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The April 2020 issue of the Hong Kong Journal of Paediatrics is an exceptionally memorable issue, particularly for our fellow colleagues working in high-risk clinical settings taking care of sick patients infected with SARS-CoV-19. The novel coronavirus infection has already killed thousands of people worldwide and has had a significant impact on children and parents and their families not only in Hong Kong, but also in other parts of the world. Since the first confirmed paediatric case admitted to Queen Mary Hospital in late February, the situation has dramatically worsened, with infected children as young as 16-month-old currently being cared for by paediatricians in hospitals scattered around the city.

As a result of the ongoing Novel Coronavirus disease 2019 (COVID-19) pandemic, all school have closed and children have been confined to their homes, which potentially has severe consequences in those with disabilities and special educational needs (SEN), as they are vulnerable to neglect and under-stimulation.¹ The school closures have disrupted all students' education, with most schools resorting to online teaching, but children with SEN trapped at home have particular needs that are not being catered for under current conditions.

Parents with children with SEN already face more severe effects from social disparity² and the digital divide, particularly as the home learning environment is a critical consideration in the provision of sensible developmental support to children and their families, especially at this current time. Four original articles related to supporting the needs of disabled children and their parents, and the influence of their environment on early child development have been selected to highlight this very important issue.^3-6 Hopefully, reading these articles will allow us to gain a better understanding of the needs of children with SEN and the potential environmental influences on child development.

In Hong Kong, there are over 57,000 children with SEN, 7,950 students with SEN are enrolled in the city's 60 aided special schools and 49,080 students with SEN are enrolled in mainstream public sector schools.⁷ These children have a wide range of developmental problems including Attention-deficit/Hyperactivity Disorder (ADHD), Autistic Spectrum Disorders (ASD), speech and language pathology, visual or hearing impairment, intellectual disability, and mental illnesses. Given the general lack of support and comprehensive interventions in the community, many parents and caregivers of disabled children experience huge amounts of stress, anxiety, insomnia, and other mental health symptoms.

Children with SEN are the most vulnerable in our society and they require parents' full attention and a great deal of resources including time and money. Simsek et al studied a representative sample of families in Turkey and identified the critical factors leading to lower health-related quality of life and higher depressive levels among mothers of disabled children. Strengthening parents' social network and providing assistance to mothers, such helping them to develop coping strategies or relieving them of the daily caring tasks, were potentially effective ways to improve their quality of life and mental well-being.³

Autistic Spectrum Disorder is a major neurodevelopmental disorder associated with severe language impairment, poor social skills, difficulty in communicating with others, and obsessive and stereotypic behaviours. Children with ASD also usually suffer from global developmental delays, learning difficulties, and emotional dysregulation. Özyurt et al conducted a randomised controlled trial on a group of families of children with ASD from similar socioeconomic background to evaluate the effectiveness of augmentative and alternative communication systems for improving autistic symptoms, language abilities, and emotional regulation. Autistic children using a computer-based voice output communication aid device (VOCA) showed improvements in receptive and expressive language skills, better emotional regulation, and reduced autistic symptoms.⁴ This study sheds light on future interventions designed to be integrated into the educational curriculum of children with ASD.

Children with profound intellectual disability with severe learning difficulties, and behavioural and caring problems, such as sleeping disorders, put their parents and caregivers in a difficult position as they often experience exhaustion and frustration. Chow et al and colleagues in the United Christian Hospital, Hong Kong conducted an interesting study on sleep-related problems among special school students with profound intellectual disabilities.⁵ Sleep disorders are very common among intellectually disabled children, and epilepsy is a common comorbidity associated with sleep-related problems. Adequate attention should be paid to potential sleep disturbances during the management of children with profound intellectual disabilities.

Emerging evidence from overseas and local studies showed that a socioeconomic gradient exists in child development and school readiness. Children in families from a lower socioeconomic status (SES) are more vulnerable to lower school readiness and are at risk of delays in different developmental domains.^8,9 An under-stimulated environment has been associated with insufficient school readiness, and such an unfavourable learning environment is particularly detrimental in children with lower SES who face the double jeopardy of more severe learning and behavioural outcomes. Leung et al echoed this observation in their study that examined a large representative sample of preschoolers with different socioeconomic backgrounds. They utilised the Hong Kong Comprehensive Assessment Scales for Preschool Children (HKCAS-P), a locally developed and validated measurement for holistic development of Chinese preschool children.⁶ The findings raised concerns on the worsening social disparity in Hong Kong, which has harmful effects on children and could lead to potential intergenerational transmission of poverty.

With the establishment of the Hong Kong Commission on Children (CoC) in June 2018, comprehensive support for children with SEN has become a major focus for the government.¹⁰ Resources are being provided in the form of services such as the Onsite Preschool Rehabilitation Services (OPRS) and the School Social Worker Scheme that support the educational and developmental needs of children with disabilities.¹¹ The implementation of such services for children with SEN and developmental needs represents a remarkable milestone in the recognition of the importance of early childhood development, and we hope there is continued investment in evidence-based early interventions.

I would like to take this exceptional opportunity to express my whole-hearted appreciation and salute our nurses, clinicians, and medical professionals who go above and beyond to provide the best care for all our patients and children in need. Let us pray for Hong Kong and support each other during this challenging time, and take comfort in the knowledge that tomorrow is only a day away.

References

1. Wang GH, Zhang YT, Zhao J, Zhang J, Jiang F. Mitigate the effects of home confinement on children during the COVID-19 outbreak. Lancet 2020;395:945-7.

2. Chan KL, Emery CR, Ip P. Children with disabilities are more at risk of violence victimization: evidence from a study of school-aged children. J Interpers Violence 2016;31:1026-46.

3. Simsek IE, Simsek TT, Erel S, Atasavun Uysal S. Factors affecting health related quality of life and depression levels of mothers in families having children with chronic disabilities. HK J Paediatr (new series) 2020;25:71-8.

4. Özyurt G, Dinsever Elíkücük C. Augmentative and alternative communication for children with Autism Spectrum Disorder: a randomised study of awareness and developmental language interventions. HK J Paediatr (new series) 2020;25:79-88.

5. Chow CK, Wong SN, Ma LCK, Fung GPG, Yam WL, Chan HB. The risk factors associated with sleep-related problems in children with profound intellectual disability. HK J Paediatr (new series) 2020;25:89-97.

6. Leung C, Leung S, Lee F, Lo SK. Socioeconomic difference in development among preschool children. HK J Paediatr (new series) 2020;25:98-106.

7. Figures on Special Education 2010. https://www.edb.gov.hk/en/about-edb/publications-stat/figures/special.html

8. Kelly Y, Sacker A, Del Bono E, Francesconi M, Marmot M. What role for the home learning environment and parenting in reducing the socioeconomic gradient in child development? Findings from the Millennium Cohort Study. Arch Dis Child 2011;96:832-7.

9. Ip P, Rao N, Bacon-Shone J, Li SL, Ho FK, Chow CB, Jiang F. Socioeconomic gradients in school readiness of Chinese preschool children: The mediating role of family processes and kindergarten quality. Early Child Res Q 2016;35:111-23.

10. Hong Kong Commission on Children, Working Group on Children with Specific Needs. https://www.coc.gov.hk/en/csnworking.html.

11. Onsite Preschool Rehabilitation Services (OPRS). https://www.swd.gov.hk/oprs/index_en.htm.