An-Najah National University Faculty of Graduate Studies Experience of Palestinian Children During COVID 19 Pandemic Lockdown: A Descriptive Phenomenological Study By Haneen Jehad Saleh Ayoub Supervisor Dr. Souad Belkebir Co-supervisor Dr. Sabrina Russo This Thesis is Submitted in Partial Fulfillment of the Requirements for the Degree of Masters of Clinical Psychology, at the Faculty of Graduate Studies, at An-Najah National University, Nablus, Palestine. 2021 Experience of During COVID A Descriptive Phenomenological Study Haneen Jehad Saleh Ayoub This Thesis was Defended Successfully on Defense Committee Members 1. Dr. Souad Belkebir 2. Dr. Sabrina Russo 3. Dr. Sama Dawani 4. Dr. Zaher Nazal ii Experience of Palestinian Children During COVID 19 Pandemic Lockdown: A Descriptive Phenomenological Study By Haneen Jehad Saleh Ayoub This Thesis was Defended Successfully on 29/9/2021 and Approved by: Defense Committee Members Dr. Souad Belkebir \ Supervisor Dr. Sabrina Russo \ Co-supervisor wani \ External Examiner . Zaher Nazal \ Internal Examiner Palestinian Children Pandemic Lockdown: A Descriptive Phenomenological Study and Approved by: Signature iii Acknowledgement I would like to thank my supervisor, Dr. Souad Belkebir for her constant support, feedback, and assistance in making this thesis come to life. I would also like to thank Dr. Lubna Al-Saudi, who despite not being an official supervisor, was an important part of this research project. I am also deeply grateful to my co-supervisor Dr. Sabrina Russo, who has been a teacher, a mentor, a colleague, a friend and a supervisor. Without her constant help, guidance, and support this thesis and my studies and career in clinical psychology wouldn’t have seen the light. Thank you. I would also like to thank my teachers at the Faculty of Graduate Studies (Clinical Psychology Department), as well as all of those who contributed and assisted in finishing this research. I thank my family, my parents Rana and Jehad, my brothers Omar and Qasem and my sisters Haifa, Hadeel, Daniela and Sara, for their endless love and support. I thank my friends Bayan, Tam, Ankhi, and Hala who stood by me despite the many setbacks. Thank you. Finally, I would like to offer a special thanks to the one person who put me back on track to finish this thesis, who has been a tremendous source of support, compassion, and understanding, who believed in me when I did not believe in myself, my friend Lisa Arnold Masri. I sincerely thank you. iv Dedication To all Palestinian children and adolescents who continue to be resilient, compassionate, and alive despite their crushing struggles. v اإلقرار : الرسالة التي تحمل العنوان ةأدناه، مقدم ةأنا الموقع Experience of Palestinian Children During COVID 19 Pandemic Lockdown: A Descriptive Phenomenological Study األطفال الفلسطينيين خالل الحجر المنزلي تجربة دراسة فينومينولوجية وصفية: لجائحة كورونا أقر بأن ما اشتملت عليه هذه الرسالة، لم يكن سوى نتاج جهدي الخاص، باستثناء ما أشرت إليه يل أي درجة أو لقب علمي، أو كلها أو بعضها ؛ لن: حيث ورد، وأن هذه الرسالة لم تقدم من قبل . بحثي، إلى أي مؤسسة تعليمية، أو بحثية أخرى Declaration The work provided in this thesis, unless otherwise referenced, is the researcher’s own work, and has not been submitted elsewhere for any other degree or qualification . vi Table of Contents No. Content Page Acknowledgment iii Dedication iv Declaration v Table of Contents vi List of Tables viii List of Figures ix List of Annexes x Abstract xi Chapter One: Introduction 1 1.1 Background 3 1.2 Significance of the Study 7 1.3 Problem Statement 8 1.4 Aim of the Study 8 1.5 Research Questions 9 Chapter Two: Literature Review 10 2.1 Bronfenbrenner’s Ecological Systems Theory 11 2.2 Psychological Symptoms 13 2.3 Ecological Change 17 2.4 Trauma and Violence 19 Chapter Three: Methodology 21 3.1 Design 22 3.2 Participants 23 3.3 Sampling 23 3.4 Data Collection 23 3.5 Data Analysis 25 3.6 Pilot Study 26 3.7 Ethical Consideration 27 Chapter Four: Results 28 4.1 Demographics 29 4.2 Results Analysis 30 4.2.1 Theme 1: Awareness 31 4.2.2 Theme 2: Momentary Relief 32 4.2.3 Theme 3: Frustration and Loss 33 4.2.4 Theme 4: Perception of Risk 35 4.2.5 Theme 5: Feelings of Anxiety 36 4.2.6 Theme 6: Feelings of Depression 37 4.2.7 Theme 7: Uncertainty 37 4.2.8 Theme 8: Routine Change 38 4.2.9 Theme 9: Family Interaction 40 vii No. Content Page Chapter Five: Discussion 42 5.1 Awareness of COVID-19 43 5.2 Ecological Systems Theory and Shift of Meanings 45 5.2.1 Negative Change 45 5.2.2 Positive Change 48 5.3 Feelings of Anxiety, Depression, and Uncertainty 49 5.4 Perception of Risk and the Palestinian Case 51 Chapter Six: Conclusions and Recommendations 54 6.1 Conclusions 55 6.2 Recommendations 57 6.3 Strengths and Limitations 59 References 61 Annexes 68 ب الملخص viii List of Tables No. Table Page Table (1) Demographic Data of Children Interviewed (N=21) 30 Table (2) Psychological Themes Descriptive of Children's Experience in the COVID-19 Lockdown 31 ix List of Figures No. Figure Page Figure (1) Bronfenbrenner Ecological Systems Theory 12 Figure (2) Psychological Themes Descriptive of Children's Experience in the COVID-19 Lockdown 43 x List of Annexes No. Annex Page Annex (1) Interview Guide 69 Annex (2) Introductory scripts and consent for the interview 71 xi Experience of Palestinian Children During COVID 19 Pandemic Lockdown: A Descriptive Phenomenological Study By Haneen Jehad Saleh Ayoub Supervisor Dr. Souad Belkebir Co-supervisor Dr. Sabrina Russo Abstract The global COVID-19 pandemic is currently one of the most important worldwide issues that is of international concern. The breakout of the disease that began in China has continued to spread to other regions and countries, Palestine included. Palestine has been in a state of emergency since March 2020 with strict policies of lockdown and home confinement implemented gradually. Students have been at home since the beginning of this emergency status. Little attention is devoted to the psychological impact of the pandemic and its measures on populations especially children. The surge of information, anxiety, panic, restlessness and uncertainty surrounding these circumstances, loss of contact with friends and school as well as changes in the daily routine leaves children vulnerable to psychological difficulties. Several studies conducted worldwide during the pandemic reflected symptoms of depression, anxiety, behavioral and emotional difficulties. The aim of this study is to explore and understand the lived experiences of Palestinian children under lockdown due to the COVID-19. The approach xii of the study is qualitative that results in comprehensive information regarding the psychological impact of this situation on children. The results of the study showed several themes of awareness, feelings of depression and anxiety, frustrations at loss of normalcy and change of routine, as well as feelings of uncertainty. The current Palestinian context also offers a perspective into the perception of risk in regards to Palestinian children. The results also provide paradoxical findings including not only negative impact but also positive impact of the lockdown in terms of family relationships and and quality time. Palestinian children and adolescent much like their peers worldwide experienced a negative psychological impact during the pandemic lockdown and probably continue to do so as the pandemic is still ongoing. The uncertainty and loss of ability to predict and plan are thought to be the riskiest one of all. Special attention should be dedicated to the psychological well-being of children and adolescent during this period and in the aftermath of the pandemic. Key words: COVID-19, coronavirus, lockdown, psychological, quarantine 1 Chapter One Introduction 2 Chapter One Introduction On 30 January 2020, the World Health Organizations (WHO) declared an outbreak of the coronavirus disease 2019 (COVID 19), a public health emergency that is of international concern. This announcement came after the disease exceeded the number of cases of the severe acute respiratory syndrome (SARS) of 2003 and had registered cases of infection in 34 regions in China (Ho, Chee & Ho, 2020). The spread of the infection continued to escalate and affect other countries worldwide. On 5 March 2020, the Palestinian government announced a state of emergency and schools and universities were closed down to combat the spread of the disease. Approximately two weeks after, the government announced a stricter lockdown policy that put not only students at home, but closed down businesses and public institutions as well as restricted movement and enforced social distancing measures. At the time of data collection there were 523 cases of COVID-19 registered in Palestine since March, 2020 (MOH, 2021). Within the past year, the speared of the pandemic only continued to escalate with surges in the number of cases and new measures of lockdown installed every so often. As of October 6, 2021, there are 440938 total cases, 23318 active cases, 4456 deaths, and 413164 recovered cases in Palestine (MOH, 2021). 3 1.1 Background The COVID 19 pandemic has been globally classified as a natural disaster and a traumatic event that forces people to confront death, insecurity, and loss, with no definitive end in sight and no effective treatment. All of which are factors that are thought to impact people’s and especially children’s mental health negatively (Liu et al., 2021). Throughout the world, strategies to reduce the risk of infection have been implemented which have mainly included social distancing, hygiene measurements and isolation. On that basis, several countries have implemented lockdowns and closures of schools and places of communal activity. The pandemic and lockdown have also brought forth feelings of anxiety, stress, helplessness and fear around the world. It has impacted the lives of people, and especially children and adolescents in unique unprecedented ways (Singh et al., 2020). Research has indicated that this pandemic might go on impacting children and adolescents for the long term in comparison to adults (Singh et al., 2020). According to UNICEF, children make up around 28% of the world’s population, which makes more than 2.2 billion children (Singh et al., 2020). Due to the pandemic, UNESCO estimates that there are 138 countries worldwide that have imposed school closures, which in turn affects 80% of the world’s children’s education (Tso et al., 2020). According to the Palestinian Bureau of Statistics, Palestine has more than a million students in primary and secondary education (PCBS, 2019), all of 4 which were within home confinement from the period of March - May 2020. While many schools, public and private worked on providing online schooling, some efforts were more successful and consistent than others. As of the start of the new school year in 2020/2021, children continued to switch back and forth between face-to-face and online schooling according to the health measures imposed by the Palestinian government. Children and adolescents are a vulnerable population in general. They are vulnerable to their environment, which, in turn, can have long-term effects on their health and productivity in adulthood (Tso et al., 2020). While children are much less prone to be infected with the COVID-19 virus, or generally either have milder symptoms or are asymptomatic when infected, they are not immune to the psychological impact of the pandemic and restrictive quarantine measures (Panda et al., 2021). Children are also known to have lesser personal resources to deal with the various changes that are being inflicted on their lives due to the pandemic (Spinelli et al, 2020). Studies show that children who are as young as two years old are well tuned to the changes around them and are affected by them (Panda et al., 2020). Due to the pandemic, children and adolescents are facing drastic changes to their everyday lives. The changes include home confinement, school closures, and social distancing. Moreover, children and adolescents are more susceptible to receive the socially restrictive measures as a burden considering that social communication is a significant part of their 5 development (Ravens-Sieberer et al., 2020). Additionally, studies report that there has been an increase in violence against children during lockdown which leaves children vulnerable to trauma and abuse (Ravens- Sieberer et al., 2021). It also leaves this vulnerable population deprived of their support systems in school and family (Liu et al., 2021). Childhood and adolescence are important stages in the lives of children that include many biopsychosocial changes and challenges that include independence, identity exploration, and coping with their life difficulties at school (Ravens-Sieberer et al., 2021). Adolescence is considered a difficult time of transitioning and maturing towards adulthood (Liu et al., 2021) that requires social interaction. Therefore, it can be extremely challenging for children and adolescents to cope and comply with health measures, especially those that go against their current developmental needs, such as social interaction (Ravens-Sieberer et al., 2021). This, in turn, can leave long-lasting impact on children and adolescents’ mental health. Moreover, much of the world’s attention is currently focused on mitigating the spread of the diseases and on the economic impact of the pandemic, which dominate media and social conversations (Dalton, Rapa & Stein, 2020). Children and adolescents are being exposed to extreme levels of anxiety and tension in the adults surrounding them as well as to large quantities of information about the disease and correspondingly facing drastic changes to their daily lives and routine (Dalton, Rapa & Stein, 2020). Little attention is currently devoted worldwide to the psychological 6 effect of the pandemic and its resulting home isolation and loss of daily routine on children and adolescents. Very few studies provide evidence of the impact of the COVID-19 pandemic and the health measures imposed on children’s psychosocial well-being, and even less research has been done to understand the factors of vulnerability and resilience; however, previous research on health- related disasters (such as the N1H1 virus outbreak in the USA in 2009) indicate that there are valid concerns over children’s mental and physical health during this period (Tso et al., 2020). Moreover, most of the research implemented in the beginning of the pandemic or during previous ones addressed the psychological impact on the general population, with less focus devoted to parents and children in particular, despite a study showing that the level of Post-Traumatic Stress Disorder (PTSD) was found to be four times higher in children who had been in quarantine compared to those who had not (Spinelli, Lionetti, Pastore & Fasolo, 2020). Despite the fact that a population’s psychological reactions to the outbreak of an infectious disease plays an important role in the forming of the transmission of the disease and the emotional social turmoil that occurs during and post the outbreak, few resources are usually allocated to manage the psychological effects of the pandemic on mental health (Cullen, Gulati & Kelly, 2020). This leaves populations, especially children, vulnerable to psychological adversities. 7 1.2 Significance of the study This urgent and necessary study seeks to be a useful contribution to understanding the impact of the pandemic-driven policies on particularly vulnerable groups, in the case children. Considering the significance of this global pandemic and the extreme changes it has inflicted on people’s lives, especially children, this study aims to contribute toward filling existing gaps in scholarship on the pandemic’s psychological effect on Palestinian children. It also contributes to the larger field of psychological research in Palestine, specifically related to Palestinian children. Moreover, much of the research that has been conducted in relation to the psychological impact of the pandemic is quantitative; therefore, the current research fills the gap of qualitative in-depth research to inform the psychological impact of the pandemic on children. Importantly, it offers a starting point to explore this issue as it pertains to Palestinian children, centering the dimensions and complexities of their perspectives and lived experiences using the Descriptive Phenomenological Psychological Method. This method focuses on the experience of the participants, including reactions and behaviors, and analyzes thoughts, feelings, interpretations and impressions of the participants’ experiences (Broome, 2011), in efforts to become better advocates for children’s mental health and well-being and contribute toward the production of evidence- based intervention strategies. 8 1.3 Problem statement Palestinian children, much the same as children in many countries around the world, currently face an unusual and unprecedented situation of lockdown imposed by the COVID 19 Pandemic. Yet, Palestinian children also grapple with a unique set of circumstances that already strain their daily lives, namely the ongoing settler colonial project, internal struggles and rising economic instability, among others. Coupled with a more challenging form of learning that has often required ongoing access to a specific set of resources (i.e. internet, computers, electricity, space), the impact of these combined challenges has not gone unnoticed. This phenomenon is expected to have affected their lives on the physical (remaining at home and social distancing) obvious aspect, and on the psychological aspect. However, little is known of these psychological effects and their impact on the children’s lives in the near or far future, especially within a Palestinian context. In this study, the experience of children will be researched and investigated by capturing their lived experiences, and giving the voice to advocate for their needs and experiences. 1.4 Aim of the study The aim of this research is to explore and understand the lived experience of children aged 7 to 17 during this unusual period of lookdown due to the COVID 19 pandemic. The approach of the study is qualitative that results 9 in comprehensive information regarding the psychological impact of this situation on children using semi-structured interviews. The interview questions focus on the children’s feelings and experience of the lockdown, and how it has affected their daily routine. 1.5 Research questions The study will attempt to answer the following research questions: 1. What is the current experience of children in the period of lockdown? 2. How has this experience changed their daily routine? 10 Chapter Two Literature Review 11 Chapter Two Literature Review The following literature review focuses on the existing research relevant to the scope of this study. Significant research findings and results relevant to this research are discussed. The theoretical framework of this research consists of four main sections that frames the foundation of the study’s methodology, referring to how the study was designed and conducted, as well as the discussion. 2.1 Bronfenbrenner’s Ecological Systems Theory The Ecological Systems Theory is a theory that studies child development within the context of relationships that make up the child’s environment (Bronfenbrenner, 1974). American Psychologist Urie Bronfenbrenner laid down the foundations for this theory as he was critical of pervious theories of child development as they do not sufficiently address the child’s relationship and influence on and from the environment surrounding them (Bronfenbrenner, 1974). In the Ecological Theory of Bronfenbrenner, he states that human beings develop as consistent parts of systems (Härkönen, 2001). The child is affecting each one of the systems, and in the same way is affected by each one; therefore, any change in one of the systems will produce a wave of changes in the life of the child. These systems are thought to be several levels that interact with each other which are micro-, meso-, exo-, macro- and chronosystems (Härkönen, 2001). 12 Figure (1): Bronfenbrenner Ecological Systems Theory The microsystem is the child’s closest environment that he/she has direct contact with, such as the home, close relatives, classmates, or neighborhood kids, while a mesosystem links and aids the development occurring between two or more settings that contain the child such as home and school. The exosystem, similar to the mesosystem, is also a link between two or more settings of the child but one of these settings does not directly include the child, but has events occurring that influence him or her such as the relation between the home and the parent’s place of work. The macrosystem comprises the all-encompassing pattern of the three previous systems traits. Harkonen describes it as a societal blueprint of a culture or social environment. The last system, the chronosystem, is one Chronosystems Changes over Time Macrosystem Social and Cultural Values Exosystem Indirect Environment Mesosystem Connections Microsystem Immediate Environment Child 13 that describes the evolution and development of several external systems in the realm of time; it includes rules and roles that influence development (Härkönen, 2001). The pandemic has brought about several changes that inflict the lives of Palestinian children. These changes are framed within three frameworks which are psychological symptoms, ecological change, and trauma and violence. 2.2 Psychological Symptoms Psychological symptoms refer to any form of deviation from typical functioning that could be indictive of psychological challenges (American Psychological Association, n.d.). The current pandemic lookdown can be considered a stressful event for children that could compromise the mental health of children. Previous research has shown that the presence of stressors such as loss of contact with teachers, friends, and classmates, financial difficulties in the family, fear of contacting the disease, and a lack of sufficient accurate information can have detrimental effects on the psychological well-being of children and adolescents (Wang et al., 2020b), all of which are stressors present in the current pandemic. In another study that was conducted in 2013 with parents of children during the N1H1 virus outbreak in the USA, that focuses on Post-traumatic Stress Disorder (PTSD), the results showed that the PTSD scores were four times higher in quarantined children compared to non-quarantined (Wang et al., 2020b). 14 Previous research on experiences that share some characteristics with the COVID-19 pandemic also indicates that there is a significant existence of psychological symptoms including stress, PTSD symptoms related to quarantine, depression and irritability, all of which have long-term consequences for years to come (Spinelli et al, 2020). Several studies have been conducted throughout the past year to investigate the mental health effect of the pandemic on children. The research focuses mainly on depressed and anxious feelings, family relations and violence, as well as sleep disturbance, and stress (Liu et al., 2021). A meta-analysis of 15 studies included research from France, Italy, China, Hongkong, Bangladesh, India, Brazil, Turkey, and Spain that included nearly 23000 children reported that 79.4% of the children’s psychological and behavioral state was affected negatively by the pandemic and quarantine, with 35.2% suffering from sleep disturbance, 21.3% from boredom, and 22.5% from fear. Moreover, 80.8% were found to suffer from inattention, 41.6% from depression, 34.5% from anxiety, and 42.3% from irritability (Panda et al., 2021). The analysis of studies showed that children are afraid and worried about infection of self and family members. They also do not like the quarantine measures, felt uncertain about the pandemic, are isolated due to closure of public life facilities especially leisure activities, and are additionally stressed about their academic future (Panda et al., 2021) Research studies have been conducted in China, Italy, Germany, Spain, USA, Brazil, and India to assess the mental health impact of the COVID- 15 pandemic, all of which found negative psychological impact (Ravens- Sieberer et al., 2021). Recent studies from the USA indicate that children and adolescents’ psychological and behavioral well-being have deteriorated compared to pre-pandemic times. The study in Brazil targeted children from 6 to 12 years old and found that children experienced psychological distress including feelings of helplessness, fear, anxiety and worries. Furthermore, research from Spain, Italy and Germany reported increased conduct problems, loneliness and irritability, and worries about the pandemic among children and adolescents (Ravens-Sieberer et al., 2021). A recent study conducted with 1210 respondents from 149 cities in China revealed that 53.8% of the sample considered the psychological impact of the pandemic to be moderate to severe, while 28.8% and 16.5% reported moderate to severe anxiety and depression respectively, and 8.1% indicated stress levels of moderate to severe presentation (Wang et al., 2020a). Another study that focused on Chinese youth suggested that approximately 40.4% of the sample were indicated to be disposed to psychological difficulties, while 14.4% to have symptoms of PTSD (Liang et al., 2020). Furthermore, a research study on Chinese college students that assessed anxiety revealed that 21.3% suffered mild anxiety, while 2.7% suffered from moderate anxiety and 0.9% reported severe anxiety symptoms (Cao et al., 2020). Moreover, the study showed that having a relative infected with the disease was a risk factor, while living with parents, income stability, and urban living were protective factors (Cao et al., 2020). 16 One study was found to focus on children’s behavioral and emotional disorders during the COVID-19 pandemic in a Chinese province (Jiao et al., 2020). The results of the study indicated that there were a number of psychological and behavioral problems common among the children and adolescents surveyed: mainly fear of asking about the pandemic, distractibility, irritability, and clinginess (Jiao et al., 2020). Clinginess and fear of family contacting the disease was more prominent in the 3-6 years age group, while inattention was more prominent in children 6-18 years old (Jiao et al., 2020). A study on Chinese children investigating the effect of the pandemic found that of all the participants, 12.33% and 6.26% reported symptoms of depression and anxiety (respectively) after the lockdown. Moreover, several symptoms during lockdown were found to be associated with depression and anxiety after lockdown including suicidal ideation, insomnia, and difficulties with attention during online schooling, and arguments with parents (Liu et al., 2021). A research study in Bangladesh also showed that, during the period of lockdown, a large number of children were experiencing mental health disturbances (Yeasmin et al., 2020). Furthermore, an Indian study on the impact of quarantine reported that children and adolescents in quarantine experienced higher psychological distress including feelings of helplessness (66.11%), fear (61.98), and worry (68.59%) than those who were not in quarantine (Saurabh & Ranjan, 2020). 17 A nationwide representative German study on the impact of the pandemic on mental health and health-related quality of life (HRQoL) found feelings of burden reported by two-thirds of children and adolescents. These feelings were related to social distancing, home and online schooling, as well as lockdown. Moreover, the study reported more mental health problems, lower HRQoL, and higher anxiety levels (Ravens-Sieberer et al., 2021). 2.3 Ecological Change Companionship and social interaction are an essential part of the normal development of children (Saurabh & Ranjan, 2020). The preventive measures of the lockdown have brought about many ecological changes to the children’s environment. A review study on the effects of the lockdown indicated that children confined at home during the lockdown spend more time on TV and the internet, increasing risk of psycho-social difficulties including lower self- esteem. Moreover, excessive use of the internet can contribute to internet addiction, with some children experiencing cyberbullying, all of which affects children’s mental health (Thakur, Kumar & Sharma, 2020). A review of several research studies also showed similar results indicating that children and adolescents’ home confinement is related with uncertainty and anxiety that is attributed to the disturbance in their physical activities, opportunities for socialization and education (Singh et al., 2020). The lack of structured school schedules results in changes in routine, lack of 18 innovation or motivation in academic and non-academic activities as well as boredom. Additionally, home confinement increased children’s use of internet and social media which puts them at risk of compulsive usage of internet, vulnerability to bullying and abuse, as well as access to inappropriate content (Singh et al., 2020). Another Chinese study investigating vulnerability, resilience, and quality of life in children aged 2-12 years old found that higher psychosocial problems among preschoolers were significantly related to extended usage of electronic devices and inadequate sleep or exercise periods (Tso et al. 2020). Previous research has repeatedly emphasized the importance of sleep in children’s quality of life and behavioral development. It was reported that children who went to sleep earlier and with a longer sleeping schedule suffered fewer psychosocial difficulties. Similar findings were indicated for exercise and activity levels as more activity correlated negatively with psychosocial problems. In terms of online learning, and despite its crucial role during the lockdown periods, the results of the study show that the extended exposure to electronic devices, for learning or entertainment, was correlated with increase of psychosocial problems in children (Tso et al., 2020). A German nationwide study found deteriorating health-related quality of life among children and adolescence as 65% of children reported feeling schooling to be more exhausting than before, 27% reported an increased number of arguments, while 37% of parents reported an increase in 19 arguments with children, and 39% of children reported deteriorating relationships with friends due to the pandemic restrictive measures (Ravens-Sieberer et al., 2020). 2.4 Trauma and Violence Research strongly indicates that traumatic childhood experiences could have long term biopsychosocial effects including: disturbed neurodevelopment, taking on health-risk behaviors; cognitive, emotional and social malfunctioning; as well as disability, disease, social problems, and early death (Phelps & Sperry, 2020). Trauma is defined as a negative emotional response to an event that disrupts a person’s capacity to cope in life. One type of trauma is child maltreatment which is continuously linked with symptoms of poor mental health (Phelps & Sperry, 2020). While a child’s response to trauma is based on many factors, research has shown that children’s preexisting problems could escalate because of disasters such as hurricane Katrina. Moreover, exposure of the pandemic might increase the risk of maltreatment and trauma in children (Phelps & Sperry, 2020). The benefits of health measures including quarantine, social distancing, and isolation, while well-established to reduce the risk of transmission, are thought to have negative consequences on levels of violence at home (Humphreys, Myint & Zeanah, 2020). Reports of increased domestic violence in China indicate the adverse effects of isolation and lockdown, and while children might not be the target of domestic violence, witnessing 20 and overhearing it can also have its harmful effects including emotional and behavioral difficulties. Moreover, children can also be a target in domestic violence and due to the home isolation, the risk of child maltreatment is expected to increase (Humphreys, Myint & Zeanah, 2020). Family confinement at home is thought to be a trigger for violence during the pandemic lockdown. Research indicates that children are at higher risk of abuse and neglect as well as enduring domestic violence and pressure when they have been at home for an extended period of time during the pandemic (Liu et al., 2021). Routine change can be a confusing and difficult experience for children, with increased oppositional behavior from children. This, coupled with parental anxiety and stress during the pandemic can elicit abusive verbal and physical behavior from parents (Humphreys, Myint & Zeanah, 2020). Such exposure to violence is thought to have negative long-term effects on the mental health of children and adolescents including anxiety, depression, and suicidal ideation and attempt (Liu et al., 2021). The previous research reflects a number of psychological difficulties that different groups of populations are experiencing during the pandemic including symptoms of depression, anxiety, PTSD, and emotional and behavioral problems including fear, helplessness, uncertainty and burden, a deteriorating family relations, friendships, activity levels, sleep pattern and exposure to electronics, as well as increased risk of abuse and maltreatment. 21 Chapter Three Methodology 22 Chapter Three Methodology This chapter outlines the methodology that was used in this study. It provides information on participant selection process, instruments, as well as the research design. This study utilizes a qualitative method: The Descriptive Phenomenological Psychological method which provides a comprehensive understanding of the children’s experiences during the pandemic lockdown. 3.1 Design A descriptive phenomenological psychological method was used in collecting and analyzing the data. This method is a qualitative research method that was developed by Giorgi based on the Husserlian Phenomenology (Broome, 2011). It is a five-step method that focuses on the experience of the participant and does not only include reactions or behaviors in its data set, but will analyze thoughts, feelings, interpretations and impressions of the participants’ experiences (Broome, 2011). This method is the most appropriate for this research as it provides detailed descriptions of the children’s experiences which cannot be captured as vividly and clearly through a method such as surveying for example. Moreover, the phenomenological method gives voice to child participants directly, whose voices are otherwise often obtained through parents. 23 3.2 Participants Participants are Palestinian children in the West Bank who have been under lockdown due to the COVID 19 pandemic. 21 children were interviewed between May 15 and May 30,2020, to gather information about their experience and feelings during the period of lockdown. Participants were aged between 7 to 17 and were recruited from the West Bank community by purposive sampling method. Parental consent was obtained via phone or Zoom calls to explain the research objectives, and children’s verbal consent was obtained before the start of the interview. 3.3 Sampling The study utilized purposive sampling for the selection of participants based on presence of shared characteristics. Purposive sample sizes are often decided on the basis of theoretical saturation (the point in data collection when new data no longer bring additional insights to the research questions). Therefore, purposive sampling is the most successful when data review and analysis are done in conjunction with data collection on smaller sample sizes, which has been undertaken during this study. 3.4 Data Collection The qualitative data for this study was obtained through in person or virtual semi-structured interviews with participants about the phenomenological aspect of their experience during lockdown. The interviews were conducted with the children in their houses via phone, Zoom call, or Skype call or in 24 person to take in consideration pandemic health measures and movement restrictions. The interviews lasted approximately 30-40 minutes using a series of predetermined open questions (Annex I). Parents were sometimes briefly present during virtual interviews to ensure that technological process is intact. Parents did not interfere with the interviewing process unless to bring the child back from a break. Based on the phenomenological method, data is obtained through nai�ve description of the participants’ experience, which is done through a first- person account of the experience as it was lived and understood through the participant’s common understanding (Broome, 2011). To initiate the conversation, participants were asked a set of predetermined questions. The children were given the space to freely and spontaneously answer all the questions until they have said everything they wanted. However, it was observed the process of interviewing children is a challenging process. Children can get easily bored and distracted and a process of online interviewing especially, can be an obstacle to building rapport with children. Furthermore, another challenge is being able to obtain information from a child without pressuring them to talk which goes against ethical standards. It was also observed that children mostly give direct short answers that address the main point of the question. Several strategies were undertaken to mitigate the abovementioned challenges as much as possible. Following the phenomenological method of interviewing, and after participants had said what they could 25 spontaneously, follow up questions to get more details were asked such as “You spoke about such and such, can you tell me more about that?” (Broome, 2011) encouraging the child to elaborate in order to obtain more lengthy and detailed account of their experience. Moreover, as the researcher is practicing in the field of psychology, this experience informs the way in which she approached the children during the interview. Also, both groups of children interviewed virtually and in person were given breaks during the interview process whenever the researcher saw fit or the child asked to stop. Finally, interviews were audio recorded, and transcribed verbatim. Relevant portions were translated to English to use in data analysis and results. Participants’ identifying information was omitted in the transcription process or replaced with pseudonyms to maintain the confidentiality and privacy of the participants. 3.5 Data Analysis There are five steps to the analysis of data obtained through the Descriptive Phenomenological method in Psychology, which are based on principles of phenomenological philosophy (Broome, 2011). These five steps are as follows: the first step is to assume the phenomenological attitude which requires the researcher to bracket their everyday knowledge and understanding of the world and put it aside, and look at the data with fresh eyes; the second step involves reading the transcription of the interviews to 26 get a sense of the participants’ whole experience and the way they experienced them; the third step includes dividing and separating the data into meaning units based on common themes or ideas so it can be analyzed in parts rather than wholes; in the fourth step, those meaning units are transformed into descriptive expressions that are psychologically sensitive; and in the last step, analysis is conducted to synthesize the general psychological structures from the experience’s psychological components (Broome, 2011). The process of data analysis was conducted several times to ensure obtaining all the possible results from the research and to truly understand the children’s meaning. The first round of data analysis was conducted with the researchers and researcher supervisors by going through the five-step process, and initial thoughts, themes and results were obtained. The researcher then went through the analytic process two times by reading and re-reading the interview transcripts thoroughly, then extracting new themes that were previously missed and discussing them with the research supervisors. This process ensured the initial important step of analysis which is bracketing, which in turn enabled the researcher to better understand the children’s voice. 3.6 Pilot Study Interview questions were piloted on two children from the target group and necessary modifications were made to the questions to improve the quality of data collection. 27 3.7 Ethical Considerations Official permission from the Institutional Review Board (IRB) of An- Najah University was obtained before performing data collection. A verbal consent was obtained from parents and children before initiating the interview and after explaining the objective of the study as well as the benefits and risk of the study. Parents were informed that the conduction of the study with the children could benefit them in that it gives them space and opportunity to express their feelings and talk about what they have been going through. This process could be beneficial to relieve the stress that pandemic and its measures have instigated in children. Moreover, further communication was offered for the children in case they would still like to talk to the researcher after the end of data collection. Participants’ confidentiality and privacy were kept safely and only the researcher and research supervisors were aware of their identities. Interviews were conducted via phone or online applications such as Zoom or Skype. This method of research gives voice to the participants to tell their stories and experiences, which makes it an ethical advantage for the research (Broome, 2011). 28 Chapter Four Results 29 Chapter Four Results This chapter highlights the main results of the research’s data analysis. It explains the type of demographics involved in the research sample, and the main results categorized in themes and subthemes. 4.1 Demographics In total, 21 interviews were conducted. The sample consisted of children aged between 7-17 years old, all of whom were interviewed towards the end of the first physical lockdown in May 2020 in their homes. The participants consisted of 21 children, 52% males and 48% female. The ages ranged as 62% were within 8-11 years old and 38% were 12-15 years old. In terms of type of residence, 67% were from the city (including Ramallah, Nablus, and Jerusalem) while 33% were from the village (including Ramallah and Hebron villages). 57% were enrolled in private schools while 38% in public schools (with 5% unknown). 67% of the total participants receiving some form of remote learning during the lockdown. Remote learning in some cases consisted of assigning worksheets and some lessons through an online platform, while in others it was more extensive to include full online class schedules. Additional information on the socioeconomic status of the children was not obtained as the interviewer did not request further clarification as the scope was limited within this study. 30 Demographic information is included in Table 1. Table (1): Demographic Data of Children Interviewed (N=21) Code Gender Age Grade at time of data collection Type of residency No. of siblings Type of school Online schooling R1 M 13 7 th Village 4 Public No R2 F 9 4 th City 1 Public Yes R3 M 10 5 th City Unknown Unknown Unknow n R4 F 15 10 th City 2 Private Yes R5 M 12 7 th City 1 Private Yes R6 M 12 7 th City 2 Private Yes R7 F 10 4 th City 1 Private Yes R8 F 10 4 th City 1 Private Yes R9 M 11 6 th Village 1 Private Yes R10 M 8 2 nd Village 1 Private Yes R11 F 11 5 th City 7 Public Yes R12 M 10 5 th City 0 Public Yes R13 M 12 6 th City 5 Private Yes R14 F 9 4 th City 5 Private Yes R15 F 9 4 th City 5 Private Yes R16 F 12 6 th City 1 Private Yes R17 M 8 2 nd City 3 Private No R18 F 11 6 th Village 0 Public No R19 M 15 7 th Village 2 Public No R20 M 14 8 th Village 8 Public No R21 F 11 5 th Village Unknown Public No 4.2 Results Analysis The analysis of the data was based on the Giorgi method in phenomenological qualitative research. Nine major themes (with 23 sub- themes) emerged after data analysis: (1) Awareness; (2) Momentary relief; (3) Frustration and Loss; (4) Perception of Risk; (5) Feeling of Anxiety; (6) Feelings of Depression; (7) Uncertainty; (8) Routine change; and (9) Family Interaction. The themes and subthemes are presented in Table 2. 31 Table (2): Psychological Themes Descriptive of Children's Experience in the COVID-19 Lockdown Themes Subthemes 1. Awareness a. Scientific information b. Knowledge of loss 2. Momentary Relief a. Negative attitude towards school b. Unexpected rest 3. Frustration and Loss a. Missed activities b. Lack of socialization c. Restriction of movement d. Boredom 4. Perception of Risk a. Safety b. Ambivalence 5. Feelings of Anxiety a. Fear b. Worry 6. Feelings of Depression a. Unhappiness 7. Uncertainty 8. Routine Change a. Schooling b. Exposure to electronics c. Eating patterns d. Sleep patterns e. New activities 9. Family Interaction a. Negative projection b. Positive 4.2.1 Theme 1: Awareness The children’s awareness and knowledge of COVID-19 was investigated during the interviews to understand the children’s perception of crisis and risk as well as the depth of their correct knowledge on the subject. Two subthemes were identified during the investigation: scientific information and knowledge of loss, both of which indicate appropriate levels of awareness of the disease and reasons for lockdown. Many of the children had scientific information on the disease while some had unscientific information. One respondent stated: “it hurts the world, 32 and people should not interact closely with each other, and there shouldn’t be gatherings, and it’s contagious, and there’s a possibility a person can die from it” (R1). Another said: “we are in lockdown to protect ourselves and others” (R3). This reflects scientific information. Children also appeared to be aware of the lethality of the disease and idea of loss associated with it despite a low number of deaths at the time of data collection. A respondent said: “it is dangerous, we will not get over it easily. It has symptoms. It is deadly” (R19), and another stated: “deadly, we have to avoid it, it occupied the world” (R18). 4.2.2 Theme 2: Momentary Relief Perhaps one of the more interesting themes that emerged from this study and that may warrant further research is Momentary Relief that was identified in all of the children, with two subthemes: negative attitude towards school and an unexpected rest. Children expressed relief and happiness at schools closing down which could reflect a negative attitude towards schooling. One respondent expressed: “[when school was cancelled] I was happy and joyous; I got a break from my friends and school” (R7). Another stated: “the best thing is that there’s no school” (R4), and another said: “yes I’m happy because when I go to school, I get a headache” (R10). These feelings reflect a general negative attitude towards attending school; however, it is important to consider that school is a duty of children, and people in general enjoy the 33 suspension of duties, including adults. Therefore, having momentary relief does not directly correlate with lack of worries about the pandemic. Children also expressed relief at the opportunity to take an early unexpected rest. Children felt they had a chance to take a break from everyday life, to rest, and enjoy family time which instigated happiness in children. Respondent R14 said: “first I was happy, fine, a chance to spend time with the family”, while R8 expressed: “the feeling was as if I’m on a break from everyday life, and that is delicious”. Another respondent said: “we rested at home, I used to feel tired from school” (R16). The relief of everyday life activities reflects children’s hectic lives and the need for a break to relieve their stress and offer them rest, but likely tied to other political and socio-economic pressures of everyday life, and the need for a break to relieve their stress and offer them rest. However, these feelings appeared to be momentary as they manifested in the beginning of the lockdown period, but were also accompanied by feelings of anxiety, fear, worries, boredom and frustration, as will be discussed below. 4.2.3 Theme 3: Frustration and Loss Another emotion that was highlighted in the results was the theme of Loss and Frustration. This theme focused on the weight of the children’s feelings and their frustration at the loss of normalcy in their everyday lives. The theme was divided into four sub-themes that highlight the meaning of 34 ‘loss’ and the frustration that this loss causes them to feel: missed activities, lack of socialization, restriction of movement, and boredom. Children expressed that they miss their everyday activities. One respondent stated: “the worst thing is that I stopped going to football training” (R6) to emphasize the theme of missing activities. Another said: “the one thing I was sad about is that we stopped going to the [activities] club” (R7), while another indicated: “before we used to go to trainings and such” (R8). In terms of socialization, children expressed grave loss at the enforced lack of socialization with relatives and friends. One expressed: “friends, we don’t meet, and even if we did with voice and video it’s different from real meeting [face-to-face]” (R8). Another said: “I feel I miss school and my classmates” (R2), while another complained about having to use screens to socialize “communication between people is through screens and this is a bad thing” (R3). One respondent said: “we’re only sitting at home; we don’t see anyone. I miss [my friends]. Every day I talk to my sister about school days” (R19). As socialization is a normal part of children’s development, its loss is a difficult consequence of the disease containment measures on the children. Moreover, restriction of movement appeared to be another issue causing frustration and disappointment. One respondent likened the experience to imprisonment: “I am locked up alone at home; I want my friends with me” (R17). Another stated: “the deprivation of travelling, that is a whole other 35 issue” (R7), and another: “the worst thing is that we don’t go out, this is not a life like before” (R20). Born out of the loss of normalcy is boredom and frustrations with boredom. A respondent indicated that the worst thing about staying at home: “[the worst thing] is boredom; we don’t study; I don’t see my friends” (R21). Another described the boredom as suffocating: “we’re at home, we don’t breathe at home, we feel lonely, we sleep while sitting, we’re bored from being at home, we want to study” (R19). 4.2.4 Theme 4: Perception of Risk Perception of risk is the child’s judgment about the possibility of harm or loss. Perception of risk was one of the themes that emerged from the interviews with two main subthemes: feelings of safety and ambivalence. Many respondents stated that they did not feel worried about or fearful for their health or safety. One respondent, when talking about feelings from the beginning of the lockdown, stated: “I didn’t feel fear or worry, [I felt] fine, comfortable” (R5) during the lockdown period. Another said: “there’s no fear or worry” (R13), while another said: “it’s fine. I’m optimistic. There are not many new cases and there are cases of recovery” (R20). This indicates a general feeling of safety that the children felt. Similarly, some children’s sentiments reflected a feeling of ambivalence to the disease and its consequences. One respondent said “in the beginning, I was careless about the situation, it didn’t make a difference to me” (R1); 36 another stated: “Why should I be nervous? It’s comfortable to stay at home… it’s just that people die… people who are close to us” (R7). One respondent indicated a feeling of faith in his destiny which gives him tranquility as he said: “I’m not afraid, what’s meant to happen to me will happen, I’m content with everything” (R6). 4.2.5 Theme 5: Feelings of Anxiety The theme of feelings of anxiety emerged as an overarching theme for several of the children’s feelings. Children expressed feelings of anxiety in the forms of fear and worry. Children exhibited feelings of fear and nervousness regarding the spread of the disease and towards the possibility of infection for themselves and their family members. One respondent expressed “I felt fear and nervousness, that there is something strange happening in the world” (R1), another stated: “I’m afraid to go out and get corona and go to the hospital” (R17), while another said: “till now I’m afraid I will get infected [corona] or it will infect other people around me” (R19). Children also expressed feelings of worry, as one child expressed fear for his father saying “[I am] afraid and worried and feel that there’s something strange, that my life is at risk every moment, and I fear for my father because he goes to work and is not in lockdown with us” (R3), and another indicated “what’s happening is strange and not normal, I’m worried and scared, but with time this worry decreased” (R2). 37 Some of the children expressed feelings of worries and fear for themselves, their health, and for their relatives, especially elderly ones, as well as had a general sense of panic and nervousness at the size of the pandemic spread across the globe. For example, one respondent said: “yes [I’m worried]. They say this virus is invading the world. It’s a scary thing, for myself, and people around me” (R21). 4.2.6 Theme 6: Feelings of Depression The children also exhibited feelings of depression in the form of unhappiness and sadness regarding the lockdown and loss of their normal routine as one stated “I’m not happy” (R1), while another said: “I was sad not to see my friends” (R16). 4.2.7 Theme 7: Uncertainty Uncertainty is the state in which a person lacks information or an outcome is not precisely known. Children also exhibited feelings of uncertainty about the future of the lockdown as one said: “I would like this lockdown to end” (R6), while another said: “I didn’t know we were not allowed to go to Ramallah and school, we were off [from school] for two weeks. I thought it would be over after that” (R9). Another respondent expressed: “the worst thing is loneliness and boredom. We don’t know how to deal with this” (R19). Uncertainty in itself can trigger feelings of depression and anxiety as a person does not know what to expect in the future. 38 4.2.8 Theme 8: Routine Change One of the immediate results of the pandemic lockdown is the routine change that was imposed on children’s everyday lives and which, in turn, compromised their well-being. The theme of routine change was investigated in regards to the type of changes occurring to the lives of children and their attitudes toward these changes. One respondent said: “everything changed” (R2). Five sub-themes were identified within this theme: change in schooling, exposure to electronic devices, change in eating patterns, change in sleeping patterns, and introduction of new activities to the daily routine. The first is children’s experience and attitude towards schooling. While not all children experienced online schooling, most children had to undergo some form of remote learning. It was found that online schooling provided an alternative daily routine to their lives. One respondent noted: “the best thing is that schooling is still going on” (R3) indicating a positive experience with online schooling; another said: “in class we’re 40 students and there’s no freedom. I understand better on Zoom classes” (R7), and another reflected the same sentiment saying: “I feel comfortable with online school, I benefit from it” (R6). On the other hand, some students experienced negative outcomes from online schooling as one stated: “honestly, it’s not fun, it’s boring, and there’s lots of noise. Learning in school is definitely better” (R2), and another said: “the worst thing is there’s no participation like in class” (R16). However, some students were 39 not provided with any type of remote learning leaving them without any school routine. Another subtheme is increased exposure to electronic devices as one respondent noted: “I would stay on my phone [a lot]” (R1), and another said: “I stopped interacting with anyone. I stay in my room. I stay on my mother’s phone” (R21). Many children reported increased use of electronic devices during the lockdown period, including phones, tablets, computers, gaming devices, and TV. Moreover, consequences of social media were observed in the form of cyber bullying. In an interview, a child expressed that his phone was confiscated and upon further investigation with the parent, it was noted that he was being pressured online to commit suicide by other children, which caused his parents to confiscate his phone. Moreover, children experienced change in their sleep and eating routines during lockdown. A respondent noted that: “we started eating more” (R8), while another stated “we started to stay up late a lot” (R5), and another stated: “I wake up late, I keep watching TV, and I eat” (R4). One participant indicated “I go to sleep whenever I want” (R12). The changes in eating and sleeping result in disturbed sleeping patterns as well as possible disordered eating habits. An additional change in children’s routine is the introduction of new activities to their routine. As children were on lockdown and most outside activities were restricted, new activities were introduced into their daily routine including drawing, reading, gardening, and others. One respondent 40 said: “I started to draw during lockdown” (R6), another said: “during school time I didn’t used to read. In the beginning of lockdown, I started to read and I finished a book in two days” (R3). 4.2.9 Theme 9: Family Interaction One theme that was underlined in the data is family interaction. It was observed that children were motivated to mention their family members and their interaction with them as part of their discussion of the current lockdown period. Two subthemes emerged from this discussion: negative projection of feelings on family members and positive interaction between them. Respondents indicated that during the lockdown period there was strain on the relationships between family members including quarrels with siblings, taking anger out on each other, and feeling irritable with family members. One respondent noted “the relationships at home] became worse, problems, no one can stand the other. I feel I have become easily irritable with this lockdown and my brother is very moody, spoiled” (R4). Another stated: “I fight with my siblings” (R17), and another said: “the family home atmosphere is tense” (R3). On the other hand, there were changes in the relationships with family members in the form of spending more time with family and doing more activities with family members including playing with siblings and helping parents with house chores. One respondent stated “we spend more time 41 with family and watch things together” (R14). Another said: “we started seeing my father more, and got to know mom better” (R15), while another reciprocated the sentiment saying: “the best thing in the lockdown is that I started to spend more time with my family and play more” (R2). Of note is that the children expressed both aspects of changes to family interactions, both the positive and negative, indicating that these were parallel yet conflicting outcomes under this theme. 42 Chapter Five Discussion The current research study i study that focuses on children’s experience during the COVID pandemic lockdown, and its resulting effects on their mental health. findings of the study resulted in several overarching themes and subthemes that reflect the experience of lockdown and its impact on mental health Figure (2): Psychological Themes Descriptive of Children's Experience in the COVID-19 Lockdown 5.1 Awareness of COVID In terms of knowledge and information, it was observed that the majority of the children provided scientific information regarding the disease and how it transfers as well as its symptoms. Children also appeared to understand the fatal impact of the disease and had accurate knowledge of loss that the disease could inflict on pe Uncertainty Routine Change Interaction 43 Chapter Five Discussion The current research study is a qualitative phenomenological descriptive study that focuses on children’s experience during the COVID pandemic lockdown, and its resulting effects on their mental health. findings of the study resulted in several overarching themes and subthemes he experience of lockdown and its impact on mental health Psychological Themes Descriptive of Children's Experience in the Awareness of COVID-19 In terms of knowledge and information, it was observed that the majority of the children provided scientific information regarding the disease and how it transfers as well as its symptoms. Children also appeared to understand the fatal impact of the disease and had accurate knowledge of loss that the disease could inflict on people. Children's Lockdown Experince Awarness Momentary Relief Frustration and Loss Perception of Risk Feelings of Anxiety Feelings of Depression Uncertainty Routine Change Family Interaction phenomenological descriptive study that focuses on children’s experience during the COVID-19 pandemic lockdown, and its resulting effects on their mental health. The findings of the study resulted in several overarching themes and subthemes he experience of lockdown and its impact on mental health. Psychological Themes Descriptive of Children's Experience in the In terms of knowledge and information, it was observed that the majority of the children provided scientific information regarding the disease and how it transfers as well as its symptoms. Children also appeared to understand the fatal impact of the disease and had accurate knowledge of 44 This can be attributed to the intensive campaigns and social media information provided online to people in general and children’s exposure to it. This also can be understood in light of children’s increased exposure to electronic devices evident in the later results of the study as children noted they spend more time on screens. This can explain their vast scientific knowledge on the subject. A study conducted by BBVA utilized big data technology to monitor the media’s treatment of the COVID-19 pandemic. Through the study, 80,000 online media publications in more than 100 languages were analyzed in terms of coverage and sentiment, in which the results showed that both provided important information about the development and impact of the pandemic on economy and politics (BBVA, 2020). Moreover, big search engines as well as popular social media outlets such as Facebook, Google, and YouTube are all utilizing advertisements on their homepages to increase awareness and draw users’ attention to the pandemic, its effects, and symptoms. In addition, the World Health Organization (WHO) is leading efforts to spread accurate information about the disease and combat misinformation through their COVID-19 specific dashboard and website that offers information in several languages including Arabic. Moreover, local campaigns by the Palestinian Ministry of Health, and the widespread access to satellite TV increased access to information. These strategies in addition to children’s exposure to news and social media can explain the respondents’ high awareness regarding the disease. 45 5.2 Ecological Systems Theory and Shift of Meanings Considering the Bronfenbrenner theory of development discussed earlier, it can be observed that several changes were observed to take place in the environment of Palestinian children. These changes can be characterized by negative and positive changes. 5.2.1 Negative Change One major change in the system of the children under lockdown is the change in routine. Research suggests that family routines, especially during early childhood, provide opportunities to involve children in activities that contribute to enriching their vocabulary, their social skills, and academic achievement. While research did not show direct causation between family routines and these outcomes, these routines in regular conditions that support child development in general (Spagnola & Fiese, 2007). The experience of online schooling provided a much-needed routine for the children considering the loss of their own; however, the children’s experiences varied towards this method of education. While some noted that they could focus better during the online classes and could feel comfortable during the class, others indicated that the loss of face-to-face contact was a difficulty, and within the family environment, it was difficult to maintain attention. Throughout the interviews, it was found that private schools had a more regular system of online schooling compared to government schools, which lacked the resources and planning to conduct effective online schooling. 46 Sleeping and eating patterns were also disturbed, which affected the children’s daily routine. A study on sleep problems during home confinement due to the COVID-19 outbreak (Altena et al., 2020) indicates that such a stressful situation that extends for unknown duration disrupts sleep. As sleep is considered to have a main role in the regulation of emotions, disrupted sleep patterns can directly affect the following day’s emotional functioning (Altena et al., 2020). Another major change is children’s sense of disappointment and frustration at the loss of normalcy in their lives and in consequence, their forced isolation. Children expressed frustrations with missing their everyday activities, the ability to socialize with relatives and friends, as well as restriction of their movement. While isolation and social-distancing were the most effective method for slowing the spread of the disease at the time, as vaccination was not yet available; isolation goes against the grain of human instinct of connection and socialization (Van Bavel et al., 2020). Socialization helps humans cope with stress, be more resilient and regulate emotions, and on the other hand, isolation aggravates the effects of stress, feelings of loneliness, and affects mental as well as immune health even on the long-term (Van Bavel et al., 2020). A meta-analysis of several studies revealed that the majority of studies found a negative impact of isolation on patients’ mental health and behavior, including in children. This includes a tendency for higher scores in isolated patients for anger, depression, and anxiety (Abad, Fearday & 47 Safdar, 2010). A more recent research investigating school students’ mental health in home confinement due to COVID-19 in Hubei province in China showed that 22.6% and 18.9% of the students surveyed reported having depressive and anxiety symptoms, respectively, which are higher than the prevalence among this population in other studies (Xie et al., 2020). The study suggests that the decrease in outdoor activities and social interaction is associated with depressive symptoms. Moreover, research on the effect of Severe Acute Respiratory Syndrome in 2003 showed an association with psychological symptoms in Chinese students, suggesting that infectious diseases affect the mental health of children (Xie et al., 2020). The impact of the pandemic lockdown appears to also affect the trajectory of close relationships inside the home, with the pandemic being a major stressful event, and the sudden forced proximity to family members. Children indicated a negative change in their relationship with family members and a general tensing of the atmosphere of the home. Research shows that when people are in quarantine, they are at greater risk of anger, explosive emotional inclinations, and confusion. Moreover, some studies show that forced proximity could be a risk factor for aggression and domestic violence (Van Bavel et al., 2020). A research study on the effect of hurricane Hugo in 1989 showed that the areas harder-hit by the hurricane experienced an increase in divorce rates (Van Bavel et al., 2020). While the current literature on the effect of the pandemic and lockdown directs strongly towards the increased risk of child abuse and maltreatment 48 (Liu et al., 2021; Humphreys, Myint & Zeanah, 2020; Phelps & Sperry, 2020), the current study did not reflect those results and only directed to negative tension inside the house; however, this is not an indicator of a lack of such a risk, but could be due to several reasons including children’s hesitance to mention such violence, the fact that the study was conducted in the beginning of lockdown, and a year later, results might have changed and said negative tension developed to more pronounced abuse. Therefore, further research should be conducted to verify findings. 5.2.2 Positive Change Change is not only negative; it can sometimes be positive. While none of the reviewed previous research studies illustrated or focused on any positive impact for the pandemic lockdown, a few positive themes emerged out of the data analysis of this study. The themes illustrated changes that the children found to be positive to their everyday lives, and these include: introducing new activities to the daily routine, positive family interaction, and a sense of momentary relief at the suspension of school responsibilities and the unexpected break time. Children expressed increased family time and opportunity to spend quality time with family, help in house chores, and starting to engage in new activities and play. They also reported relief at being given an early break away from their school responsibilities. These feelings, while some of them momentary, such as relief from school, also reflect children’s negative attitude towards school. They also reflected the busy and hectic everyday 49 lives of children. Moreover, the current positive feelings indicate that quality family time and interaction can be considered protective factors during the pandemic. These findings, while not replicated in other research, can reflect the complexity and multiplicity of children’s experiences. 5.3 Feelings of Anxiety, Depression, and Uncertainty The COVID-19 pandemic and its resulting quarantine and lockdown measures have had an impact on the mental health of children and adolescents. Previous research conducted in several countries throughout the past year has shown that children’s mental health was affected and that feelings of anxiety and depression and their related feelings including fears, worry and unhappiness have significantly increased (Spinelli et al., 2020; Liu et al., 2021; Panda et al., 2021; Ravens-Sieberer et al., 2021; Wang et al., 2020a; Cao et al., 2020). Much the same as other children, among the main themes of this study are symptoms of depression, anxiety and the multifaceted relation between these symptoms and uncertainty. Children expressed feelings of fear and worry over the possibility of getting infected themselves or their friends, but mostly their older family members. They also expressed worries about the large scale of the pandemic phenomena that has threatened their world, changed their everyday lives, and taken things from them. Children’s anxiety was centered on infection and the ‘strangeness’ of the situation as they described it. Moreover, feelings of depression were focused on 50 unhappiness and sadness regarding the situation, the loss of their everyday routines and normality. Uncertainty can be defined as “a cognitive perceptual state that ranges from a feeling of just less than surety to vagueness; it changes over time and is accompanied by threatening and/or positive emotions” (Hilton, 1994, p18). Feelings of uncertainty include lack of feelings of security and safety, not being able to predict the future, feelings of doubt, indecisiveness, vagueness, and the inability to rely on someone or something (Hilton, 1988). In terms of Palestinian children, the main feelings of uncertainty were focused around not being able to predict the future, doubt, and lack of safety. As the pandemic has no end in sight yet after a year from its outbreak, the past year has been unpredictable and unexpected. Children were not able to foretell or plan for the future, which had left them with heightened feelings of insecurity. Feelings of depression and anxiety are also related to uncertainty. Research has continuously been conducted on the relation between anxiety and anxiety disorders and uncertainty, and specifically intolerance of uncertainty. One research study points out that intolerance of uncertainty is a main transdiagnostic feature in anxiety and depression (Carleton et al., 2012). Another research found that intolerance of uncertainty is associated with anxiety disorder and depression (McEvoy et al., 2012). It is believed that anxiety needs a sense of uncontrollability of the future, of risk, or negative events to thrive (Carleton et al., 2012). Therefore, the absence of 51 certainty only helps anxiety to heighten as lack of certainty means unpredictability and lack of controllability. In terms of depression, the presence of uncertainty impairs children’s capacity to plan for the future which, in turn, could contribute to feelings of hopelessness. Therefore, feelings of uncertainty take away the capacity to plan and increase hopelessness which can heighten symptoms of anxiety and depression. 5.4 Perception of Risk and the Palestinian Case Considering the complexity of the human experience and in this context Palestinian children living under occupation and currently under the COVID-19 pandemic lockdown, it was observed that on the other hand of anxiety, fear, and worries, children paradoxically exhibited feelings of safety and ambivalence in their perception of the risk of the situation. These feelings can be attributed to Palestinian children’s own perception of safety and risk that is modified to accommodate the current Palestinian situation. In Palestinian children’s everyday reality, more people (and children in particular) are killed or wounded by the Israeli Occupation Forces or during family disputes than by COVID-19 infection at the beginning of the pandemic. According to the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) database, between July 1, 2014 – July 1, 2020, 731 children were killed by the Israeli Occupation Forces, most of whom were boys, and 21,563 were injured (OCHA, n.d.). Moreover, an average of 500-700 children, some as young as 12 years old, are detained every year by the Israeli Occupation Forces according to the 52 reports of Defense for Children Palestine (Defense for Children Palestine, 2020). As perception of risk is subjective, and considering the occupation phenomena particular to Palestine, the daily desensitization and normalization of violent events in Palestine alters children’s perception of risk, and makes the outbreak of the disease not a very stressful event for Palestinian children. Moreover, the impact a global crisis can have on a place that has a daily crisis such as in the Palestinian context can differ from other places, which can lead to different attitudes towards the crisis. A study on the effect of living in a militarized zone on Palestinian children resulted in similar themes of normalization and underestimation of danger (Abu Liel et al., 2017). The study proposed that children in militarized zones are continuously exposed to intermittent violence which forces them to normalize and integrate traumatic events in order to ensure their normal development. However, the normalization of violence could potentially contribute to long-term difficulty to realistically perceive and evaluate risks and self-protect (Abu Liel et al., 2017). Moreover, research shows that parenting and parent’s behavior promote children’s development of fear and anxiety. Research specifies two kinds of parent behaviors that are involved in this regard: one is the vicarious learning or modeling, which refers to when children watch their parents exhibiting fearful and anxious behavior and they learn it; the other is when parents transmit information in a way that instills fear in the child by 53 indicating how dangerous a particular situation is, in this case COVID-19 (Fliek et al., 2017). In the case of the children interviewed, most of their parents have lived their youth throughout the Palestinian Uprising in 2000, in which curfews, scarcity of food and resources, and imminent danger was an everyday reality. Moreover, a lockdown can be seen like one of the curfews that were regularly imposed on Palestinian people, and they have learned to navigate daily life and cope during curfews. Therefore, it is expected that parents’ perception of danger and risk has been altered and their transmission of this fear or lack thereof, contributed to the children’s perception of risk that is characterized by safety and ambivalence, and, in some form, normalization. 54 Chapter Six Conclusions and Recommendations 55 Chapter Six Conclusions and Recommendations 6.1 Conclusions This research study attempted to answer several research questions related to the experience of children during COVID-19 pandemic lockdown, how did this experience change their daily routine. Palestinian children and adolescents, much like their peers worldwide, experienced a negative psychological impact during the pandemic lockdown and probably continue to do so as the pandemic is still ongoing. Yet the circumstances of the Palestinian experience are different than that of others due to an inherent set of challenges which make life for children pre and post pandemic difficult. The The findings of the study reflect the experience of lockdown and its impact on mental health. However, the study also presented paradoxical results of negative and positive themes working in parallel to one another reflecting the intricate complexity of the experience of the children during lockdown. Future research could investigate these paradoxes in relation to the different context in which these children exist. Understanding these results through the Ecological Systems Theory offers important context to the relationship between childhood development and environment, supporting the idea that changes affect all the components of the system, and the pandemic and lockdown are a new phenomenon that breaks and transforms the system. it can be observed that the drastic change 56 in children’s lives during the lockdown period and the spread of COVID- 19 has unsettled and drastically changed the course of their everyday lives as well as their connection to the different microsystems from interpersonal relationships within the home, to relations with peers and teachers, which in turn, affects all of their systems of development. The lockdown resulting from the COVID-19 pandemic which disrupted children’s daily lives, took them out of school and kept them at home clearly has had an impact. A direct negative psychological impact on the mental health of the children manifested in symptoms of depression and anxiety, specifically feelings of unhappiness, worries, anxiety, and fear, as well as uncertainty. The impact of routine change appeared to be one of the most significant. Disrupted sleep and eating patterns and an increase in use of electronic devices can have a major impact on children’s health and well-being. Family relationships also changed during this time, manifesting in both positive and negative manners. There was also a difference between children who had no daily routine and those who had online schooling. The continuation of schooling through remote learning appeared to support students and reduce the negative impact of the lockdown to an extent. However, the change of routine and the inability to make plans creates a feeling of uncertainty. Taking away the capacity for planning and lack of certainty leaves room for incoming symptoms of anxiety and depression as well as negative coping behaviors 57 in the future of the situation of the COVID-19 lockdown is farther prolonged. 6.2 Recommendations This study sought to provide an initial analysis on the impact of confinement measures on children by centering their experiences and identifying their needs. Several shorter lockdowns have followed the data collection period, and the pandemic remains ongoing, therefore, future research will be able to use a much larger and comparative data set to further understand the impact of the pandemic on children’s mental health, and to mitigate and prevent negative consequences. Accordingly, the several recommendations are made to further mitigate undesired impacts to children’s well-being and mental health. • Mental health support be provided to children specifically with plans to give all children structure and routine for their lives. • Mental health programs to handle traumatic experiences and to screen for those children who might have suffered from violence or other threats in the lockdown. • Prepare children in times of normalcy to provide them with resilience skills to utilize in times of crisis and serve as protective factor. • Online schooling should be facilitated fully to maintain students’ relationships with friends and teachers, and to keep their routine stable. Also, as school is a place of not only learning but also socialization, it 58 is crucial that online schooling also mirrors that role, Therefore, it should provide not only academic teaching but opportunities for socialization between students through teacher supervised activities for children and adolescents. • Family time to be utilized as a protective factor. Families be supported through remote counseling services and other awareness raising and education methods to reduce tension and build upon the positive outcomes resulting from increased time spent together. • To allocate resources and time to train and follow-up with school counselors on dealing with the after math of the pandemic on students’ mental health, as they are the first line of mental health intervention for children and adolescents • Mental health specialists should be a part of emergency committees for the emergency state of COVID-19, considering that mental health should be on all levels from top (government) down (community, hotlines, etc.). • To continue with follow-up research addressing the following: - Specific research to understand more in-depth the experience of the children and the after impact on their lives now that the second wave of lockdown came and the general lockdown is over, as well as understand the experience of parents and teachers. 59 - Quantitative quantitative studies in order to quantify the burden of mental health within the current pandemic. - Specific research on themes of risk and normalization, momentary relief and attitudes towards the school system in the Palestinian context. - Investigating life-satisfaction and the impact of possible change in life satisfaction in light of the frustrations and negative feelings of the children regarding the loss of their everyday normalcy 6.3 Strengths and Limitations The current research offers some strengths as it provides a detailed account of Palestinian children and adolescent’s experience of the lockdown and its potential impact from the perspective of the children. It also fills a gap in this field of research on the pandemic, as well as psychological research on children in Palestine. The results also offer a starting point for future research. There are a few limitations to this research study. Translation of the data collected from Arabic to English might have contributed to loss of meanings of participants’ accounts. This limitation was mitigated by conducting a translation and back-translation of the interviews transcripts to ensure accuracy of data. As the interviews were directed toward children and the time was limited, the interviews did not capture disparate socio-economic conditions that 60 would further contextualize their experiences during confinement periods, not least access to resources, such as internet and computers for distance learning. Moreover, the research was conducted during the period of the pandemic lockdown which in itself poses a limitation to the research process. In particular, most of the children were interviewed virtually which poses a challenge in the ability to obtain sufficient information from the children. The limitation was accounted for by giving the children breaks during the process whenever the researcher felt appropriate to gain back their attention and cooperation. So often research focuses on differentiating Palestinian context from others, yet our struggle shares structural similarities with other parts of the world, but also this focus on differentiation limits our ability to differentiate people’s experience within Palestine. There are geographical reasons that make this possible, but also issues of outreach complicate an ability to capture and represent different parts of society equally. 61 References Abad, C., Fearday, A., & Safdar, N. (2010). Adverse effects of isolation in hospitalised patients: a systematic review. Journal of hospital infection, 76(2), 97-102. Abu Liel Rn, Mmhn, F., Ziya Berte, D., & Russo, S. (2017). 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Impact of COVID-19 pandemic on the mental health of children in Bangladesh: A cross-sectional study. Children and youth services review, 117, 105277. 68 Annexes 69 Annex (I) Interview Guide Demographic information: 1. Gender: male, female (don’t ask the child) ذكر، انثى؟: الجنس 2. Age: (7-17 years) قديش عمرك؟ 3. Current Grade: بأي صف انت؟ 4. City/governorate (don’t ask the child) :المحافظة 5. Type of residency: Village, camp, city (don’t ask the child) مخيم، قرية، مدينة: نوع مكان السكن 6. Number of siblings: كم اخ واخت عندك؟ 7. Type of school: public, private, UNRWA شو نوع مدرستك، خاصة، حكومة، وال وكالة؟ 8. Do you receive/have you received online schooling: yes, no او اخذت حصص اونالين؟/ عم تأخذ حصص اونالين 70 Interview questions: 1. What do you know about the COVID 19? Why are we in Lockdown? في البيت؟/ شو بتعرف عن فايروس كورونا؟ ليش احنا في الحجر البيتي 2. How would you describe your feeling at the beginning of the Lockdown؟ Has it changed now? شو كنت حاسس في بداية الحجر في البيت؟ طيب كيف هال حاسس؟ 3. What are your feelings about all of this situation? Are you afraid/worried? شو رأيك باللي عم بصير او بهذا الوضع؟ كيف حاسس؟ خايف؟ قلقان؟ 4. How the lockdown changed your life? شو تغير عليك في الحجر؟ كيف تغيرت حياتك؟ 5. How is your daily routine nowadays? كل يوم؟ كيف روتينك بالبيت؟ شو بتعمل 6. What is the worst and the best thing about this lockdown? شو احسن شي واسوأ شي في هذا الحجر؟ 7. Can you tell me what do you miss the most? بتقدر تحكيلي شو اكتر شي اشتقتلو وانت بالبيت بالحجر؟ 8. What is the first thing you will do when the lockdown will end? شو اول شي رح تعملو لما نخلص من الحجر البيتي؟ 71 Annex (2) Introductory scripts and consent for the interview :معلومات وموافقة األهل مرحبا، أنا حنين أيوب طالبة في برنامج علم النفس االكلينيكي في جامعة النجاح الوطنية، واقوم ذا البحث الدكتورة بحثية إلنهاء متطلبات شهادة الماجستير، ويقوم باإلشراف على هبعمل دراسة .، والدكتورة سعاد بلكبيرسابرينا روسو سنة خالل مرحلة الحجـر 17الى 7هو دراسة تجربة األطفال من عمرالهدف من هذا البحث البحث مما يعني أننـي تم اختيار طفلك طفلك للمشاركة في هذا. المنزلي بسبب جائحة الكورونا ألغـراض البحـث (سأجري مقابلة مع طفلك على اعتبار أن المقابلة سيتم تسـجيلها صـوتياً يتم تسجيل جميع البيانات لغرض البحث . دقيقة 40-30، ومن المتوقع أن تستمر بين )والتحليل أسماء حقيقيـة لن يتم ذكر . فقط، وستظل مخزنة في ملف آمن، ويتم إتالفها بعد اكتمال الدراسة مشاركة طفلك ف