Let the children play: Getting children and youth outdoors now for an active recovery

Summary

As Ontario strives to rebuild and recover from the effects of the COVID-19 pandemic, action is needed now to prioritize our children’s optimal health and development. By applying Indigenous tools and approaches to well-being through access to the outdoors and physical activity, we can help to reduce the consequences of the pandemic and shape the future trajectories for a generation at risk. This call to action was created in partnership between Native Child and Family Services of Toronto (NCFST), The Hospital for Sick Children (SickKids) and researchers from the Factor-Inwentash Faculty of Social Work at the University of Toronto. 

Overview: Children and youth have been severely impacted by the COVID-19 pandemic

Children and youth have been profoundly affected by the ongoing COVID-19 pandemic. While the prevalence, symptoms and health outcomes of COVID-19 tend to be much less severe for children and youth compared to adults, the toll of the pandemic and the associated public health restrictions on child health, development and well-being is severe. Evidence indicates that the social, emotional and educational impacts of the pandemic, including prolonged isolation, repeated school closures, hours of screen time and increased stress and fears about the virus, have all had a dramatic effect on both physical and mental health in children and youth (Tombeau Cost et al., 2021; Public Health Ontario, 2020). Children have missed out on opportunities for learning and skills development, including positive and safe practices for outdoor activities – both at school and in the community. Furthermore, the pandemic has been associated with disruptions to critical developmental milestones, increased symptoms of anxiety and depression in children of all ages, increases in speech delay in young children and a rise in emergency department visits for eating disorders (Couturier et al., 2021). Children and youth are different than adults – their brains continue to develop and the pandemic restrictions have deprived them from important social, emotional and physical interactions. This deprivation, in combination with increased levels of stress experienced by caregivers and children and youth themselves during the pandemic, can have a long-lasting effect on brain development (Center on the Developing Child, 2020).

This report is a call to action – Ontario cannot afford to ignore the increasing consequences of pandemic restrictions on the health and well-being of children and youth.

We are currently experiencing the effects of a difficult third wave of COVID-19, with schools closed indefinitely and families restricted to staying home at all times except for essential trips. While we need to continue to implement public health measures to prevent the spread of COVID-19, we must prioritize schools as the first doors to open before other parts of the economy and open outdoor activities for children and youth to protect their health, safety and well-being. Given the numerous benefits of participation in physical, social and other outdoor recreational activities, strategies are needed to overcome barriers to participation and promote alternative approaches to support outdoor activities for children now, and throughout the pandemic recovery period. The science is clear that the risk of outdoor transmission of COVID-19 is substantially lower than indoor transmission, especially with appropriate distancing and personal protective equipment (PPE). Therefore, there is an urgent need to prioritize outdoor activities for children and youth to begin to mitigate the devastating and inequitable effects of pandemic-related restrictions on their health and well-being, and to support an active recovery for children, youth and their families. We propose a way forward that acknowledges and respects Indigenous land-based approaches to health and wellness to reconnect children to the outdoors.

A framework for action: Leaning into the land for wellness

Indigenous Peoples have long known the importance of leaning into the land for wellness. For millennia, Elders and knowledge keepers have recognized that interaction with the natural world around us promotes physical, emotional, mental and spiritual wellness for all people. This important principle provides a fundamental lesson on the effectiveness of Indigenous tools and approaches to well-being that can be applied to the current COVID-19 crisis.

By strengthening connections to the outdoors, the consequences of the pandemic can be reduced not only for Indigenous communities, but for all children and youth in Ontario and beyond.

The value of this approach can be seen in the successful implementation of recent outdoor programming offered by NCFST. In March 2020, NCFST suspended the majority of face-to-face services in compliance with local and provincial guidelines. As other countries that were further along in their pandemic trajectories generated new data, it appeared that many of the challenges children and youth were experiencing could be mitigated through trauma-informed land-based practices. Following this model, NCFST began offering safe outdoor programming in select City of Toronto parks starting June 15, 2020, enabled by the agency’s status as an essential services provider.

Families from a single household could register for hour-long sessions where they would meet a single staff member delivering programming while physically distancing and wearing appropriate PPE. Indigenous approaches to engagement with trees, water, the earth (grass, soil) and urban wildlife were accompanied by cultural songs, crafts, games and other activities. A rapid evaluation of over 50 families participating in the program throughout the first and second waves of the pandemic showed that participants experienced increases in physical activity and wellness, improvements in their overall mental health and an increase in feelings of family, community and cultural connectedness (On the Land Report, 2020). This pivot to land-based practice demonstrates how Indigenous innovation can provide critical direction for instituting safe outdoor practice supporting the physiological, mental health and developmental needs of children and youth throughout this pandemic.

The importance of outdoor activity for children and youth

The benefits of physical activity for the growth and development of children and youth prior to the COVID-19 pandemic are unquestioned. Recent studies demonstrate that greater physical activity and movement levels in children and youth are associated with the following outcomes: higher health-related quality of life; improved cardiovascular health, bone health, immune function, and indices of adiposity (e.g., body mass index, fat mass, waist circumference); cognitive development; and academic achievement (ParticipACTION, 2020). Notably, physical activity is known to promote healthy brain development and to be effective for preventing and treating both mental health conditions (i.e., anxiety and depression) and brain-based disorders in children (Biddle & Assare, 2011; Hillman et al., 2008; Monti et al., 2012; Riggs et al., 2017; Szulc-Lerch et al., 2018; ParticipACTION, 2018) and youth (DiPietro et al., 2019).

Different types of physical activity, including both structured and unstructured activities, have wide-ranging benefits. For example, unstructured, free play outdoor activity is effective at promoting cognitive skills and learning, socio-emotional skills such as resilience and self-regulation, as well as motor development in young children (Tremblay et al., 2015). Activities such as running, cycling, swimming, hiking and exploring not only improve physical fitness, but can also stimulate creativity, imagination and problem-solving abilities. In addition, children are more motivated to participate in physical activities that are play-based and group and team-based, which support social development (ParticipACTION, 2020). Children’s participation in organized sports increases their self-esteem and ability to regulate their emotions, and provides opportunities for positive social interactions and experiences, which is particularly valuable for children who may struggle in other domains, such as academics. Moreover, physical activity helps improve social integration for children with disabilities, enhancing their interaction and communication skills, resulting in improved daily functions, health-related outcomes and quality of life (ParticipACTION, 2018).

Outdoor activity during the pandemic

Despite numerous and well-documented benefits of physical activity and outdoor recreation for children and youth, participation in these activities has been severely limited as a result of mandated public health restrictions since the beginning of the COVID-19 pandemic (Chafee et al., 2021). For example, organized team sports through schools and community centres have been cancelled, outdoor recreational amenities and facilities have been closed and even playgrounds, outdoor play equipment and recreational amenities were off-limits to children in Ontario during parts of the first and third waves of the pandemic. New research reports that COVID-19 restrictions are associated with an overall lower amount of time spent in outdoor play among Canadian children and youth (Chafee et al., 2021; Moore et al., 2020, de Lannoy et al., 2020). Findings from an online survey of Canadian parents conducted in April 2020 demonstrated that children and youth spent less time outdoors, were less physically active and more sedentary, slept more and spent more time on screen-based recreational activities compared to pre-COVID-19 (Moore et al., 2020).

Considering the unprecedented impact of the pandemic on the health and well-being of children and youth in marginalized communities and those with specific vulnerabilities due to brain-based disorders and disabilities, outdoor physical activity remains an essential tool to support our most at-risk citizens. Structured physical activity in schools, community organizations, sport and child centres are ideal during the pandemic because appropriate public health measures can be implemented and monitored in these settings. However, children and youth can still participate in unstructured activities, can be active in small groups and can engage in outdoor sports − all while maintaining safe public health practices (i.e., physical distancing).

Evidence is clear that the risks of COVID-19 transmission are much lower outdoors and that moving activities from indoor to outdoor settings may reduce infections (Bulfone et al., 2020). Moreover, there are effective mitigation strategies and protocols that can be implemented to enable safe outdoor activities for children, including active screening measures, masking, cohorting with small groups, physical distancing, handwashing, distanced eating and environmental cleaning and disinfection. Strategies can also be implemented to enhance protection for outdoor staff and counsellors, such as PPE and vaccination. Outdoor sports organizations in Ontario have demonstrated the effectiveness of these measures thus far. For example, across 120 clubs and 7,000 participants within Athletics Ontario, there were zero reported cases of COVID-19 during outdoor training sessions (Hustwick & Oslan, 2021).

Parents, caregivers and educators also play an important role in collaborative efforts to increase children’s activity levels. There is good evidence that parents and caregivers have an influence on children’s physical activity, through active participation, providing access to outdoor spaces and activities, role modelling and providing support and encouragement (ParticipACTION, 2020).

Therefore, to support greater physical activity in young children, we need to support their families and caregivers as well.

This can be done through family-based play and physical activity. The benefits of strategies to enhance outdoor activity for families as a whole extends to parents’ and caregivers’ mental health as well. For example, the majority of parents of young children in Canada report high levels of concern and stress over their children’s isolation and loneliness, and lack of opportunities to socialize with friends during the pandemic (Statistics Canada, 2020). Three-quarters (74 per cent) of parents were also very or extremely concerned about their ability to balance child care, schooling and work. This burden on parents may be reduced by increasing opportunities for outdoor programming for children, including outdoor summer camps.

Considerations for ethnic, racialized, minority and marginalized children and youth

While all children and youth have been impacted by the COVID-19 pandemic, the impact is disproportionately greater for children in certain population groups, including Indigenous and racialized children, newcomers, those living in poverty, those with pre-existing physical and mental health conditions and those with disabilities. Across the globe, COVID-19 and the public health measures put in place to contain its spread have magnified pre-existing health and socioeconomic inequities between these population groups (Chagla et al., 2021; Hahmann, 2021). These inequities are rooted in structural drivers such as political and socioeconomic structures, as well as colonialism and racism, which affect both an individual’s risk of exposure and susceptibility to the disease and the impact of pandemic-related measures (Del Pino & Camacho, 2020; Saint-Girons et al., 2020). Moreover, the long-term consequences of the pandemic and its restrictions on child development are expected to be worse for children already in disadvantaged situations, such as those experiencing poverty, racism or violence, because of the added stress of the pandemic (Center on the Developing Child, 2020; United Nations, 2020).

Indigenous children, especially those living in remote communities, also face greater challenges and barriers in access to essential supports and services including education, and access to green space and other fundamental health and cultural services, and these inequities will widen as a result of ongoing public health restrictions (Hahmann, 2021). Considering this multitude of risk factors for Indigenous children during the pandemic, there is an even greater need to strengthen and expand equity-oriented strategies, such as the land-based wellness practices described above, to begin to address the inequities facing Indigenous children that have been magnified by the pandemic.

Recommendations

In recognition of the disproportionate impact of the COVID-19 pandemic and its associated public health restrictions on children and youth, including those who are Indigenous and those living in marginalized communities with less access to outdoor space, the recommendations presented below aim to facilitate increased activity levels among children and youth during and after the pandemic, with a focus on outdoor activity. Recommendations are targeted towards different groups, each of whom have important roles and responsibilities in promoting safe and active recreational opportunities for children and youth in Ontario.

Provincial and municipal governments

• Promote outdoor public spaces including parks, playgrounds, schoolyards, sports fields, skate parks, sport courts, trails, city beaches, pools and camping spaces, and re-open those spaces that are currently closed now. This should not be dependent on the conclusion of stay-at-home orders. 
  Restart and expand organized sports and activities and outdoor community camps, following appropriate public health guidelines, for children and youth in all communities.
• Improve resourcing and access to safe outdoor spaces and activities for all children and youth with a focus on reaching marginalized and isolated families, including those living in high-density spaces such as apartment buildings with limited access to safe outdoor spaces. Engage community members including children and youth in the planning process.
• Ensure public health messages about outdoor activities are communicated clearly, consistently and in multiple languages to remove barriers to participation. 
• Explore alternative delivery methods for recreational programming for children, such as allowing EarlyON Child and Family Centres and other organizations across Ontario to deliver outdoor programming in public spaces.
• Ensure equitable access to physical activities and outdoor space for children with special needs and health conditions, and provide alternative options and adaptations as needed.
• Ensure strong coordination and collaboration between municipal, provincial and local public health leaders, park and recreation staff, physical activity and sports organizations, parents/caregivers and children and youth.
• Support a multisectoral pedagogical approach to outdoor learning in school curricula that teaches about human responsibility for stewardship of the land and respect for its resources.

Educators and school, child care and early learning centre administrators

• Identify and remove barriers for outdoor learning and participation in outdoor physical activity and play. Invest in infrastructure, programs, training and policies now and for the upcoming school year to remove these barriers.
• Incorporate more outdoor physical activity into daily school and child-care lessons and programming, including active breaks and access to outdoor time to encourage physical activity and minimize long periods of sedentary behaviours among children and youth.
• Prepare for school sports and other extra-curricular physical activities for the upcoming school year. 

Community programming organizations and staff

• Follow all public health safety protocols to allow safe participation in outdoor activities and sports while protecting the safety of the staff and participants.
• Hire youth in leadership roles (counsellors, counsellors-in-training, etc.) to help staff summer camps, parks, pools and recreation activities.
• Continue to plan for outdoor activities and sports for children and youth during this summer and into the next school year.

Public health professionals and health-care providers

• Provide clear safety procedures and policies for outdoor activities and sports to encourage skill development and social interaction.
• Provide education, resources (e.g., PPE) and training for outdoor staff and counsellors on health, safety and mental health support for children and youth during the pandemic.
• Prioritize and facilitate vaccination of outdoor recreation staff, such as camp counsellors, and ensure access to appropriate PPE, policies and procedures for staff. 
• Educate and reinforce the physical, developmental and mental health benefits of outdoor play and physical activity for children and their families.
• Advocate for access to physical activity and safe outdoor places for children, youth and their families.

Parents/caregivers, children and youth

• Make family time active time – look for opportunities to get active and spend time outdoors as a family.
• Support children and youth in maintaining physical activity and outdoor time by encouraging, facilitating, modelling, setting expectations and engaging in physical activity and outdoor time with them.
• Encourage and support children and youth to advocate and stand up for their rights to safe, accessible outdoor space and opportunities for physical activity and sports through the summer and into the upcoming school year.

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Acknowledgements

This call to action was created in partnership between Native Child and Family Services of Toronto (NCFST), The Hospital for Sick Children (SickKids) and researchers from the Factor-Inwentash Faculty of Social Work at the University of Toronto. 

Principal authors

• Jeffrey Schiffer PhD, Executive Director, Native Child and Family Services of Toronto; adjunct Professor, Factor-Inwentash Faculty of Social Work, University of Toronto
• Catherine S. Birken MD, M.Sc., FRCPC, Senior Scientist, Child Health Evaluative Sciences, Staff Paediatrician, The Hospital for Sick Children; Professor, Department of Paediatrics, University of Toronto 

Co-authors

• Eyal Cohen MD, M.Sc., FRCPC, Program Head, Child Health Evaluative Sciences, Staff Physician, Complex Care Program, The Hospital for Sick Children; Professor, Paediatrics and Health Policy, Management & Evaluation, University of Toronto; Co-Director, Edwin S.H. Leong Centre for Healthy Children
• Barbara Fallon PhD, Professor, Factor-Inwentash Faculty of Social Work, Canada Research Chair in Child Welfare, University of Toronto
• Donald J. Mabbott PhD, C.Psych, ABPP-cn, Senior Scientist and Program Head, Neurosciences and Mental Health, The Hospital for Sick Children; Professor, Department of Psychology, University of Toronto
• Steven P. Miller MD, FRCPC, Head, Neurology, The Hospital for Sick Children; Professor, Department of Paediatrics, University of Toronto
• Genevieve Sansone MASc, PhD, Research Associate, Factor-Inwentash Faculty of Social Work, University of Toronto
• Sima Sajedinejad MD, MPH, PhD, Research Associate, Factor-Inwentash Faculty of Social Work, University of Toronto
• Meta Van den Heuvel MD PhD, Staff Pediatrician, The Hospital for Sick Children; Assistant Professor, Department of Paediatrics, University of Toronto
• Ashley Vandermorris, MD, M.Sc., FRCPC, Staff Physician, Department of Adolescent Medicine, The Hospital for Sick Children; Assistant Professor, Department of Paediatrics, University of Toronto 

Reviewers/ contributors/ acknowledgements

We are very grateful for the reviews and contributions provided by:

• Daphne J. Korczak MD, M.Sc., FRCPC (Paediatrics), FRCPC (Psychiatry), Associate Scientist, Neuroscience and Mental Health, Psychiatrist, The Hospital for Sick Children; Associate Professor of Psychiatry, Faculty of Medicine, University of Toronto
• Nisha Thampi MD, M.Sc., FRCPC. Assistant Professor and Pediatric Infectious Diseases Consultant, University of Ottawa
• Leigh M. Vanderloo, M.Sc., PhD. Adjunct Professor, School of Occupational Therapy, Western University

We appreciate the lived expertise and detailed review of Family Advisors Ashley Audrain, Eugene Cortes, Nasra Aidarus and other members of the SickKids Centre for Innovation & Excellence in Child and Family-Centred Care.

Endorsements

This document has been endorsed by:

• Athletics Ontario
• Black Health Alliance
• Canadian Coalition for the Rights of Children
• Canadian Paediatric Society
• Children’s Health Coalition
• Children’s Mental Health Ontario
• Empowered Kids Ontario
• Holland Bloorview Kids Rehabilitation Hospital
• Ophea (Ontario Physical and Health Education Association)
• Ontario Soccer Association
• ParticipACTION
• SickKids Centre for Community Mental Health
• TARGetKids! (The Applied Research Group for Kids)
• Toronto Aboriginal Support Services Council
• Toronto Baseball Association
• Unicef Canada