Impacts of the COVID-19 Pandemic on Children and Families from Marginalized Groups: A Qualitative Study in Kingston, Ontario

: The COVID-19 pandemic has been associated with unprecedented changes to societal structure. School closures, unstable employment, and inaccessible health services have caused enormous disruptions to child and family wellbeing. This study identiﬁes major themes illustrating how child and family wellness were impacted by COVID-19, including unique effects experienced by Indigenous families. In-depth interviews were conducted with key informants ( n = 31) recruited from organizations providing healthcare and social services in Kingston, Ontario. Interview transcripts and written survey responses were analyzed using a phenomenological approach to explore themes related to child and family wellbeing. Three major themes identiﬁed include school closures, home safety, and outdoor spaces. School closures were generally reported as negatively impacting learning and social development; however, school closures allowed for some Indigenous children to be removed from a colonized education system, contributing to cultural and spiritual growth. Sec-ond, respondents reported increased severity and frequency of domestic violence, which negatively impacted child wellbeing. Third, the closure of public outdoor spaces created barriers to maintaining good physical health for children. This study recommends the prioritization of (1) child learning and development by avoiding school closures in pandemic settings and (2) the safety of Indigenous students by decolonizing education. To address the increased exposure to adverse childhood experiences (ACEs) during COVID-19, we recommend improved training for identifying and reporting domestic violence amongst service providers. Our study also reﬂects the broader need to redeﬁne “essential services”, considering culturally speciﬁc services for Indigenous Peoples.


Introduction
Child and family wellness can be broadly described using an ecological framework integrating individual, family, community, and societal factors [1]. The promotion of child and family wellness relies on factors such as education, material needs (e.g., housing, food security), childcare coordination, mental health, cultural health, and psychosocial support [2,3]. These factors are intrinsically linked to one another, and imbalances in one aspect are likely to influence individual as well as family health and function [1]. An individual's or community's definition of wellness may also change depending on cultural factors.
Since March of 2020, the COVID-19 pandemic has been associated with unprecedented changes to societal structure. School closures, unstable employment, and inaccessible healthcare services, among other changes, have drastically affected people's ability to work, receive education, access healthcare, and engage in cultural or community supports, resulting in enormous disruptions to the wellbeing of children and families with young children [1,4]. Current research suggests child wellbeing during the COVID-19 pandemic has been adversely affected, especially by financial pressures on families and limited access to school support systems. However, local contexts differ, and qualitative data from a small urban Canadian perspective have yet to be explored [5]. The city of Kingston is located in Southern Ontario and has a population of over 130,000 residents. In Kingston, social distancing and other public health measures began in March of 2020. Safety measures included school closures, non-essential business closures, mandatory face coverings, quarantine between high-risk neighboring regions, and isolation between houses [6].
Although early research suggested children were less vulnerable to COVID-19 infection and illness, it is clear that children are experiencing the effects of the pandemic in different ways [3,7]. In a US-based study, 34.7% of children (0-12) were reported as experiencing behavioural changes since the beginning of the pandemic, including being lonely, sad, or depressed [8]. This study also identified increased rates of major depression and severe anxiety in parents, which were negatively associated with the ability to provide education at home and positively associated with higher child anxiety scores [8]. Another US study found recent social isolation and employment loss to be associated with changes in parent-reported disciplining techniques, including an increase in spanking, physical and emotional neglect, and verbal aggression against the child [9]. These findings reflect how the COVID-19 pandemic has created broader disruptions in family functioning, resulting in negative effects on child wellbeing.
Healthy emotional and social development in early childhood is known to reduce the need for mental and physical health services later in life [8,9]. School is an important setting for this socialization and development to happen [10]. Following the closure of Ontario schools in March of 2020 and several periodic school closures since, many teachers have expressed particular concern for the wellbeing of students from marginalized groups [11]. This includes, for example, children from lower socioeconomic status households, children identifying as Black, Indigenous, or persons of colour, children from single-parent families, and children requiring additional educational services (i.e., educational assistants) [12]. Preliminary research suggests that children from these groups may not have the same resources, such as parents who are available to support curriculum during periods of online learning, resulting in learning loss and widening of educational inequities [12].
Indigenous children in Canada may experience pre-existing health inequities as a result of systemic racism, intergenerational trauma due to Canada's legacy of colonialism, and structural factors such as a high prevalence of poverty, which were heightened during the pandemic [13][14][15][16]. The pandemic has made connecting to cultural supports increasingly difficult [17]. Cultural health is important to child development, and it is hypothesized that this lack of community connection has negatively impacted the health of Indigenous children and families [18].
There is clear quantitative evidence to suggest that child and family wellbeing has suffered as a result of COVID-19; however, qualitative data can be used to contextualize these challenges during this socially and culturally complex time. This paper aims to identify major themes illustrating how child and family wellness were impacted by COVID-19, including unique effects experienced by Indigenous children and their families, to inform actionable policy and programming interventions directed towards improving child and family health.

Data Source
The data for this analysis come from the Cost of COVID study, a mixed methods study exploring the social and emotional impacts of the COVID-19 pandemic in South Eastern Ontario, Canada, specifically in the Kingston, Frontenac, Lennox, and Addington public health region (KFL&A). The in-depth interviews used for this analysis were conducted with key informants recruited from organizations providing healthcare and social services in KFL&A, including child welfare services, school support, mental health services, domestic violence services, and primary care, among others (Table 1). Service providers included in the study reported on changes observed in their clients throughout the COVID-19 pandemic. Service providers and volunteers from organizations providing services to Indigenous Peoples were intentionally recruited.

Participants
Participants were recruited by email or phone. Trained Research Assistants conducted interviews via Zoom, a video conferencing platform, between October and December 2020 in order adhere to public health social distancing guidelines. Interviews lasted approximately 60 min. Participant consent was obtained, and the confidentiality of participants was maintained by removing identifiable information from interview transcripts. Ethics approval was obtained through Queen's University Health Sciences and Affiliated Teaching Hospital's Research Ethics Board.
An Indigenous oversight committee was involved in every step of data collection and analysis, aligning with the First Nations Principles of OCAP ® (ownership, control, access, and possession of research data and findings) [19]. The project was led by members of the Cost of COVID Indigenous Health Council (IHC) subcommittee, and monthly meetings were held to ensure all aspects of the study were properly conducted and responsive to community needs. Members of the IHC guided the data analysis so that themes were appropriately interpreted and analyzed.

Data Analysis
A phenomenological approach was used to explore themes related to child and family wellbeing from the perspective of family and child service providers [20]. Phenomenology is the study of people's experience of a phenomena and allows for an intimate, first-person perspective on otherwise complex topics [20]. In-depth interviews with health and social service providers were audio recorded and transcribed verbatim. Transcripts were read in their entirety twice by two researchers (H.L. and E.P.). Transcripts were analyzed and coded as one dataset using the NVivo software seeking themes related to child and family wellbeing. An Indigenous Research Assistant (AW) also reviewed the data and was consulted to provide validation on themes as they pertained to Indigenous Peoples. A double-coded phenomenological analysis was performed to assess inter-coder agreement and to validate identified themes [21,22].

Results
Thirty-one interviews were conducted between 22 October and 14 December 2020. Six themes related to the experiences of children and families with young children during the COVID-19 pandemic were identified from the results. These include routine, school closures, home safety, socialization and development, outdoor spaces, and Indigenous ways of knowing and being. Quotations used to illustrate each theme were intentionally selected to reflect a variety of participant experiences.

Routine
Lack of structure and inconsistent routines during the COVID-19 pandemic due to changes in school attendance, online classes, canceled recreational activities, services, and supports was an important theme affecting child and family wellness. Inaccessible childcare during the pandemic also contributed to disruptions of routine, particularly affecting low-resourced families.
"Even though they're really little, you could see that they were very sad, missing their daily routine and structure of going to Daycare or going to school, playing with their peers, going to that home Daycare, going out to the park, seeing their friends. There was a sadness in them . . . you could kind of see it in their behaviour because their behaviour would escalate . . . when they were frustrated and they couldn't get out and . . . advocate for themselves that they wanted to [be] with their friends." (Service Provider, Indigenous, 1A) "A lot of the kids that I saw were struggling with anxiety because they weren't able to see their friends, their family, having no routine." (Service Provider, Indigenous, 1A) "Whether that be children, small children or adult children, what we saw was an immediate stripping of peoples' supports . . . Their social supports . . . their structural supports and all of those things that they depended on to keep them well and regulated." (Service Administrator, 10B) "Some people struggled immensely with children and family members that require 24 h care and . . . previous to [the] pandemic were shared between systems like health and school and developmental services. So we saw people physically tired very early. We saw the effects of isolation in care giving come on very early. (Service Administrator, 10B) In general, routine disruptions were reported as negatively affecting child and family wellness. Nevertheless, some respondents indicated that a subset of children and families for whom the rigid structures of school and family life are a source of stress actually seemed to benefit without the pressure of a strict routine.
"I have had a handful of children who we support that have done much better without the demands of society telling them they must get up at a certain time. They must brush their teeth. They must go to a school environment that . . . might not work for them. They must participate in the socially acceptable activity in a socially acceptable way. And they must continue with their programs . . . But those are the families that have had the necessary means to maintain an income . . . And they perhaps have some family support that allows for that to happen." (Service Administrator, 10B)

School Closures
The closure of schools had numerous effects on child wellbeing. Children did not receive the same quality of education, which in some cases had harmful effects on learning. The uncertainty around how to return to school safely during the pandemic was a source of anxiety for many young children and families. Additionally, school closures were a significant burden for some families who relied on school for childcare during the day.
"I worry deeply about learning loss." (Service Administrator, 1B) "We're seeing lots of kids that are really . . . falling behind in school . . . And now the kids are not able to receive the specialized supports that they would have needed. And I'm worried that they're falling farther and farther behind." (Service Provider, 5B) "When you have families, young families that are where there is a lot of stress, there's food insecurity, housing insecurity and like inadequate housing like just under housed, it makes it just really hard to create an online learning environment for their children . . . [T]here is continuing to be a profound impact on kids learning." (Volunteer, Indigenous, 13A) "I think having kids go to school during the day is really important for a lot of reasons. It gives parents a break from kids. It gives kids a break from parents . . . And it's actually really important . . . for kids that have behavior struggles and parents that struggle to manage them" (Service Provider, 5B) While, in general, school closures were seen as negative, for Indigenous children, the closure of schools meant removal from an education system built by colonizers, which in some cases allowed for cultural and spiritual growth. For a minority of students, school was an unsafe environment before COVID-19, and school closures allowed children to be extricated from potentially harmful situations.
"I feel that it was really humbling to see finally some Indigenous families not having to be in the colonial structure of schools and school boards." (Volunteer, Indigenous, 9A) "They were including their children in the baking. They were including their children in the measuring. They were going back to our traditional ways of how we teach our young. And it wasn't the western reading, writing, arithmetic. It was in the most holistic way." (Service Administrator, Indigenous, 9A)

Home Safety
The pandemic forced families to live and work within close quarters of one another, with little access to other means of support. Many service providers reported that this resulted in increased levels of interpersonal stress and conflict among both adults and children. Some providers suggested increased household anxiety was associated with increased anxiety in children. Respondents reported increased severity and frequency of intimate partner violence for their adult clients, putting children in the damaging position of new or increasing exposure to domestic violence. Increased levels of domestic violence contributed to heightened risk of family separation.
"Parental stress piece is something that obviously is filtering down into . . To contrast, a minority of service providers described improved home environments for their clients as a result of spending more time together.
"Some families are happy that they're spending more time together" (Service Provider, Indigenous, 5A

Socialization and Development
Interpersonal interaction has been challenging during COVID-19. The lack of play and human interaction for young children at crucial stages in their development was reported as detrimental for social, emotional, and cognitive development. For some children, the drastic changes in their surrounding environments resulted in concerns with meeting developmental milestones, due to an inability to integrate their experiences through normal play. For children who were used to a pre-pandemic world, the sudden changes in socialization, such as mask wearing or required distancing, made previously familiar environments feel strange.
"There hasn't been the kind of play that normally there would be due to . . . the effects of social distancing. And that's really had a big impact on kids' . . . socialization. Like the kids that come to [name of social service] tend to be younger and so . . . they really need that play socialization... I think that it's had a big impact on children in terms of play as being their usual and normal way that they integrate the complexity of their social lives" (Volunteer, Indigenous, 13A) "That was really tough just in terms of just mental health and general wellbeing, not being able to socialize with their peer group the way that they did or were used to doing. And that being such a huge part of their development" (Service Provider, 3B) "Now that the children are integrating back into what normal is, it's evident that their personalities have changed. The experiences that they've experienced have changed them, have maybe perhaps made them a little bit more jaded, has perhaps made them a little bit more grown" (Volunteer, Indigenous, 9A) "One [concern] is the impact on young children and their development in both physical development, their physical wellbeing, their cultural connection, their language." (Volunteer, Indigenous, 13A) "The kids under [ . . . ] four [ . . . ] there were new behaviours that popped up. So a little bit of depression, a little bit of behaviours regressing. Some of them regressed. Some were potty trained. Some of them regressed . . . and went back and weren't potty trained. Some of them decided they weren't eating." (Service Provider, Indigenous, 1A) "They weren't understanding why they couldn't go into the grocery store with mom. Why everybody was wearing a mask. It became scary. Kids that were going to the day care, that went so willingly, were scared because they were getting screened at the door with someone in a full body suit with . . . the temperature thing at their head . . . So a lot of them have said the kids are adjusting." (Service Provider, 4B)

Outdoor Spaces
The combination of online school and the closure of public outdoor spaces created barriers to maintaining good physical health for some children during the pandemic. This was particularly true for families and children who did not have access to backyards or other private outdoor spaces and for those who perceived public outdoor spaces as potential sources of infection. This limited access to spaces was related to increased stress on family dynamics. "They're afraid to let them play outside, so the kids are bouncing off the walls and the parents are stressed." (Service Provider, 5B) "Parents that don't have a lot of resources, have decided to keep their kids home, they're sedentary all day. So they're on the screen or they're watching TV, they're gaining weight . . . even if all the restrictions were lifted tomorrow . . . these new pattern of increased . . . sedentariness [has] long-lasting consequences." (Service Provider, 5B) "They don't have private back yards so those kids are not going outside because there's no private space to play. The parks were closed . . . so they're all cooped up in a small room together. That's not going to go smoothly for any family." (Service Provider, 5B) To contrast, for those who were able to take advantage of outdoor spaces, school closures provided some children unique opportunities to connect with the land. For Indigenous children, connection with the land allowed for unlearning of western norms and revitalization of Indigenous ways of life.
"I feel that it was really humbling to see finally some Indigenous families . . . connecting to the land." (Volunteer, Indigenous, 9A)

Indigenous Ways of Knowing and Being
The pandemic has made it increasingly difficult to connect with one's culture through ceremony or cultural gatherings. This theme was raised primarily by Indigenous respondents, emphasizing togetherness as crucial to a sense of community cohesion. Respondents described togetherness as opportunities to relate and share the same world view through ceremony, language, and song, contributing to a sense of identity, belonging, and overall wellness. Due to social distancing and public health countermeasures, children and families did not have the same opportunities to access community supports. Definitions of "essential services" allowed to remain open during the pandemic did not include culturally important gatherings. Excluding cultural supports from the definition of "essential services" is especially harmful given the history of past and ongoing colonization of Indigenous Peoples in Canada, which has often included restrictions on rights to ceremony and cultural gatherings.
"We used to do like traditional teaching workshops with families where we would make let's say earrings or moccasins or do a teaching or have dinner together... We're unable to do those things right now and are unable to provide the services for them. We have gone virtual with some of our workshops, but it's just not quite the same when you're at home trying to do it on your own." (Service Provider, Indigenous, 1A) "We love our people. And we like to be together and it's being together, sharing and loving and giving kindness to one another .

Discussion
These findings reflect the broader narrative of disruptions to child and family wellbeing during the COVID-19 pandemic [9,12,23]. These disruptions can be categorized into six themes: routine, school closures, home safety, socialization, outdoor spaces, and Indigenous ways of knowing and being. Although the aforementioned themes have been presented discretely, it is important to acknowledge that they are inextricably linked to one another. The six themes reflect the extensive and profound effects the COVID-19 pandemic has had on all aspects of child and family wellbeing. Underlying each of these themes is the issue of disruption of routines, which was shown to affect mood and increase anxiety for many children who relied on structure in their lives. Studies show that flexible routines and proactive adaptations to daily structure to support children during the pandemic and beyond should be encouraged [24,25]. It is important to highlight that COVID-19 has had differential impacts on different groups, depending on their location, perspectives, and ways of living. The themes outlined in this study may not apply to all children and families across all communities.
Family and child wellness are complicated, and these findings confirm this. The COVID-19 pandemic has allowed us to pause and rethink societal structures affecting children and families. The results highlight three important priorities for the recovery phase of the pandemic and future public health disasters: (1) education reform, (2) improved education of service providers to the impacts of child and family adverse childhood experiences (ACEs), and (3) re-defining "essential services" to include culturally important supports.
School closures have greatly impacted family wellbeing and function, especially families who lack resources to support their children with online learning at home. These findings support current recommendations for schools to provide additional educational supports to families for periods of remote learning [12] and with the transition back to in person learning. Ontario's schools have been closed for longer than any other jurisdiction in Canada, and online learning continues to be an option for the 2021-2022 academic year in elementary and high school [26]. Many service providers voiced concerns about perceived learning loss for young children, as a result of prolonged school closures. This reflects the broader discourse about online school in Canada, where many teachers in Ontario have reported being inadequately resourced to teach young children especially in a virtual setting [27].
In Ontario, children start school at the age of 3-4 years old. Young children achieve major physical, social, emotional, and cognitive developmental milestones at this age through socialization and routine play [28,29]. It is, therefore, unsurprising that participants reported concerns with social, emotional, and cognitive development for young children during the pandemic. Some examples include new fears related to basic tasks (e.g., grocery shopping or attending daycare), depressed mood levels and social withdrawal, and regression in toilet training. These findings stress the importance of addressing barriers to maintaining socialization for young children, including lack of supervision, accessible outdoor spaces, and material resources, during periods of school closure and the closure of early years playgroups.
Although current literature suggests school closures were primarily detrimental to the wellbeing of children and families, this study found a subset of children reported improved wellness during periods of school closure [12,30,31]. The results identified that school remains an unsafe environment for a variety of children, including Indigenous children. During the pandemic, Indigenous children were removed from school systems built by colonizers, which may have led to improved cultural and spiritual wellbeing for some children. These results agree with the literature that Eurocentric school systems are unsafe for many Indigenous and marginalized children [32][33][34]. Overall, findings from this study illustrate two themes to inform policy recommendations: (1) the importance of in-person education for learning and healthy child development or adequate supplemental in-person interactions during pandemic settings, and (2) the need to decolonize western education systems to create safer learning environments for Indigenous children, among others [35]. Prior research suggests the decolonization of schools requires a four-pronged approach: (1) reflecting on the structure of educational institutions and their role within society, (2) confronting power relations within institutions, (3) addressing systemic racism experienced by Indigenous students, and (4) continual reflection of curriculum [36].
Another important finding echoing existing literature was the increased concerns related to home safety during the COVID-19 pandemic. Service providers observed increased reports of family conflict, domestic violence, and Children's Aid Society (CAS) referrals. Exposure to adverse childhood experiences (ACEs), such as child maltreatment or domestic violence, early in life increases one's risk for long-term poor health outcomes [37,38]. Children exposed to four or more ACEs are at a significantly increased risk of chronic diseases, including ischemic heart disease, cancer, mental illness, and health risk behaviours [37,38]. Literature supports the need for all health and social service providers to receive training in identifying and responding to child abuse, as well as to children's exposure to intimate partner violence (IPV) [39,40]. Responses to suspected IPV should prioritize child safety and include emotional support, education about IPV, and signposting to accessible IPV services [40]. The increased number and severity of domestic violence cases reported in this study and in other literature emerging from the pandemic warrants better preparation of health and social service providers, educators, and those who work with children to identify cases of family violence and mitigate the long-term negative effects on children [41].
Although some service providers reported increased levels of stress, conflict, and domestic violence amongst families, others reported increased family bonding and improved family dynamics. We suspect the pandemic has exacerbated current living situations, leading to either stronger family bonds or increased rates of conflict depending on prepandemic family situations. We also recognize that the respondents are service providers and, therefore, interact selectively with families that need or choose to seek access to health and social services during the pandemic. While the literature supports increases in both intimate partner violence and child abuse during the pandemic, these findings may reflect a potentially distorted view of the overall experience of home safety [9,41].
Finally, an important discussion during the COVID-19 pandemic has surrounded which services were deemed "essential". Current literature suggests that failure to consider marginalized populations when classifying "essential services" resulted in negative impacts for these groups [42,43]. For example, the closure of public outdoor spaces such as parks and playgrounds, initially deemed "unessential", made it increasingly difficult for children to maintain good physical health. This was especially difficult for families without access to private outdoor spaces. Closure of public outdoor spaces has resulted in changes in behaviour including increased screen time, unhealthy weight gain, and increased sedentary behaviour [44]. These data show that children without access to greenspace became increasingly restless during periods of quarantine, contributing to family stress and conflict. To contrast, children who did have access to outdoor spaces reported improved spiritual and emotional wellbeing, especially Indigenous children who were able to connect with the land. These findings support recommendations to create and maintain public spaces for socialization and outdoor play to encourage healthy child development and wellness [13,45]. They also highlight the need for programs and resources to support the unlearning of some of the unhealthy behaviours that developed during the pandemic.
Cultural and spiritual health were also not prioritized when identifying which services were deemed "essential". The results show how challenging this has been for many Indigenous families in particular, where in-person gatherings are important for cultural teachings and language revitalization that have been lost to some degree through past and ongoing colonization. The data show that a lack of cultural connection has been detrimental to overall wellbeing, disproportionately affecting certain groups, and stressing the importance of finding unique ways to safely maintain community connection and support during periods of quarantine. It raises questions around which services are essential to whom, and how the process of reconciliation in Canada can be practically actualized through engaging Indigenous voices when making decisions during times of crisis.

Limitations
The service providers recruited for this study described the experiences of service users and not necessarily their own experiences. Service providers may have made inaccurate assumptions about how their patients/clients were feeling. Service providers also only have access to those who seek health/service support, which may contribute to a lack of generalizability of these results to the broader population. The data for this study were also collected in semi-structured interviews that explored topics beyond child and family wellness. Questions targeting other topics may have yielded additional information.

Conclusions
There are three key conclusions from this study: The first is the need for education reform. This study recommends the prioritization of (1) child learning and development by avoiding school closures in the context of pandemics or other disasters and (2) the safety of Indigenous students through efforts to decolonize education. School closures can be avoided with strategies to keep community transmission low through vaccination mandates for education workers and eligible students, smaller class sizes, and mask mandates [46,47].
Second, to address the increased exposure to ACEs during the COVID-19 pandemic and prevent long-term health implications, we recommend improved training for identifying and reporting child maltreatment and intimate partner violence for health and social service providers and educators [40]. We also recommend family services, including support for material, educational, and mental health needs, be better resourced during periods of quarantine to help prevent ACEs and rebuild strong and healthy family relationships.
Third, this study reflects the broader need to re-assess the definition of "essential services" as they relate to children and families, considering culturally specific services for Indigenous Peoples. The ongoing connectedness of many Indigenous Peoples throughout periods of isolation reflects the power of language and culture in maintaining a sense of community. We need more fulsome consultation around the designation of "essential services" to ensure child health and safety and engage in meaningful reconciliation practices with Indigenous communities. Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Data are available upon request by contacting hlee@qmed.ca. The full data are not freely available to respect the confidentiality of our participants, ensure data integrity, and avoid scientific overlap between projects. Once initial contact has been made, we request a short research proposal which will be subject to review by the Cost of COVID Committee and approval by institutional IRBs.

Conflicts of Interest:
The authors declare no conflict of interest.