[Paper] Changes in Emotions and Worries During the Covid-19 Pandemic: An Online Survey of Children and Adults With and Without Mental Health Conditions

Summary

Background

The novel coronavirus disease (Covid-19) has dramatically impacted our daily lives and rapidly spread worldwide. The detrimental psychosocial effects of Covid-19 may be particularly severe for children and adolescents, parents of young children, and individuals with mental health conditions (MHC), as they are more susceptible to experiencing psychosocial stress and rely on access to professional psychosocial support. Therefore, this survey aims to investigate the perceived stress and emotional responses of both children and adolescents, as well as adults, with and without MHC, during the social restrictions imposed by the Covid-19 pandemic.

Methods

The survey collected information on 284 children and adolescents (parent-reported) and 456 adults (including 284 parents, self-reported). Participants were divided into four groups: children and adolescents with MHC, children and adolescents without MHC, adults with MHC, and adults without MHC. The survey included general questions about sociodemographic characteristics and mental health status, the Coronavirus Health Impact Survey, and the Perceived Stress Scale (data on adults only). The Wilcoxon signed-rank test was used to compare emotions before and during the Covid-19 pandemic. Independent samples t-tests were used to compare levels of perceived stress between adult groups, and linear regression analysis was conducted to examine which variables predicted perceived stress during the Covid-19 restrictions.

Results

An increase in worsening was observed for most emotions and worries during the Covid-19 restriction period across all four groups (children and adolescents with MHC, children and adolescents without MHC, adults with MHC, and adults without MHC). Contrary to our expectations, significantly more instances of emotional worsening were observed in children and adolescents without MHC, as well as in adults without MHC, compared to those with MHC. We found that parents, both within the same household and those with MHC, had higher perceived stress compared to adults without children and adults without MHC.

Discussion

Covid-19-related social restrictions and potential health risks appear to impact emotions and perceived stress in children, adolescents, and adults. In particular, Covid-19 seems to have worsened the mental well-being of children and adolescents who were mentally healthy before the pandemic, as well as their families.

Keywords:

Psychological stress, Crisis, SARS-CoV-2, Family, Lockdown

Introduction

The novel coronavirus disease (Covid-19) has had dramatic effects on our daily lives and quickly spread worldwide. To slow the spread of the virus globally, public life has been severely restricted. Universities, schools, and kindergartens have closed, leaving home activities heavily restricted, and visits with friends and relatives banned domestically and internationally. Constraints on free movement coupled with social isolation are well-known major features impacting psychological well-being. Unlike prior severe outbreaks (e.g., Ebola, SARS, HIV), which were detrimental not only to infected individuals but also to non-infected groups, initial findings on the psychological impact on the general population related to Covid-19 have emerged. For example, an online survey (Ntotal=1639) indicated that 48.2% of respondents reported low psychological well-being associated with the Covid-19 outbreak (measured by the Psychological General Well-Being Scale with scores ≤ 60 out of a maximum of 110) [8].

While adverse psychological and social effects related to Covid-19 are observed throughout the general population, they are particularly severe for those prone to psychological stress and reliant on access to professional psychological support (such as individuals with mental health conditions (MHC), children, adolescents, and their parents).

For families with children and adolescents needing mental health support, cancellations or limitations in access to mental health support and the inability of remote online or phone support to fully substitute for face-to-face contact pose additional challenges. Asbury et al. [9] asked parents of children with special education needs and disabilities in the UK to describe, via free-response questions, how the Covid-19 outbreak affected their children's and their own mental health. Many parents reported burdens affecting the entire family, including loss of children's daily routines (35%), loss of friends and children's communities (12%), and loss of professional opinions (11%). Pisano, Galimi, and Cerniglia [10] found increased hypersensitivity (53.53%) and increased lethargy (43.2%) in Italian children aged 4-10 during the Covid-19 period. Di Giorgio et al. [11], also from Italy, examined the interaction of behavioral and psychological factors between mothers and children during Covid-19 using the "Strengths and Difficulties" questionnaire (parent version), revealing increased emotional symptoms, behavioral problems, and hyperactivity/inattention issues in children. Interestingly, these findings were unrelated to the mother's work status during Covid-19 (regular work, non-work, furlough, work from home). In contrast, parental personal and secondary stress significantly mediated the impact of quarantine difficulties experienced by parents on children's behavioral and emotional issues [12]. Further evidence on the mediating role of perceived stress comes from Cerami et al. [3], who reported that about 48% of the total effect of loneliness on perceived health impacts of Covid-19 among adult Italian residents was mediated by perceived stress.

During Covid-19, most children and adolescents received home education from their parents without support from trained teachers or with limited support. Most parents also needed to fulfill job responsibilities at the same level as before Covid-19 while educating their children at home. Such situations are likely to cause mental overload and consequently a heightened level of psychological stress. Parental stress correlates with changes in children's behavior [13] and also affects child obesity [14].

This study aimed to investigate emotional responses in children, adolescents, and adults, as well as perceived stress in parents and adults without children, regardless of the presence of MHC, exposed to social constraints during the Covid-19 pandemic. We hypothesized that all survey participants would experience worsening emotions and concerns during the Covid-19 pandemic compared to before Covid-19. Furthermore, we hypothesized a greater increase in the worsening of emotions and concerns among children, adolescents, and adults with MHC compared to those without MHC.

Regarding perceived stress, authors assumed higher levels in parents (compared to adults without children) and in children, adolescents, and adults with MHC. Using an exploratory approach, we conducted regression analysis to evaluate the contributions of pre-existing individual characteristics (e.g., age, number of minors in the same household, pre-pandemic mental and physical states) and psychosocial changes (e.g., economic concerns related to Covid-19 outbreaks and changes in the quality of relationships with family and friends) attributable to Covid-19 to stress perception in adults during the restriction period of Covid-19.

Methods

The online survey in Germany was conducted from April 4 to May 6, 2020. At that time, all schools and kindergartens in Germany were closed for three weeks, and physical distancing (at least 1.5 meters apart, moving alone or with only one other person in public spaces) was mandatory for two weeks. Additionally, stricter restrictions were enforced in two federal states of Germany, Saxony and Bavaria (leaving home only for work, shopping, or medical purposes). These federal regulations affected over 90% of the respondents. SARS-CoV-2 infections had increased exponentially in the two weeks prior to the survey (with 70,000 new cases in Germany over the past two weeks). By the survey start date (April 4), Germany had exceeded 100,000 cases, but hospital capacity was still available, and the death rate was increasing relatively slowly. However, media reports were dominated by dramatic situations in other countries, making Germany appear to be in a threatening situation.

Participants

We invited families of patients from the Clinic for Child and Adolescent Psychiatry and Psychotherapy at University Hospital Dresden, as well as families of previous research participants and young adult participants from past studies, to participate in the survey via email. In our department, we conduct research in the field of child and adolescent psychiatry, investigating various conditions such as ADHD, autism spectrum disorders, chronic tic disorders, and Tourette syndrome (including eating disorders), among others. Therefore, we sought participation from a broad spectrum of individuals.

Parents were invited to complete surveys about their children and themselves. Initially, invitations were extended to parents to respond to surveys regarding their children who are patients at our clinic and/or who had participated in previous research. If parents needed to respond for multiple children, separate surveys for each child could be initiated. However, only one parent from participating families chose to do this (thus, no correction in analysis was necessary). Therefore, responses were collected for four groups: children and adolescents with or without mental health conditions (MHC), and adults with or without MHC.

After obtaining informed consent from participants, they answered several general questions about sociodemographic characteristics and mental health status. Subsequently, they completed questionnaires corresponding to the National Institutes of Health's Coronavirus Health Impact Survey v.01 (CRIS) and the Perceived Stress Scale (PSS-10; [15]). This survey was conducted in accordance with the recommendations of the Helsinki Declaration. A total of 284 children and adolescents and 456 adults participated. Among the 456 adults, 284 parents responded to questionnaires about their children and themselves. Sample characteristics are presented in Table 1.

Measures

The Coronavirus Health Impact Survey (CRISIS) questionnaire was developed through collaborative work between Kathleen Merikangas and Argyris Stringaris' research teams at the National Institute of Mental Health. The questionnaire investigates daily behaviors, emotions, worries, media and substance use, using a 5-point Likert scale for both current conditions (last 2 weeks, i.e., during the Covid-19 pandemic) and pre-Covid-19 conditions (last 3 months). For this analysis, questions regarding emotions and worries over the past 3 months and 2 weeks were used (e.g., How worried were you/your child generally?). It also assessed how happy or sad you/your child felt, how relaxed you/your child were in response to anxiety, how restless or agitated you/your child were, how well you/your child could concentrate, how irritable or easily angered you/your child were, how lonely you/your child felt, and how much negative emotions your/your child had. Additionally, it evaluated reports on overall mental and physical states before the pandemic, economic anxieties related to the Covid-19 outbreak, and changes in the quality of relationships with family and friends.

Perceived Stress Scale (PSS-10)

To assess current stress levels, a well-established Perceived Stress Scale [15] was used. This scale measures stress based on a 5-point response scale assessing how respondents categorize their life situations. The German version of the 10-item scale (maximum score = 40) has reported good internal consistency (Cronbach's α = 0.84) [16]. For the analysis, information was collected using the PSS-10 based on norms from the Harris Poll Survey, targeting 2,387 respondents in the United States using t-scores [17]. The PSS-10 was collected solely as self-reported by adults (see Table 1).

Statistical Analysis

We conducted a priority frequency analysis using G*Power 3.1 [18]. Based on the applied tests (t-test, Wilcoxon signed-rank test, Mann-Whitney U test), the required total sample size ranged from 120 to 228, with a medium effect size (d=0.50), and a power of 0.80.

Data on 10 emotions and concerns were measured using a 5-point Likert scale (thus, typically scaled). The surveyed 4 groups (children and adolescents with MHC, children and adolescents without MHC, adults with MHC, adults without MHC) did not show a normal distribution. Therefore, for all 4 groups, we used Wilcoxon signed-rank tests and Mann-Whitney U tests to compare emotions and concerns during the Covid-19 outbreak (last 2 weeks) and before the outbreak (last 3 months). Given 10 comparisons for each group, we used Bonferroni-adjusted α level (0.05/10=0.005).

Table 1: Sample Characteristics

We conducted independent samples t-tests to examine differences in perceived stress scores (PSS-10) between adults with and without MHC. Additionally, using independent samples t-tests, we investigated differences in perceived stress between adults living in the same household (referred to as both parents) with at least one minor (under 18 years old) and adults living in households without minors. Despite significant results from Shapiro-Wilk tests indicating departure from normality in the data of the four studied groups (adults with MHC: W=0.96, p=0.02; adults without MHC: W=0.97, p<0.01; both parents: W=0.97, p<0.01; households without minors: W=0.97, p<0.01), we used t-tests to examine differences in perceived stress.

We also conducted linear regression analyses to investigate whether age before the pandemic, number of minors in the household, mental and physical health (self-reported), economic anxiety related to the Covid-19 outbreak, and changes in the quality of relationships with family and friends (self-reported) predicted perceived stress (t-score) among adults during the Covid-19 restrictions. Separate regression analyses were conducted for adults regardless of MHC status.

Results

Differences in Emotions and Worries Before and During Covid-19 Restrictions

During the Covid-19 period, increases in worsening were observed for most emotions and concerns across all four groups (children and adolescents with MHC, children and adolescents without MHC, adults with MHC, adults without MHC). Data on response frequencies are provided in additional files 1 and 2. In children and adolescents without MHC, Wilcoxon signed-rank tests showed significant increases in 5 out of 10 emotions and concerns (worry, happiness, sadness, fun activities, fatigue or tiredness). Among children and adolescents with MHC, emotions and concerns (activities, fatigue or tiredness, loneliness) significantly worsened in a ratio of 3 out of 10 individuals. For adults without MHC, a series of Wilcoxon signed-rank tests indicated significant increases in 8 out of 10 captured emotions and concerns (excluding fatigue or tiredness and negative thoughts). Adults with MHC showed significant increases in 2 out of 10 captured emotions and concerns (worry, enjoyment). Table 2 shows the means and standard deviations of emotions and concerns, and Table 3 presents the results of Wilcoxon signed-rank tests.

Differences in Emotions and Worries Between MHC and Non-MHC Patients

In children and adolescents, the Mann-Whitney U test showed that children with MHC exhibited poorer values in all captured emotions and concerns compared to children without MHC, except for fatigue or tiredness before the Covid-19 restrictions. During the Covid-19 restrictions, parental reports indicated that children with MHC showed worse values in all captured emotions and concerns compared to children without MHC, except for worry, enjoyment, and fatigue or tiredness. A series of Mann-Whitney U tests indicated that assessments of MHC in adults showed increases in all captured emotions and concerns compared to adults without mental health conditions before and during the Covid-19 restrictions. Table 2 shows the means and standard deviations of emotions and concerns, and Table 4 presents the results of the Mann-Whitney U tests.

Table 2: Means and Standard Deviations of Emotions and Worries Before and During Covid-19, Divided Into Four Groups (Adults and Children, With and Without MHC)

Table 3: Wilcoxon Test Comparing Emotions and Worries Before and During Covid-19 for Four Groups (Adults and Children, With and Without MHC)

Table 4: Mann-Whitney U Test Comparing Emotions and Worries Between Adults With and Without MHC, and Children With and Without MHC, Before and During Covid-19

Differences in Stress Perception

An independent samples t-test showed that parents (N=324, M=56.66, SD=13.39) experienced significantly higher levels of perceived stress during Covid-19 compared to minors (N=132, M=52.92, SD=12.14), t(454)=-2.78, p<0.01. Furthermore, adults with MHC (mental health conditions) (N=85.474) exhibited significantly higher levels of perceived stress during Covid-19 compared to adults without MHC, t(85.474)=6.18, p<0.001.

Predictors of Perceived Stress

Using the enter method, it was found that the model significantly explains variance in perceived stress among adults with MHC (mental health conditions) (F(7,62)=5.33, p<0.001, R2=0.38, adjusted R2=0.31). However, only physical health status emerged as a significant predictor of perceived stress. In adults without MHC, the regression model also significantly explained variance in perceived stress (F(7,378)=13.56, p<0.001, R2=0.20, adjusted R2=0.19). Mental health status, relationships with family and friends, economic insecurity, and having multiple minors in the same household were identified as significant predictors of perceived stress. The results of the regression coefficients are shown in Table 5.

Discussion

This project provides insights into the different emotional responses of children, adolescents, and adults (parents and non-parents) to social constraints and potential health risks associated with Covid-19, regardless of the presence of MHC (mental health conditions). According to our hypotheses, all captured emotions and concerns (in adults) or most captured emotions and concerns (in children) were more adverse among those with MHC compared to those without MHC, both before and during Covid-19 restrictions. Consistently, it was found that parental stress perception was higher compared to adults without children and those with MHC compared to those without MHC. Furthermore, as expected, our results demonstrate significant changes in emotions and concerns across all four groups (regardless of MHC status, adults, MHC status, children and adolescents) from before Covid-19 restrictions to during Covid-19 restrictions.

Among children, the most pronounced increases were observed in "How much did your child enjoy activities?" and "How lonely was your child?" In both groups, the largest increases in worry were "How much fun did you have?" Interestingly, contrary to our expectations, there were many cases where emotions significantly deteriorated in individuals without MHC (children, adolescents, and adults) compared to those with MHC. Correspondingly, changes in the quality of relationships with family and friends, as well as economic insecurity, predicted perceived stress only in adults without MHC.

For adults with MHC, physical health status before Covid-19 was the sole predictor of perceived stress.

Our findings on the deterioration of emotions and concerns during Covid-19 restrictions in children, adolescents, and adults without MHC align with previous studies reporting a correlation with larger social networks and better psychological well-being [19-21]. Additionally, our findings are consistent with research on post-traumatic stress disorder (PTSD). For example, meta-analyses have shown that lack of social support (e.g., from family and friends) and previous psychological adjustment are predictors of PTSD [22]. Furthermore, financial losses due to natural disasters have also been identified as predictors of PTSD [23].

Table 5: Regression of Predictors of Perceived Stress (T Scores) in Adults With and Without MHC

However, our findings raise questions about why emotions deteriorated in individuals with MHC (mental health conditions), and why changes in the quality of relationships with friends and family did not predict perceived stress in the adult MHC group.

One explanation could be that MHC patients often experience smaller social networks or tense family relationships (e.g., [24]). Therefore, these individuals may not have experienced as negative changes due to social constraints related to Covid-19. Additionally, the higher proportion of females in the MHC group (80.05% vs. 94.28%) suggests that the impact of family networks may vary between genders. While family networks are associated with better well-being in males, they can also impose more obligations and burdens on females [19]. Another explanation from our findings may be that MHC patients have learned strategies to cope with stressful family relationships, such as seeking professional support. These strategies may include daily routines, sports, or music. Therefore, the stressful family situations and coping mechanisms known to some MHC patients may be a reason why changes in family relationships and the number of minors in the same household did not significantly predict stress perception. Typically, patients without recognized MHC cannot resort to such conscious coping with stressful family situations, so changes in family relationships significantly predicted perceived stress.

Another possible explanation for our finding that emotions significantly deteriorated more in individuals without MHC (children, adolescents, and adults) compared to those without MHC is that individuals with MHC often experience social contacts as filled with fear. Avoidance of social contacts to evade negative social evaluations is a known characteristic of social anxiety disorder and depression. Furthermore, performance anxiety is often observed in MHC children and adolescents. Youth in clinical samples reported higher levels of academic stress than those in non-clinical samples [25]. For such individuals, reducing personal stress levels by avoiding attending school may be a strategy that is not normally applicable due to compulsory education in Germany. Avoidance strategies are generally ineffective in the long term as they maintain the illness but often provide short-term relief from fear and anxiety. From this perspective, social constraints related to Covid-19 and school closures may have served the purpose of avoidance strategies aimed at short-term relief from social performance and anxiety for MHC patients. Perhaps this short-term relief contributed to the finding that emotions and concerns expected during Covid-19 did not show as much deterioration in children, adolescents, and adults. However, since avoidance strategies typically sustain the illness in the long term, observing how emotions and concerns in MHC children and adolescents manifest during Covid-19 restrictions would be very interesting.

Conclusion

In summary, social constraints and potential health risks associated with Covid-19 appear to impact the emotions and concerns of most populations. Therefore, observing the trajectory of mental health conditions (MHC) in the general population is crucial. These trajectories indicate factors beneficial for emotional recovery and may be linked to chronic stress in physically isolated environments like the Covid-19 pandemic.

Limitations and Strengths of the Study

The main limitations of this study include the retrospective measurement of emotions and concerns before Covid-19, which may introduce recall bias affecting our results. Additionally, the data are limited in measuring emotions and concerns in children and adolescents solely through parental reports. Furthermore, due to the small number of participants with psychiatric disorders, this data may not adequately inform how emotions and concerns vary across different psychiatric conditions. Moreover, the data collection in Germany had specific circumstances, limiting comparisons with other studies. Considering Covid-19's unique characteristics, it's important to recognize that situations it has caused are highly specific and may not easily translate to other common experiences like natural disasters or accidents.

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