I have been struggling with an eating disorder for the past few years. I am afraid to eat and afraid I will gain weight. The fear is unjustified as I was never overweight. I have weighed the same since I was 12 years old, and I am currently nearing my 25th birthday. Yet, when I see my reflection, I see somebody who is much larger than reality.
I told my therapist that I thought I was fat. She said it was 'body dysmorphia'.
She explained this as a mental health condition where a person is apprehensive about their appearance and suggested I visit a nutritionist. She also told me that this condition was associated with other anxiety disorders and eating disorders. I did not understand what she was saying as I was in denial; I had a problem, to begin with. I wanted a solution without having to address my issues.
Upon visiting my nutritionist, he conducted an in-body scan and told me my body weight was dangerously low.
I disagreed with him.
I felt he was speaking about a different person than the person I saw in the mirror. I felt like the elephant in the room- both literally and figuratively. He then made the simple but revolutionary suggestion to keep a food diary to track what I was eating.
This was a clever way for my nutritionist and me to be on the same page. By recording all my meals, drinks, and snacks, I was able to see what I was eating versus what I was supposed to be eating. Keeping a meal diary was a powerful and non-invasive way for my nutritionist to walk in my shoes for a specific time and understand my eating (and thinking) habits.
No other methodology would have allowed my nutritionist to capture so much contextual and behavioural information on my eating patterns other than a daily detailed food diary.
However, by using a paper and pen, I often forgot (or intentionally did not enter my food entries) as I felt guilty reading what I had eaten or that I had eaten at all.
I also did not have the visual flexibility to express myself through using photos, videos, voice recordings, and screen recordings. The usage of multiple media sources would have allowed my nutritionist to observe my behaviour in real-time and gain a holistic view of my physical and emotional needs.
I confessed to my therapist my deliberate dishonesty in completing the physical food diary and why I had been reluctant to participate in the exercise. My therapist then suggested to my nutritionist and me to transition to a mobile diary study.
Whilst I used a physical diary (paper and pen), a mobile diary study app would have helped my nutritionist and me reach a common ground (and to be on the same page) sooner rather than later.
As a millennial, I wanted to feel like journaling was as easy as Tweeting or posting a picture on Instagram. But at the same time, I wanted to know that the information I provided in a digital diary would be as safe and private as it would have been as my handwritten diary locked in my bedroom cabinet.
Further, a digital food diary study platform with push notifications would have served as a constant reminder to log in my food entries as I constantly check my phone. It would have also made the task of writing a food diary less momentous by transforming my journaling into micro-journaling by allowing me to enter one bite at a time rather than the whole day's worth of meals at once.
Mainly, the digital food diary could help collect the evidence that I was not the elephant in the room, but rather that the elephant in the room was my denied eating disorder.
The elephant in the room
I believe that this pandemic and the lockdowns are more deadly than we thought. Outside the symptoms which can easily be measured, like fever or shortness of breath and loss of taste and smell, it has had consequences on something that we avoid talking about: mental health.
Among the youth, the pandemic has led to short-term and long-term psychosocial and mental health implications. Although clinicians have been restricted to video calls with patients and research participants, smartphones have opened a whole realm of research interventions.
Research methodologies like the Experience Sampling Method have allowed researchers to collect valuable data from subjects remotely and in their daily life.
A famous quote from one of the great actresses of all time, Glenn Close says, “What mental health needs is more sunlight, more candor, and more unashamed conversation.” The World Health Organization (WHO) defines mental health as the state of well-being in which an individual realises his or her own abilities, can cope with the normal stresses of life, can work productively, and can contribute to his or her community.
Mental health conditions have a significant contribution to disease and injury in youth. In most cases, it is usually undetected and untreated until adulthood, impairing both physical and psychosocial health, thus limiting opportunities to lead fulfilling lives as adults. (1)
The CDC reports that Coronavirus disease can affect youth directly and indirectly. Beyond the direct impact of a potentially severe physical illness, this pandemic has also significantly impacted the mental well-being of many youths. The following challenges can attribute this:
Social distancing required physical distance from influential, supportive individuals, including friends, significant others, family members or the worship community.
Not attending school in person impeded the continuity in youth’s academic development and reduced athletic or hands-on vocational skills, potentially impacting their higher education and professional future.
Most households and youth’ families have economic difficulties due to lost jobs and wages during COVID-19. (2)
A recent poll conducted by the United Nations Children’s Fund (UNICEF) showed that the COVID-19 crisis is having a marked effect on the mental health of adolescents and young people, with 27% of participants reported feeling anxiety and 15% depression. Moreover, their perception of the future has been negatively affected, particularly in young women, 43% of the women feeling pessimistic about the future compared to 31% of the male participants. (3)
Social distancing has meant that researchers have had to rely on means of data collection that excluded face-to-face interviews with subjects. Below are six highly cited publications during the pandemic.
Loades et al. conducted a Rapid Systematic Review that employed a brief search of MEDLINE, PsycInfo, Web of Science, and the Cochrane Library.
Most studies originated from the United States, China, Europe, and Australia. Other countries which contributed publications included India, Malaysia, Korea, Thailand, Israel, Iran, and Russia.
Out of these studies: the majority were observational and cross-sectional studies. In other words, subjects experienced no treatment or interventions, nor were they follow-up across time. Interestingly, one study was a retrospective study after a pandemic.
The main criteria for the selected studies in this review were:
Results found a clear association between loneliness and mental health problems in children and adolescents. The lasting effects and difficulties of loneliness could be observed up to 9 years later.
The strongest association was with depression. There may also be sex differences, with some research indicating that loneliness was more strongly associated with elevated depression symptoms in girls and elevated boys’ social anxiety.
The major impediment of this review is the lack of high-quality studies investigating mental health problems after enforced isolation.
Moreover, most studies were cross-sectional, and therefore the direction of the association cannot be inferred. Very few studies used independent (not self-report) mental health or social isolation/loneliness measures, thereby creating more bias. Furthermore, the majority of the studies were observational and did not consistently control for potential confounders.
Orgiles et al. carried out a cross-sectional study that recruited 1,143 parents of Italian and Spanish children aged 3 to 18 years. The parents completed an online survey providing information about how the quarantine affects their children and themselves, compared to before the home confinement.
Participants were recruited from social networks such as Twitter, Facebook, WhatsApp and Instagram, as face-to-face contact was not allowed. Online survey forms were distributed in each country using a snowball sampling strategy.
Snowball sampling is the scientific sampling technique where existing subjects recruit from their acquaintances’ other future subjects. This method of recruiting study participants is also called chain-referral sampling and can be particularly useful when trying to reach populations that are harder to access.
This study showed that the majority observed changes in their children’s emotional state and behaviours during the quarantine. The most common changes were that most of them experienced difficulty concentrating and unusual boredom while the minority had increased restlessness, nervousness, loneliness, anxiousness, and irritability.
This review study employed a comprehensive and non-systematic search in PubMed, Scopus, SciELO, and Google Scholars databases.
The selected articles were more than 77, the majority being original data from surveys, cross-sectional and longitudinal studies, and editorials, research letters, and original papers from China, the United States of America, Europe, and South America.
These studies assessed the presence of Post-Traumatic Stress Symptoms (PTSS) through different Post-Traumatic Stress scales: IES-R (Impact Event Scale revised) and Post Traumatic Stress Disorder Checklist-Civilian Version (PLC-C). Some studies have measured mental health conditions, including the General Health Questionnaire - 12 (GHQ -12) or the COVID-19 Peritraumatic Distress Index (CPDI). These inquire “about the frequency of anxiety, depression, specific phobias, cognitive change, avoidance, and compulsive behaviour, physical symptoms and loss of social functioning”. Other mental health scales utilised were stress levels, through the Stress Subscale from Depression, Anxiety and Stress Scale (DASS-21) and Coping Styles, which were measured by the Simplified Coping Style Questionnaire (SCSQ).
Results showed that adolescents are generally less depressed and stressed than adults, although results are similar for depression compared with the ≥50 years-old groups. Some studies also showed that older adolescents exhibit more depressive symptoms than younger ones and children.
Study results also showed children less than 18 years old were more clinging and irritable, they also were more likely to manifest fear that family members might contract the infection.
The choice for a non-systematic review was associated with the circumstances. This search was carried out in an early phase of the pandemic when much fewer original data addressing pediatric mental health during the COVID-19 pandemic was available. Besides, some of the original data obtained were not published as original articles but as research letters and even editorials.
This cross-sectional study was conducted in China two weeks after the COVID-19 declaration in the country, where 584 youth were enrolled. The participants of this survey were mainly youth who were using the social media “WeChat”.
The Snowball sampling approach was used to distribute questionnaires online to WeChat circles of friends who later forwarded it to their circle of friends to expand the sample size.
They completed the questionnaires about cognitive PTSD Checklist-Civilian Version (PCL-C) status of COVID-19, the General Health Questionnaire(GHQ-12), and the Negative coping styles scale.
Junior high school and secondary school students had higher scores of PTSD than undergraduate or college and master’s students. In contrast, married students scored lower on PTSD compared to divorced or widowed students.
The main limitation encountered in the study included the use of cross-sectional design, which cannot provide strong evidence for causality, unlike the longitudinal technique, which involves looking at variables affecting youth mental health with respect to COVID-19 over an extended period.
This cross-sectional study was done in Bangladesh among 384 parents with at least one child aged between 5 and 15.
Non-probability sampling (Purposive sampling), this scientific technique, was employed to collect the primary data from participants.
The sampling technique selected members of the population based on the researcher’s subjective judgement ( no equal chance of participating in the study).
Firstly, Researchers invited parents known by their Facebook friends to complete the survey by filling the online questionnaire. The children’s major depressive disorder was measured by The 47-item Revised Child Anxiety and Depression Scale (RCADS), while the Generalised Anxiety Disorder (GAD) scale was used to assess children’s anxiety.
Results showed that depression, anxiety, and sleeping disorder scores were higher for a child whose family lived in the urban areas (63.3%) and those who had a corona positive relative/neighbour. The score was also higher for children whose parents needed to go to the workplace (25%), had a smoking habit (35.7%) and had the chance of losing their job (28.6%).
Moreover, idle children, the ones having busy parents, as well as those whose parents used to hit during the home quarantine period, scored higher
Singh et al. conducted a review that employed a brief search of MEDLINE through PubMed, Cochrane Library, Science-direct and Google Scholar databases.
The findings were categorised into thematic areas, which include the following:
In one of the preliminary studies during the ongoing pandemic, younger children (3-6years old) were more likely to display symptoms of clinginess and the fear of family members acquiring infections. Results also showed that children experienced disturbed sleep, nightmares, poor appetite, agitation, inattention and separation-related anxiety.
The home confinement of children and adolescents is associated with uncertainty and anxiety, which is attributable to disruption in their education, physical activities and opportunities for socialisation. A study found that older adolescents and youth are anxious regarding the cancellation of examinations, exchange programs and academic events. Consequently, the constraint of movement imposed on them can have a long term adverse effect on their overall psychological well-being.
These children with special needs [autism, attention deficit hyperactivity disorder, cerebral palsy, learning disability, developmental delays and other behavioural and emotional difficulties] encounter challenges since they have an intolerance for uncertainty, and there is usually aggravation in the symptoms such as outburst of temper tantrums due to the enforced restrictions and unfriendly environment which does not correspond with their routine.
The imposed lockdown subjects disadvantaged youth, including children working on farms, fields in rural areas, children of migrants, and street children, to acute deprivation of nutrition and overall protection. There is also a higher risk of being exploited and becoming victims of violence and abuse, which could have a long term negative impact on their development.
I concur that the COVID-19 pandemic has fractured the mental health of most youth in the world; this needs more attention to ensure they are well being.
Most publications provide baseline evidence that signifies the change in youth’s emotional state and behaviours during the quarantine.
There is a need for more surveys with larger sample sizes to clearly show the extent of this global catastrophe, especially in Africa, where available data on youth mental health in the pandemic is still limited.
There is also a more significant opportunity to use mobile devices, which are ubiquitous among youth, to collect mental data in novel ways. In a moment of crisis, the creativity of researchers can thrive within limitations.
While having physical and face-to-face access to participants may be impossible because of the pandemic, the use of alternative data collection methods, like the experience sampling method, can provide clinicians valuable and much-needed data to understand how our youth is coping.
A famous quote by an American singer, Demi Lovato, says, “You don’t have to struggle in silence. You can be un-silent. You can live well with a mental condition, as long as you open up to somebody about it.”
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Dear Digital Diary,
I realized that there is an unquestionable comfort in being misunderstood. For to be understood, one must peel off all the emotional layers and be exposed.
This requires both vulnerability and strength. I guess by using a physical diary (a paper and a pen), I never felt like what I was saying was analyzed or judged. But I also never thought I was understood.
Paper does not talk back.Using a daily digital diary has required emotional strength. It has required the need to trust and the need to provide information to be helped and understood.
Using a daily diary has needed less time and effort than a physical diary as I am prompted to interact through mobile notifications. I also no longer relay information from memory, but rather the medical or personal insights I enter are real-time behaviours and experiences.
The interaction is more organic. I also must confess this technology has allowed me to see patterns in my behaviour that I would have otherwise never noticed. I trust that the data I enter is safe as it is password protected. I also trust that I am safe because my doctor and nutritionist can view my records in real-time.
Also, with the data entered being more objective and diverse through pictures and voice recordings, my treatment plan has been better suited to my needs.
No more elephants in this room