Injustices confronted by children & youth during the COVID-19 pandemic

Children are people too!

Written by: Sydney Campbell & Franco A. Carnevale — July 19, 2020

Photo by Kelly Sikkema on Unsplash

Despite reassuring statistics indicating the lower risk children and adolescents (henceforth, young people) have in developing severe COVID-19 infections, young people have still faced a number of serious impacts due to the pandemic (1–3). These impacts include:

• Unique physiological manifestations of COVID-19 among young people (4–6);
• Increased illness risk for those with underlying or pre-existing health conditions (7–11);
• Mental health impacts, particularly those arising from prolonged confinement (12, 13) and heightened familial stress (14), and those leading to an increase in mental health disorder diagnoses (14, 15) as well as motivational and emotional concerns (16);
• Impacts resulting from school closures, including increased worries and stresses associated with upholding completion of required school work without adequate resources (17, 18), behavioural impacts of missing school (19), and anxieties related to returning to school (20);
• Lost opportunities for needed peer socialization and out-of-home activities (21–23), thereby increasing risks for psychosocial problems (13, 24);
• Increased risk of violence (1, 25) and barriers to accessing supports for those experiencing violence, abuse, and other forms of maltreatment (26);
• Changes in behaviours, such as having a hard time going to sleep, an increase in crying or bouts of anger, an increase in clinginess, or use of self-soothing techniques (27, 28);
• Increased risk for long-term impacts in young people living in low-income or at-risk communities because they are already more likely to experience adverse childhood experiences (i.e., abuse, neglect, or familial dysfunction) (29) and COVID-19 has also led these young people to have less opportunities to access essential resources (such as stable housing), less opportunities for advanced or even minimal education, and it has exacerbated pre-existing inequalities faced by these young people (11, 30);
• Deprived parental access for children living in foster care or residential care because of “confinement” practices (31, 32).

Although this is only a partial listing of the many serious COVID-19-related impacts affecting young people, it reveals the breadth and depth of major concerns that have been inadequately addressed.

While researchers and policy-makers focus on the important work of tracking and analyzing data related to the economic, physiological, and psychosocial impacts of the pandemic on populations as a whole, attention is drawn away from young people who are experiencing their own very particular immediate and long-term impacts. To support pandemic measure policy decisions, causal narratives have been constructed that positioned young people as “germ spreaders” that needed to be confined (33) (particularly in the early days of the pandemic), despite developing contrary evidence (34). Prolonged total confinement of young people has been seen as necessary at all costs, without consideration of the harmful impacts borne by young people.

An ethical perspective has been missing from the already limited stories and evidence that have emerged regarding the ways young people have been impacted by COVID-19. Drawing on the evidence outlined above, a focus on justicecan help highlight the major young people-related ethical concerns arising during this pandemic. Here, the term justice is defined as being “concerned with securing and maintaining the social conditions necessary for a sufficient level of well-being” in six core, irreducible dimensions (35, pg. 50), namely: health, personal security, reasoning, respect, attachment, and self-determination (35). Health refers to the “rich and diverse set of considerations characteristic of public health and clinical medicine”, such as premature mortality and preventable morbidity, but also mental health, pain, and the biological basis of behaviours (35, pg. 16–17). Personal security refers to appreciation and acknowledgement of the human interests everyone has to maintain physical, psychological and bodily integrity (35). Reasoning refers to the intellectual skills and mental habits that a person uses to understand the world they encounter, including imagination, reflection, and analytical capacities (35). Respect refers to treating others as “dignified moral beings deserving of equal moral concern” and seeing “oneself as the moral equal of others and as an independent source of moral claims” (35, pg. 22). Attachment refers to the formation of relational bonds found in friendship, love, and solidarity with others in one’s community (35, pg. 24). Finally, self-determination refers to “having control over who we are and who we will become” (35, pg. 28). The focus on well-being, comprised of the six dimensions listed above, means that justice is achieved if a sufficient level of each dimension is fulfilled.

Though these dimensions can be construed as focusing primarily on the necessary conditions for “adult maturity”, Powers and Faden (35) do acknowledge that for young people these dimensions are still relevant as current and future well-being of children depend on the extent to which these dimensions are nurtured at younger ages. For example, “without a sufficient level of health in childhood, systematic constraints on well-being that are inescapable are locked in at an early age” (35, pg. 94). In addition, the six dimensions seem to closely align with the notion of best interests being advanced in childhood ethics literature, whereby a young person’s best interests are rooted in the individual child’s experiences and voice regarding the interests that matter most for them (36). Specifically: the notion of self-determination, reasoning, personal security, and respect encourage adults to appreciate the capacities, agency, and autonomy of young people, while weighing their obligation to protect them; the notion of attachment acknowledges the importance of relationality in the lives of young people as social beings; and the notion of health (as highlighted in the example above) appreciates the immediate and life-long impacts of health in childhood on well-being. Overall, to build on what has been said earlier, the sufficient recognition and satisfaction of these dimensions in childhood — whereby sufficiency depends on the dimension in question (as some may have a sliding scale of sufficiency, whereas others are sufficient in a binary manner) and the context a person comes from (37) — helps to ensure young people’s well-being (at present and in the future). Powers and Faden consider their theory to be a broad form of egalitarianism, such that all people deserve to have equal well-being (and have the six dimensions achieved to equal levels), but if differences emerge between individuals then it requires policymakers, politicians, and other people in authoritative positions to provide moral justification for why these differences are permissible (37). Injustice, then, arises when these dimensions of well-being are not upheld for an individual without an adequate moral justification (35).

Like justice, injustice can be either procedural or substantive (38). Procedural injustice arises when the process that is used to determine how burdens and benefits are allocated is not sufficiently ethically justified or is not guided by ethical values (38) like those identified by Daniels (39) and revisited in the Thompson et al. (40) pandemic planning framework — specifically, values of: accountability, inclusiveness, openness and transparency, reasonableness, and responsiveness. Connecting to the definition of justice used in this commentary, procedural injustice could also arise from the process used to determine whose six dimensions of well-being are secured and for which reasons; as such, procedural injustice focuses on getting a result in the wrong way (41). Substantive injustice arises not from the processes used to determine how benefits and burdens are distributed, but from the final allocation of benefits and burdens amongst individuals/communities, whereby those final allocations are deemed to be unfair (38); in other words, substantive injustice focuses on getting the wrong result (41). Here, the claims about the final distribution of benefits and burdens being ‘unfair’ may be based on some of the principles that arise from the Thompson et al. framework (40) — for example, in the case of children it seems the harms they have faced without rectification or attention have not been granted enough proportionality or proportionate weight compared to the weight granted for concerns about transmission and mortality. Connecting to the definition of justice used in this commentary, once more, substantive injustice might mean that well-being is not sufficiently secured for an individual/group or the final proportions of each well-being dimension are not achieved for an individual/group due to the unresolved harm that these individuals continue to face.

In the context of COVID-19, as situated in this commentary, there are two main ways that justice relates to these conversations: (i) concerns about the unjust way that the impacts affecting young people have not been adequately considered, but rather overshadowed by statistical tracking of COVID-19 infections, illness and deaths that have been primarily affecting older people (i.e., a form of substantive injustice) and (ii) the ways in which injustices borne by young people are perpetuated by policy-makers’ disregard for the perspectives and voices of young people themselves during the pandemic, revealing how policies are therefore not attuned to the interests of young people, who have been systematically silenced (i.e., a form of procedural injustice).

First, media, public news, and researchers have been largely focused on examining or developing solutions to keep all people from exposure to the SARS-CoV-2 virus, to prevent infection, illness and death as well as preserve the economy. This work is certainly vital and driven by a utilitarian approach that upholds collective interests over individual ones. However, this affects which adverse effects are given the limelight in the policy arena and which are pushed to the margins. This is due, at least partially, to the bounded rationality that constrains the number of issues that any person, including policymakers, can consider at any given time (42), and due to broader economic, political, and sociocultural considerations that dictate what policy issues ought to be prioritized. Since immediate physiological and economic impacts have taken precedence, and young people have been shown to have better survival rates from SARS-CoV-2, other concerns affecting young people have been granted lower proportional consideration — which is unjust as it undermines the ultimate well-being of young people by reducing the resources allocated to resolving the impacts affecting them. Consequently, support for young people to help them deal with pandemic-related struggles (whether academic, emotional, social, or otherwise) has fallen to their parents, many of whom are already overworked, distressed, and facing their own impacts. Despite dominant conceptions of children and youth as “immature and incapable” moral “objects” in need of protection (43) that commonly underlie health and social policies, within the COVID-19 pandemic these same persons are expected to be resourceful and resilient. This imposes a paradox, whereby young people are seen as too incapable to contribute to policy discussions, but capable enough to deal with the impacts they are facing. For example: young people are expected to successfully complete school work in a virtual or online format, without being guaranteed sufficient support from teachers, parents, and/or caregivers (18).

This paradox reveals the second justice concern within these conversations, as young people are also not given opportunities to meaningfully contribute to COVID-19 related policy decisions. Some publications have described encouraging strategies to engage with young people (44), including one paper by Larcher and Brierley that discusses the distinctive ways the interests of young people can be regarded in COVID-19 policy conversations (45). Some non-profit organizations and community groups in Canada are aiming to undertake research and implement programs to engage young people, such as Children’s First Canada — an organization that seeks to improve child wellbeing in Canada — who spearheaded the “Young Canadians’ Parliament” and recently facilitated a session to bring together young people and politicians to offer a space for young people to share their worries related to COVID-19 (46). In addition, the VOICE Childhood Ethics Team at McGill University (VOICE: Views On Interdisciplinary Childhood Ethics), in Montreal, is conducting projects to advance our understanding of how young people and their families have been affected by COVID-19. Collectively, this work reveals that young people have been treated unjustly in the context of COVID-19, as the political processes that have governed COVID-19 responses have not demonstrated meaningful consideration of the voices and experiences of young people and the impacts that have affected them.

The perspectives of young people remain in the margins of local, regional, and national policy conversations rather than at the forefront. Pandemic policies should be inclusive of all population perspectives, including those of young people. We draw on advances in childhood ethics, whereby young people are recognized as active moral agents that should be regarded as moral subjects (rather than objects) who should have unimpeded opportunities to participate in policy-making (36).

It is important to acknowledge that COVID-19 has led some young people to also experience some positive impacts, including:

• Finding new solutions to maintain connections with friends, family, and neighbours (47, 48);
• Hearing researchers encourage parents/caregivers to be transparent with their children when discussing COVID-19 (49);
• Witnessing attentive adaptations in childcare settings to ensure the safety of young people when they return to care (50);
• Being encouraged and able to ask leaders of the country (and certain regions/states/provinces) questions about their pandemic-related worries (51, 52);
• Finding new ways to honour and celebrate meaningful cultural and religious holidays with family and loved ones (53).

However, there has been inadequate formal analysis and acknowledgement of these positive impacts, which could help drive policy change improvements.

Based on our analysis, we call for the following urgent policy changes and actions:

• National and state/provincial governments, schools, community organizations, hospitals, and academic institutions should develop policies, practices, and programs to encourage young people to actively contribute to pandemic-related policy discussions and decisions in meaningful ways. Research supporting engagement of young people in pandemic contexts has been undertaken in the past, following the 2003 SARS pandemic (54), and has demonstrated the capacities for young people to engage in rich, meaningful, and crucially valuable discussions about their preferences, perspectives, experiences, and suggestions. Widespread inclusion will likely involve pushing against dominant development-based conceptualizations of childhood (36);
• National and state/provincial/local governments should (a) devote more resources to funding analyses/studies that investigate the ways in which young people have been adversely impacted by COVID-19 and (b) create government-funded child/youth advocate officials (e.g., Children’s Commissioner; 55) to help ensure child welfare impacts are continually assessed within all policy initiatives and that concerns related to child well-being gain more traction on government policy agendas;
• Research studies should be expediently designed and implemented to fully investigate the scope and depth of impacts (negative and positive) that young people face due to this pandemic and as a result of the pandemic-related measures that have been implemented. These should involve participatory methodologies where possible, to ensure young people can help orient the aims, objectives, and approaches within these studies as well as dissemination strategies that align with young people’s aspirations and interests;
• Community organizations, community-based social services, clinics, and research teams that have been working with/hearing from young people during the pandemic and acknowledging the impacts of COVID-19 on this population should contribute policy briefs based on the urgent and long-term needs that have been identified as essential by young people and their families, to help improve their experiences;
• Public media and social media should prioritize the voices of young people to highlight the ways in which they have been impacted, the changes they would like to see, and the ways they would like to be included in pandemic strategy decisions.

The capacities of young people have been made especially evident by the current pandemic in profound and deeply moving ways. But their experiences have also highlighted the many under-recognized injustices faced by young people as a result of many pandemic measures that have been undertaken. Moving forward, policy makers need to urgently redress the harms that have resulted from these injustices and ensure young people are actively involved in shaping future pandemic measures.

Sydney Campbell, MA is a PhD student studying health policy in the Institute of Health Policy, Management and Evaluation at the University of Toronto, and simultaneously completing a Collaborative Specialization in Bioethics through the University of Toronto Joint Centre for Bioethics. She works as a research assistant with the VOICE Childhood Ethics team at McGill University (www.mcgill.ca/voice).

• Email: sydney.campbell@mail.utoronto.ca

Franco A. Carnevale, RN, PhD (Psych), PhD (Phil) is a nurse, psychologist and child and youth services ethicist. He leads the VOICE Childhood Ethics research program at McGill University in Montreal, Quebec, Canada (www.mcgill.ca/voice).

• Email: franco.carnevale@mcgill.ca

Acknowledgement: This work was supported by generous funding from the Newton Foundation.

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