Evidence-based risk reducing initiatives for children in schools

Evidence-based risk reducing initiatives for children in schools:

Schools and education play an important protective role for all children, including the most vulnerable, in terms of cognitive, language, social, emotional and physical development, mental health, physical health, social risk and well-being.  Please see statements relating to evidence-based protective factors and normative activities.

Systemic risk and protective factors in the context of #covid19 must however be assessed, identified, considered, weighed and managed by professionals with experience in this context (experience in respiratory infections, children’s health, children’s social, emotional, language, cognitive and physical development, including children’s neurodevelopment, children’s mental health and social risk).

Doctors with training and experience in neurodevelopment, especially in the context of respiratory infections, will likely have concerns regarding schools opening without additional and effective (based ONLY on GOOD clinical evidence) risk reducing initiatives, that do not increase risk for children in other ways.  

Most adults who work with children present with frequently increased incidence of upper respiratory infections (colds or flu).  Children also visit grandparents and elderly relatives, and engage within the general community unsupervised or supervised.  This impacts on risk for communities.  

Normal neurodevelopmental stages of children indicate that children (without learning, neurodevelopmental and mental health problems) are often significantly more physically playful, fidgety, impulsive, inattentive and forgetful than adults.  Consider research where authority figures inform children that they cannot touch an object; that it would very likely result in imminent death.  Children proceed to touching and playing with the object within minutes.  This is normal behaviour for most children without mental health, neurodevelopmental or learning problems.  Research indicates that adults (mostly with fully developed frontal lobes and neurological systems) touch their faces more or less 16-23 times per hour, often without registering this behaviour.  In Europe and the UK, we observe most adults #touching their #faces underneath their #masks with #unwashed #hands on a daily basis, masks hanging on #ears or #chins, or adults dropping masks on wet floors and wearing it again – this increases risk and harm relating to general health significantly.  We can provide many photographs from many countries. Children’s behaviour in this context will likely not be safer or more #responsible, the contrary will be likely. 

Mental health problems, learning problems or neurodevelopmental disorders such as #ASD or #ADHD, often increase these features, relating to physical playfulness, fidgeting, impulsivity, inattentiveness and forgetfulness, markedly for children or adults.  

In the UK more or less 2.5% of children present with #learning disabilities, as reported by MENCAP.  Learning problems are more prevalent, 14.9% of school aged children have special educational needs, as reported by GOV. UK.  Many children with learning problems have not been identified.  More or less 30% of children with developmental delay, present with associated mental health problems or concerns. 

Prevalence of neurodevelopmental disorders, such as ADHD, in children is more or less 3-4% in England and Wales.  It must be noted that children in this category are often most vulnerable for co-morbid mental health morbidity, often presenting with more than one co-morbid mental health diagnosis or concern, which are not always easy to identify; this is one of the reasons we recommend that children are assessed, diagnosed and treated or managed by Child Psychiatrists with training, CCTs, in Child Psychiatry, and that children with #ADHD or #ASD remain within generic #CAMHS teams, rather than be referred to separate neurodevelopmental, ADHD or ASD teams.  Children also often wait months or years on ADHD waiting lists, whilst presenting with serious co-morbid concerns such as #depression and #suicidal ideation, which lead to markedly increased risk.  Co-morbidities of ADHD include depression (15%), anxiety disorders (25%), learning disabilities (15-40%), language impairment (15-75%), Oppositional Defiant Disorder (35-50%) and Conduct Disorder (25%).  More than 50% of children with ADHD meet criteria for 2 co-morbid conditions.  

The WHO reports that more or less 20% of adolescents may experience a mental health problem in any given year.  GOV.UK reports that more or less 12.5% of 5-19 year olds had at least one mental health disorder and that more or less 5% met criteria for 2 or more mental health disorders (survey 2017, published 2019).  The Children’s Society reports that more or less 10% of children and young people aged 5-16 years have a clinically diagnosable mental health problem, yet 70% of children and adolescents with mental health problems have not had appropriate interventions at a sufficiently early age. This is one of the reasons we recommend that children referred to CAHMS are seen by a medical doctor / Child Psychiatrists within 2 weeks of referral.

It might be relevant to add in this context, considering recent research published by the Lancet, that longstanding research indicates that all or most physical health problems or disorders can increase mental health morbidity by up to 50%, neurological injury can increase prevalence by up to 500%, and neurological injury associated with epilepsy can increase prevalence by up to 1000%.

Biological risks in schools will affect risk in communities.  Risk reducing initiatives, based ONLY on GOOD clinical evidence, have been employed to reduce risk and harm from a bio-psycho-social point of view for children attending schools in many nations – we will provide examples.  

Evidence-based risk reducing initiatives for children in schools:

1. Children now rotate through schools in some countries to keep the numbers down per classroom (if a large number of children in a small classroom) and at the school in general, for instance in corridors, to facilitate social distancing and reduce risk.  

2. We have observed that social distancing is possible in almost all contexts in the public.

3. Good ventilation is facilitated, even if it has to be through open windows and doors.

4. Some classes are taught in gym class or outside if weather permits.

5. Clear instructions are given to staff and pupils to remain at home if a raised temperature, symptoms or recent confirmed contact (some include a recent traveller at their homes).

6. Temperature screens and symptom or health questionnaires are in place for every student, staff member and teacher to complete every morning at home before attending schools on interactive apps or on paper format. Many countries still identify individuals with symptoms by paper questionnaires and old fashioned temperature screens, this is equally effective.

7. It is our clinical opinion as Consultant Child Psychiatrists with more or less 15 years training and more than 20 years clinical experience that indiscriminate mandatory mask wearing will likely increase risk markedly from a general health, mental health, child development and social risk point of view for children (and adults).

There is no good clinical evidence that supports the wearing of face masks in the community for healthy individuals, there is however significant evidence indicating increased risk.

The WHO and ECDC agree that there is no good clinical evidence to support face masks for healthy individuals in the community:

“At present there is only limited and inconsistent scientific evidence to support the effectiveness of masking healthy people in the community to prevent infection with respiratory viruses, including SARS-CoV-2”  World Health Organisation https://apps.who.int/iris/rest/bitstreams/1319378/retrieve

“There is limited evidence on the effectiveness of medical face masks for the prevention of COVID-19 in the community.” ECDC, European Centre for Disease Prevention and Control https://www.ecdc.europa.eu/sites/default/files/documents/covid-19-face-masks-community-first-update.pdf

In our opinion it is not clinically indicated and it is not based on good clinical evidence to ask all children to wear face masks in schools.

Children at high risk for severe COVID-19 and children who have symptoms need to follow different protocols.

8. It is our clinical opinion that face masks should never be ‘normalised’ for children or adults, considering the lack of good clinical evidence to support face masks in the community for healthy individuals, and the evidence that risk is increased for many. We have written extensively on this topic, normalcy (and evidence-based protective factors), liaising with appropriate parties.

9. It is our clinical opinion that absolutely no #clinical #tests (side-room or special #investigations) should be completed on children unless there are clinical #indications based on good clinical #research.

Children are very sensitive to various mental health problems including different anxiety disorders at different ages, which can cause long term, sometimes life long, debilitating symptoms, distress and impairment. Medical #tests provide a very strong #message to a #child, often of ‘sick’ or ‘patient’, which often causes emotions such as fear, panic, frustration, anger or low mood, and negative beliefs regarding germs, sickness, health, death and safety – this affects behaviours, general health, mental health and social risk.

Most professionals who work with children with mental health problems have seen children referred with little or no #skin on their hands due to excessive, repetitive and longstanding #handwashing eg due to #OCD or #germ #phobias , or children with serious #wounds due to #selfharm (we have often had to refer children to plastic surgery). Children may also present with wounds inside of their mouths due to regular biting, secondary to high levels of anxiety or stress – adults, parents or carers, are sometimes not aware that children engage in these behaviours. These are often complex matters with complex predisposing, precipitating and maintaining factors, and it is essential that clinical experts in this domain be consulted.

It is our clinical opinion that indiscriminate mandatory mask wearing initiatives, along with other initiatives associated with deprivation of liberty, not based on clinical indications and good clinical evidence, such as ongoing and repetitive quarantine, curfews, stay at home and lockdown, will likely markedly affect children’s social, language, cognitive, emotional and physical development, along with mental health, general health and social risk in negative ways.

Children’s development often (not always) experiences ‘catch up’ when they are removed from abusive or neglectful environments, however, we have to ask whether it is ethical to expose children to initiatives associated with risk, when there is no good clinical evidence to support these initiatives. We have to first do no harm, as per the oath most medical doctors took after their initial 6 years of training.

Increased risk in terms of mental health, general health and social concerns, such as violence, however, can be associated with significant long term consequences. It is also important to note that mental health affects general health and social risk; any one of these factors, including child development, affects the other factors. Immediate, short term, long term risk is therefore increased.

Ethical and medico-legal questions have to be asked and answered in these contexts, considering that this is a health (or medical) crisis and medical (or clinical) decisions are (or should be) made based on medical (clinical) evidence and patient specific clinical indications to protect children and adults in the community, preventing increased risk and harm.

10. Education is key – regarding good hand or food #hygiene and #healthy #food and life style – but this has to be executed in a #fun and ‘ #normalising ‘ manner – children should not experience increased anxiety, anger, frustration or sadness by these ‘ #lessons ‘, the opposite should be relevant – children should be #distracted, #relax, #enjoy themselves and feel #empowered by these #narratives and #activities, by #learning new #skills and developing exciting dreams for tomorrow. This is essential.

It is very important to focus on age appropriate topics for children, considering their developmental age, not chronological age – and to execute the lessons or education in an age appropriate manner.

We receive too many statements from children age 3 to 13, that are not appropriate for children relating to the pandemic. Many children do not have the tools, due to their normal developmental age, to manage these concerns. Let children be children and let them deal with children’s issues, until it is their time to gradually start taking different roles, and eventually lead. We often refer to children taking adult roles as ‘young carers’ – this is not in the best interest of a child’s development, mental health and general health.

#Creative evidence-based options to reduce risk are always available in every domain and context, however, it is essential that risk factors and protective factors are assessed, identified, acknowledged, understood and managed appropriately, by professionals with experience in this domain, with regular review.  

The importance of #eduction for the general public is relevant in this and every context.  It is our opinion, based on observation in more or less 20 countries since the pandemic was reported, that this has not been achieve in many nations regarding the basic evidence-based (good clinical evidence) risk reducing and protective factors in the context of respiratory infections.

We have shared observations and concerns with relevant authorities since March 2020. Many authorities, health ministries, public health departments as well as international and national organisations safeguarding children are working together to ensure that good clinical evidence is followed to prevent increased risk and harm for children and adults. We thank everyone for their responses and efforts to work in collaboration to achieve clinical goals.

We offer pro bono training and presentations relating to this topic to staff supporting vulnerable children such as teachers, youth offending teams, Social Care or the Police, twice a year. Please contact us at admin@cinaps.co.uk for details of upcoming training events.

For more comments on protecting children, please see comments on:

An Achievable, Sustainable New Normal


Our General Recommendations to Maintain Good Health


Healthy Enjoyable Food Options


Simple Initiatives to Support the Immune System



The Importance of Normalcy for Children and Adults


Simple Initiatives Can Positively Impact on Mental State


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