during childhood as it creates opportunities for the development of cognitive skills throughout child development, and social isolation has led many of them to lose this part of their lives (Scott & Cogburn, 2020). Therefore, actions such as day camps provided the children with an oasis where they could play with their peers again. This research is not without limitations. First, the sample is limited to a specific context, San Sebastian (north of Spain). Nevertheless, at the same time, it should also be taken into account that children from very different contexts, areas, and neighborhoods could be reached through this municipal day camp program. Second, multi-modal data collection is often made possible when children are drawing, especially youngsters. They talk, sing, narrate and draw, and all this serves to give meaning to the way in which they express themselves. Moreover, one of the strengths of the research is that very few studies have been done that focus on children's perceptions, least of all from drawings, even though due to social distancing, researchers could not be with the children. In conclusion, this investigation contributes to identifying how children understand, cognitively represent, and emotionally face the COVID-19 pandemic. Our findings show that, contrary to popular belief, children are not impervious to the impact of COVID-19. They are experiencing this health crisis and its consequences first-hand, and they are very aware of what is going on and have incorporated it into their everyday thinking. However, this research also points out that emotional education should be promoted, above all, to enable the necessary competence to express emotions. Moreover, the excessive use of screens should also be addressed, and safe spaces for children to enjoy the outdoors, physical activity, and contact with their peers should be promoted while respecting health measures. Therefore, actions such as the day camps where this research was carried out or other leisure and free time activities could be key to ensuring children's well-being during the pandemic. Data availability statement The data that support the findings of this study are available on request from the corresponding author, XXXX. The data are not publicly available due to their containing information that could compromise the privacy of research participants. Disclosure statement No potential conflict of interest was reported by the authors. Funding KideOn. Research Group of the Basque Government, Ref.: IT1342-19 (A category) References Banks, E. (1990). Concepts of health and sickness of preschool‐ and school-aged children. Child. Health Care 19, 43–48. https://doi.org/10.1207/s15326888chc1901_6 Basque Government (July 15, 2020). ORDER of July 15, 2020, of the Regional Minister of Health, amending the annex of the Order of June 18, 2020, of the Regional Minister of Health, on prevention measures necessary to deal with the health crisis caused by COVID-19, once phase 3 of the Plan for the transition to a new normality has been overcome. Department of Health of the Basque Government. https://documentos.deia.eus/2020/07/Orden_Mascarillas_Euskadi.pdf Bates, L. C., Zieff, G., Stanford, K., Moore, J. B., Kerr, Z. Y., Hanson, E. D., Barone Gibbs, B., Kline, C. E., & Stoner, L. (2020). COVID-19 Impact on Behaviors across the 24-Hour Day in Children and Adolescents: Physical Activity, Sedentary Behavior, and Sleep. Children (Basel, Switzerland), 7(9), 138. https://doi.org/10.3390/children7090138 Berasategi Sancho, N., Idoiaga Mondragón, N., Dosil Santamaría, M., Eiguren Munitis, A., Pikatza Gorrotxategi, N., & Ozamiz Echevarria, N. (2020). Las voces de los niños y de las niñas en situación de confinamiento por el COVID-19.UPV/EHU. Berasategi, N., Idoiaga, N., Dosil, M., & Eiguren, A. (2021). The Well-being of children in lockdown: Physical, emotional, social and academic impact. In press Bibace, R., & Walsh, M. E. (1980). “Children’s conceptions of illness” in New directions for child development: Children’s conceptions of health, illness and bodily functions. eds. R. Bibace and M. E. Walsh (San Francisco, CA: Jossey-Bass), 34– 42. Brechet, C., D'Audigier, L., & Audras-Torrent, L. (2020). The use of drawing as an emotion regulation technique with children. Psychology of Aesthetics, Creativity, and the Arts. https://doi.org/10.1037/aca0000314 Brooks, S. K., Webster, R. K., Smith, L. E., Woodland, L., Wessely, S., Greenberg, N., & Rubin, G. J. (2020). The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet (London, England), 395(10227), 912–920. https://doi.org/10.1016/S0140-6736(20)30460-8 Bruce, M. (1941). Animism vs. evolution of the concept “alive”. The Journal of Psychology, 12(1), 81-90. Byrne, J. (2011). Models of Micro‐Organisms: Children’s knowledge and understanding of micro‐organisms from 7 to 14 years old. International Journal of Science Education, 33(14), 1927-1961. Cao, W., Fang, Z., Hou, G., Han, M., Xu, X., Dong, J., & Zheng, J. (2020). The psychological impact of the COVID-19 epidemic on college students in China. Psychiatry Research, 287, 112934. https://doi.org/10.1016/j.psychres.2020.112934 Carson, D. K., Gravley, J. E., & Council, J. R. (1992). Children’s prehospitalization conceptions of illness, cognitive development, and personal adjustment. Child. Health Care 21, 103–110. https://doi.org/10.1207/s15326888chc2102_6 Chambonniere, C., Lambert, C., Fearnbach, N., Tardieu, M., Fillon, A., Genin, P., Larras, B., Melsens, P., Bois, J., Pereira, B., Tremblay, A., Thivel, D., & Duclos, M. (2021). Effect of the COVID-19 lockdown on physical activity and sedentary behaviors in French children and adolescents: New results from the ONAPS national survey. European journal of integrative medicine, 43, 101308. https://doi.org/10.1016/j.eujim.2021.101308 Cifuentes-Faura, J. (2020). Consecuencias en los niños del cierre de escuelas por Covid– 19: el papel del gobierno, profesores y padres. Revista Internacional de Educación para la Justicia Social, 9(3), 1-12. Council of Europe (2020). Covid pandemic responses. Lessons learnt from management and adaptation to ensure that children are treated as rights holders during the pandemic and beyond. Council of Europe. Retrieved from: https://rm.coe.int/finalsummary-report-covid-19-pandemic-responses/16809f8032 Cucinotta, D., & Vanelli, M. (2020). WHO Declares COVID-19 a Pandemic. Acta biomedica : Atenei Parmensis, 91(1), 157–160. https://doi.org/10.23750/abm.v91i1.9397 da Silva, F., & Neto, M. (2021). Psychological effects caused by the COVID-19 pandemic in health professionals: A systematic review with meta-analysis. Progress in neuropsychopharmacology & biological psychiatry, 104, 110062. https://doi.org/10.1016/j.pnpbp.2020.110062 Dalton, L., Rapa, E., & Stein, A. (2020). Protecting the psychological health of children through effective communication about COVID-19. Lancet 4, 446–447. doi: 10.1016/S2352-4642(20)30097-3 de Miranda, D. M., da Silva Athanasio, B., de Sena Oliveira, A. C., & Silva, A. C. S. (2020). How is COVID-19 pandemic impacting the mental health of children and adolescents?. International Journal of Disaster Risk Reduction, 101845. Deng, J., Zhou, F., Hou, W., Silver, Z., Wong, C. Y., Chang, O., Huang, E., & Zuo, Q. K. (2021). The prevalence of depression, anxiety, and sleep disturbances in COVID-19 patients: a meta-analysis. Annals of the New York Academy of Sciences, 1486(1), 90–111. https://doi.org/10.1111/nyas.14506 Dockett, S., & Perry, B. (2005). Children’s drawings: Experiences and expectations of school. International Journal of Equity and Innovation in Early Childhood, 3(2), 77-89. Garcia, C. (14th,, April, 2020). Los psicólogos insisten: “Si se flexibiliza el estado de alarma, los niños deben ser los primeros en salir” [Psychologists insist: "If the state of alarm is relaxed, children should be the first to leave"]. El País. https://elpais.com/elpais/2020/04/14/mamas_papas/1586856472_075125.html Ghosh, R., Dubey, M. J., Chatterjee, S., & Dubey, S. (2020). Impact of COVID -19 on children: special focus on the psychosocial aspect. Minerva pediatrica, 72(3), 226– 235. https://doi.org/10.23736/S0026-4946.20.05887-9 Gillis, A. J. (1990). Nurses knowledge of growth and developmental principles in meeting psychosocial needs of hospitalized children. J. Pediatr. Nurs. 5, 78–87. Ghosh, R., Dubey,M., Chatterjee, S. & Dubey, S. (2020). Impact of COVID-19 on children: Special focus on psychosocial aspect. Minerva Pediatrica, 72. 226-235. 10.23736/S0026-4946.20.05887-9. Goodsell, D. S., Voigt, M., Zardecki, C., & Burley, S. K. (2020). Integrative illustration for coronavirus outreach. PLoS biology, 18(8), e3000815. https://doi.org/10.1371/journal.pbio.3000815 Gorriaran, R. (2020). Los niños podrán salir a la calle a partir del 27 de abril «un rato» y con restricciones [Children will be able to go out on the street from April 27 "for a while" and with restrictions]. El Correo. https://www.elcorreo.com/politica/gobierno-20200418121505nt.html?ref=https:%2F%2Fwww.google.com%2F Hämeen-Anttila, K., Kemppainen, K., Enlund, H., Bush Patricia, J., & Marja, A. (2004). Do pictograms improve children's understanding of medicine leaflet information?. Patient education and counseling, 55(3), 371–378. https://doi.org/10.1016/j.pec.2003.04.006 Hergenrather, J. R., & Rabinowitz, M. (1991). Age-related differences in the organization of children’s knowledge of illness. Dev. Psychol. 27, 952–959. doi: HTTPS:// https://doi.org/10.1037/0012-1649.27.6.952 Idoiaga, N., Berasategi, N., Dosil, M., & Eiguren, A. (2021). Struggling to breathe: a qualitative study of children's well-being during lockdown in Spain. Psychology & Health, 36(2), 179–194. https://doi.org/10.1080/08870446.2020.1804570