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[paper] Changes in emotions and worry during the Covid-19 pandemic: an online survey of children and adults with and without mental health conditions.

[paper] Changes in emotions and worry during the Covid-19 pandemic: an online survey of children and adults with and without mental health conditions.

Summary

Background

The new coronavirus disease (Covid-19) has spread rapidly throughout the world with dramatic consequences for our daily lives.
The adverse psychosocial consequences of Covid-19 can be particularly severe for children and adolescents, parents of young children, and persons with mental health conditions (MHC) who are more likely to experience psychosocial stress and depend on access to professional psychosocial support. Therefore, this study aimed to investigate the perceived stress and emotional responses of children and adolescents with and without MHC, as well as adults, during the social constraints of the Covid-19 pandemic.

Method

The survey collected information on 284 children and adolescents (parent-child reporting) and 456 adults (284 parent, including self-report). Participants were assigned to four groups: children and adolescents with MHC, children and adolescents without MHC, adults with MHC, and adults without MHC. The survey included general questions on sociodemographic characteristics and mental health status, the Coronavirus Health Impact Survey, and a perceived stress scale (data for adults only). Wilcoxon signed-rank tests were used to compare pre-Covid-19 pandemic emotions with emotional responses during the Covid-19 pandemic. Independent samples t-tests were used to compare levels of perceived stress across adult groups, and linear regression analyses were conducted to determine which variables predicted perceived stress during the Covid-19 constraint.

Result

Increased worsening during the Covid-19 restriction period was observed for most emotions and worries in all four groups (children and adolescents with MHC, children and adolescents without MHC, adults with MHC, and adults without MHC). Contrary to our expectations, more children and adolescents without MHC and adults with MHC had significantly worse emotions than children and adolescents with MHC. We found higher perceived parental stress in the same households and among adults with MHC compared to adults without MHC, as well as among adults without children.

Consideration

The social limitations and potential health risks associated with Covid-19 appear to affect emotions and perceived stress in children, adolescents, and adults. In particular, Covid-19 appears to have worsened the mental well-being of children and adolescents and their families who were mentally healthy before the Covid-19 pandemic.

Keywords:

Psychosocial stress, crisis, SARS-CoV-2, family, lockdown

Introduction.

The new coronavirus disease (Covid-19) has had a dramatic impact on our daily lives and is rapidly spreading throughout the world. Around the world, public life has been severely restricted in order to slow the spread of the virus. Universities, schools, and kindergartens have been closed, leaving one's home has been strongly restricted, and visits with friends and relatives have been prohibited, as has travel at the national and international levels. It is well known that restrictions on free movement linked to social isolation are one of the main features affecting psychological well-being. From previous severe epidemics and not from widespread epidemics (e.g. Ebola, SARS, and HIV) have been found to have detrimental psychosocial effects on infected as well as non-infected populations [1, 2]. For Covid-19, there are first findings on psychosocial effects on the general population [3-7]. For example, an online survey (Ntotal=1639) showed that 48.2% of respondents had low psychological well-being (a crude score of 60 or less and a maximum crude score of 110;[8] on the PsychologicalGeneral Well-Being questionnaire) associated with Covid-19 expansion [4].

The adverse psychosocial effects of Covid-19 can be found anywhere in the general population, but the negative effects can be severe, especially in those who are more likely to experience psychosocial stress and who are dependent on access to professional psychosocial support (e.g., in people with mental health conditions (MHC), children and adolescents, and their parents). The negative effects may be severe.

Even more challenging for families of children and adolescents with mental health needs is the fact that access to mental health support can be withdrawn or limited, and that remote online or telephone support cannot fully replace face-to-face contact. Asbury et al [9] asked parents of children with special educational needs and disabilities in the UK to describe (open-ended question) how the Covid-19 outbreak had affected their own mental health and that of their children. Many parents reported loss of daily life for their children (35%), loss of friends and community for their children (12%), and loss of professional opinion (11%) as burdens for the entire family. Pisano, Galimi, and Cerniglia [10] found that Covid-19
period, increased irritability (53.53%) and sluggishness (43.5%) in Italian children aged 4~10 years. Di Giorgio et al [11], in an Italian sample, examined the interaction of behavioral and psychological factors between mothers and their children during COVID-19, and found that the "strengths and difficulties" questionnaire (parent version), which the mothers and found that children reported increased emotional symptoms, behavioral problems, and hyperactivity/inattention problems when assessed using the COVID-19. Interestingly, this finding was unrelated to the mother's work status (regular work, non-work, stop, or work at home) during the COVID-19. In contrast, parental personal and secondary stress significantly mediated the effects of quarantine on children's behavioral and emotional problems (difficulties experienced by parents during quarantine) [12]. Further evidence on the mediating role of perceived stress comes from Ceram et al [3], who report that among adult Italian residents, approximately 48% of the total impact of loneliness on the perceived health effects of Covid-19 was mediated by perceived stress.

During Covid-19, most children and adolescents were home-schooled by their parents, with no or limited support from trained teachers. Most parents had to perform the same level of duties as before Covid-19, in addition to home-schooling their children. This situation was most likely to cause mental overload and, in turn, high levels of psychosocial stress. Parental stress varies concurrently with children's behavioral problems [13] and also affects children's obesity [14].

The purpose of this study was to examine the emotional responses of children, adolescents, and adults with and without MHC exposed to the social constraints of the Covid-19 pandemic, as well as perceived stress among parents and adults without children. We hypothesized that all study participants would be worse off during the Covid-19 pandemic with respect to emotions and worry, compared to pre-Covid-19. We further hypothesized that children, adolescents, and adults with mhc compared to children, adolescents, and adults without MHC would experience a greater increase in worsening emotions and worry.

With respect to perceived stress, the authors hypothesized higher levels in parents (compared to adults without children) and in children, adolescents, and adults with MHC. Using an exploratory approach, we hypothesized that the previous personal characteristics (e.g., age, number of minors in the same household, mental and physical status prior to the pandemic) and psychosocial changes (e.g., regression analysis to assess the contribution of economic concerns and changes in the quality of relationships with family and friends) related to the Covid-19 outbreak.

Method

The German situation in the online survey was conducted between April 4 and May 6, 2020. At that time, all schools and kindergartens in Germany were closed for three weeks and physical distance (minimum 1.5 m, alone or with one other person in a public space) was mandatory for two weeks. In addition, more stringent restrictions were applied in two federal states (Germany, Saxony, and Bavaria) (leaving home only for occupational, shopping, or medical purposes). Tese federal restrictions were relevant for more than 90% of the respondents; SARS-CoV-2 infections increased exponentially in the two weeks prior to the survey (70,000 new cases in Germany within the past two weeks). At the start of the survey (April 4), the number of cases in Germany exceeded 100,000, but there was still hospital capacity and the mortality rate increased relatively slowly.
The mortality rate increased relatively slowly. However, the press coverage was dominated by the dramatic situation in other countries, and Germany appeared to be under threat.

Participant

Families of patients at the Clinic for Child and Adolescent Psychiatry and Psychotherapy at University Hospital Dresden, families of previous study participants, and young adult participants in previous studies were included in the survey via email. The Department conducts research in the field of child and adolescent psychiatry on a variety of disorders (e.g.) . ADHD, autism, chronic tic disorder, and Tourette's (eating disorder) are affected as well as healthy individuals. Therefore, a wide range of people were invited to participate. Parents were invited to complete a questionnaire about their children and themselves. Initially, parents were invited to complete a survey of their children who were patients in our department and/or had participated in previous studies. Parents could have more than one child.
If they wished to respond, they could initiate a separate survey for each child. However, this was done for only one of the participating parents (thus, no correction for analysis was necessary). Thus, responses were collected for four groups: children and adolescents with and without MHC, and adults with and without MHC. After participants provided informed consent, they answered several general questions about sociodemographic characteristics and mental health status. They then completed questionnaires corresponding to the 10-item version of the National Institutes of Health Coronavirus Health Impact Survey v.01 (CRIS) and Perceived Stress Scale (PSS-10; [15]). The survey was conducted according to the recommendations of the Declaration of Helsinki. A total of 284 children and adolescents and 456 adults participated in the survey. Of the 456 adults, 284 parents completed the questionnaires for their children and themselves. Sample characteristics are presented in Table 1.

Measure

Coronavirus Health Impact Survey (CRISIS) The CRISIS questionnaire was developed "in collaboration between the research teams of Kathleen Merikangas and Argyris Stringaris of the National Institute of Mental Health. In addition, questions regarding daily behavior, emotions, worry, media and substance use were explored using a 5-point Likert scale with respect to both current conditions (last 2 weeks, i.e., during the Covid-19 pandemic) and pre-Covid-19 conditions (last 3 months). Questions regarding emotions and worry for the past 3 months and 2 weeks were used in this analysis (how worried were you/your child in general). How happy or sad were you/your child? How relaxed were you/your child
How relaxed were you/your child with anxiety? How immobile and restless was your/your child? How well did you/your child focus or concentrate? How irritable or easily angered were you/your child? To what extent do you/your child have negative feelings? In addition, we assessed reports of pre-pandemic general mental and physical status, economic insecurity 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, we used the well-established Perceived Stress Scale [15]. This scale measures whether life situations are classified as stressful on a 5-point response scale. The German version of the 10-item scale (maximum score = 40) has been reported to have good internal consistency (Cronbach's α = 0.84) [16]. For the analysis, t-scores were used for 2387 U.S. respondents based on the norms of the Harris poll, which collected information using the PSS-10 [17]. Te PSS-10 was collected only as self-reported by adults (see Table 1).

Statistical Analysis

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

Data on the 10 emotions and worries were measured on a 5-point Likert scale (and thus usually scaled) and were not normally distributed across the four groups studied (children and adolescents with MHC, children and adolescents without MHC, adults with MHC, and adults without MHC). For this reason, Wilcoxon signed-rank and Mann-Whitney-U tests were used to compare affect and worry before (in the last 3 months) and during (in the last 2 weeks) the Covid-19 outbreak in all 4 groups. A Bonferroni adjusted alpha level (0.05/10=0.005) was used because 10 comparisons were made for each group.

Table 1: Sample characteristics

Adult (self-report) = adult (self-report), Child or adolescent (parent-report) = child or adolescent (parent-report), With mental health condition = person with a mental health condition, Without mental health condition = without mental health condition, Sex, frequency (male/female/other) = sex, frequency (male/female/other), Mean age (SD) = mean age (SD), Age range = age range, Perceived stress scale, mean t-value = perceived stress scale, mean t-value (SD), Frequencies of mental disorders = frequency of mental disorders, ADD/ADHD = attention disorder/attention deficit hyperactivity disorder, Anxiety disorder = anxiety disorder Autism = autism, Borderline = borderline abnormality, Conduct disorders = conduct disorder, Disruptive Mood Dysregulation Disorder = disruptive mood regulation disorder, Eating disorders = eating disorder, Intellectual disabilities = Mood intellectual disabilities, Mood
disorders = mood disorders, Nocturnal enuresis = nocturia, OCD = obsessive-compulsive disorder, Reaction to severe stress/adjustment disorders Schizophrenia = schizophrenia, Sleep disorder = sleep disorder, TicDisorders = tic disorder, Trichotillomania = trichotillomania, Unspecified disorder of psychological development = psychological development disorder of unknown details, Not reported = not reported

Independent sample t-tests were conducted to examine differences in t-scores on the Perceived Stress Scale (PSS-10) between adults with and without MHC. In addition, an independent samples t-test was used to examine differences in perceived stress between adults with at least one minor (under 18 years of age) living in the same household (also called parents) and adults without a minor in the same household. Given the robustness of the t-test to normality violations, we examined differences in perceived stress using the t-test, even though data from the four examined groups showed significant results in the Shapiro-Wilk test (adults with MHC: W=0.96,p=0.02; adults without MHC: W=0.96,p=0.02; adults with MHC: W=0.96,p=0.02). Adults without MHC: W=0.97,p<0.01; Parents: W=0.97,p<0.01; Minors in the household Linear regression analysis was performed to examine changes in pre-pandemic age, number of minors in the household, mental and physical status (measured by self-report), economic anxiety related to the Covid19 outbreak, and quality of family and friends relationships. We examined whether changes in the quality of relationships with family and friends (measured by self-report) predicted perceived stress (t-score) among adults during Covid-19 restriction. Separate regression analyses were conducted for adults with and without MHC.

Result

Covid-19 Differences in Emotions and Concerns Before and During Restriction

During Covid-19, increased worsening was observed for most emotions and worry in all four groups (children and adolescents with MHC, children and adolescents without MHC, adults with MHC, and adults without MHC). Data on response frequency are presented in Additional Files 1 and 2. In children and adolescents without MHC, the Wilcoxon signed rank test indicated significant increases for 5 of the 10 emotions and worries (worry, happiness, sadness, pleasurable activities, fatigue or exhaustion, and loneliness). For children and adolescents with MHC, 3 in 10 showed significantly worse affect and worry (activity, fatigue or exhaustion, and loneliness). In adults without MHC, a series of Wilcoxon signed-rank tests showed that this increase was significantly greater than the increase in captured affect and worry (excluding fatigue or exhaustion and negative thoughts).
or all but fatigue and negative thoughts) were significant at 8 out of 10. For the adult MHC, significant increases were found for two of the ten captured emotions and worries (worry and enjoyment). Means and standard deviations for emotion and worry are shown in Table 2. The results of the Wilcoxon signed rank sum test are shown in Table 3.

Differences in emotions and concerns between MHC and non-MHC patients

With regard to affect and worry in children and adolescents, the Mann-Whitney-U test showed that children with MHC had poorer values compared to children without MHC in all captured affect and worry, with the exception of fatigue or exhaustion in the period before Covid19 restriction. During Covid-19 restriction, parental reports were worse in children with MHC compared to children without MHC in all captured emotions and worry, with the exception of worry, enjoyment, fatigue or exhaustion. A series of Mann-Whitney-U tests showed that adults' ratings of MHC were elevated in all 10 captured emotions and worry compared to adults without mental health before and during Covid-19 restriction. Means and standard deviations for emotion and worry are presented in Table 2. The results of the Mann-Whitney-U test are presented in Table 4.

Table 2: Means and standard deviations of sentiment and worry before and after Covid-19, divided into 4 groups (adults and children, with and without MHC)

Table 3: Wilcoxon test comparing emotions and worry isolated before and after Covid-19 for the four groups (adults and children with and without MHC).

Adults with MHC = Adults with MHC, Adults without MHC = Adults without MHC, Children with MHC = Children with MHC, Children without MHC = children without MHC, Before = before, During = during, Worried = worried, Enjoy activities = activities, enjoyment, Concentrated = concentrated, Lonely = alone, Negative thoughts = negative thoughts, Happy or sad = happy or sad or Relaxed or anxious = relaxed or anxious, Fidgety or restless = agitated or restless, Fatigued or tired = fatigued or tired, Irritable or easily angered = irritable or easily angered, Irritable or easily angered = irritable or easily angered or fatigue, Irritable or easily angered = irritable or easily angered

Table 4: Mann - Whitney-U-test comparing emotions and worries of adults with and without MHC and children with and without MHC, separated before and after Covid-19

Adults before Covid-19 = Adults before Covid-19, Adults during Covid-19 = Adults during Covid-19, Children
before Covid19 = child before Covid19, Children during Covid-19 = child during Covid-19, Worried = worried, Enjoy
activities = enjoy activities, Concentrated = concentrated, Lonely = alone, Negative thoughts = negative thoughts, Happy or sad = happy or sad, Relaxed or anxious = relaxed or anxious, Fidgety or restless = agitated or restless, Fatigued
or tired = tired or fatigued, Irritable or easily angered = irritated or easily angered

Differences in stress sensation

Independent sample t-tests showed that higher perceived stress levels in Covid-19 compared to minors (N=132,M=52.92,SD=12.14,t(454)=-2.78,p<0.01) and parents (N=324,M=56.66,SD= 13.39) Furthermore, adults with MHC had significantly higher perceived stress levels during Covid-19 than adults without MHC (t(85.474)=6.18,p<0.001).

Predictors of Perceived Stress

Using the Enter method, we found that the model explained significant variance in perceived stress among adults with MHC (F(7,62)=5.33,p<0.001,R2=0.38,R2 adjusted=0.31). However, only physical status reached significance as a predictor of perceived stress. For adults without MHC, the regression model also explained a significant amount of variance in perceived stress (F(7,378)=13.56,p<0.001,R2=0.20,R2 Adjusted=0.19). Mental status, family relationships, relationships with friends, economic insecurity, and a large number of minors in the same household were identified as significant predictors of perceived stress. The results of the regression coefficients are presented in Table 5.

Consideration

This project will provide insight into the different emotional responses of children, adolescents, and adults (parents and non-parents) with and without MHC to social constraints and potential health risks associated with Covid-19. The hypothesis is that all captured emotions and worry (adults) or most captured emotions and worry (children) were poorer in persons with mhc compared to persons without MHC before and during Covid-19 restriction. Consistent with this, we found higher parental stress perception in adults without children and with MHC compared to those without MHC. Also, as expected, our results show that between the pre-Covid19 regulation and the Covid-19 regulation period, all four groups (adults with and without mhc,
children and adolescents with and without MHC) showed significant changes in affect and worry.
The strongest increase among children was in ˈHow did your child enjoy activitiesˈ and lonely ˈHow was your child?" said. In both groups, the largest increases in worried ˈHow much fun were "How much fun did you have?" and "How much fun were you having?" in both groups. Interestingly, contrary to our expectations, those without mhc (children and adolescents and adults) showed significantly worse emotionality in more cases than those with MHC. Correspondingly, changes in the quality of relationships with family and friends and economic insecurity predicted perceived stress only in adults without MHC.

In adults with MHC, pre-Covid-19 physical status was the only predictor of perceived stress.
Our findings regarding worsening emotions and worry during Covid-19 restriction in children, adolescents, and adults without MHC are,
consistent with previous studies reporting an association between larger social networks and better psychological well-being [19-21]. The authors' findings are also consistent with results from studies on post-traumatic stress disorder (PTSD). For example, meta-analyses have shown that lack of posttraumatic social support (e.g., from family and friends) and previous psychological adjustment are predictors of PTSD [22]. In addition, financial losses associated with natural disasters have also been identified as predictors of PTSD [23].

Table 5 :Regression of predictors of perceived stress (T-values) in adults with and without MHC

However, the present findings raise the question of why emotions were worse in children, adolescents, and adults with MHC and whether changes in the quality of relationships with friends and family were predictors of perceived stress in the adult group with MHC.

One explanation is that MHC patients often have smaller friend and family networks and strained family relationships (e.g., [24]). Thus, these individuals may not have experienced more negative changes due to the social constraints associated with Covid-19. It is also important to consider that a higher proportion of women in the MHC patient group (80.05% vs. 94.28%), and the influence of family networks differs between the sexes. In men, family networks are associated with better welfare, while in women, family networks can also impose more obligations and burdens [19]. Another explanation for our findings is that MHC patients learned to develop strategies to cope with strained family relationships, for example, professional support
for example, professional support. These strategies include daily routines, sports, music, etc. Therefore, stressful family situations and coping strategies may already be known to some MHC patients. This could be one reason why changes in family relationships and the number of minors in the same household do not predict stress perception in MHC patients. Change in family relationships significantly predicted perceived stress, since patients without MHC usually cannot return to this type of conscious coping with stressful family situations.

Another possible explanation for our finding that individuals without MHC (children and adolescents and adults) experienced significantly worse emotionality than individuals without MHC is that social contact is often fearful for individuals with MHC. Avoidance of social contact to avoid negative social evaluations, for example, is a known feature of social anxiety disorder and depression. In addition, performance anxiety is often observed in children and adolescents with MHC. Adolescents in the clinical sample reported higher levels of academic stress than adolescents in the non-clinical sample [25]. In these individuals, avoidance of schooling may reduce the individual's stress level. This is due to the lack of compulsory education in Germany,
strategy that is usually not applicable. Avoidance strategies are effectively maladaptive in the long term because they require maintenance of the illness, but often lead to short-term relief from fear and anxiety. In this regard, for MHC patients, the social constraints and school closures associated with Covid-19 may have served the purpose of avoidance strategies with short-term relief from social performance and anxiety. Perhaps this short-term relief contributed to the finding that children, adolescents, and adults did not exhibit the degree of worsening of emotion and worry expected during Covid-19. However, since avoidance strategies are usually maladaptive in terms of long-term maintenance of disease, it would be of great interest to observe how emotions and worry develop in children and adolescents with MHC during Covid-19 restriction.

Conclusion.

In summary, the social constraints and potential health risks associated with Covid-19 appear to influence emotions and concerns in most populations. Therefore, it will be important to observe the trajectories of MHC in the general population. Four trajectories indicate factors that favor emotional recovery and may lead to chronic stress in physically remote areas such as the Covid-19 pandemic.

Research Limitations and Strengths

The main limitation of this study is that recall bias may affect our results because pre-Covid-19 emotions and worry were measured backward. Te data are also limited in that children and adolescents' emotions and worry are measured by parental report. Furthermore, because of the small number of mental disorder groups, the data are not suitable for providing information on how emotions and worry vary in different mental disorders. In addition, there were special circumstances during data collection in Germany, which limited comparisons with other studies. It is also important to consider that the situations caused by Covid-19 have very specific characteristics and cannot be easily transferred to other common experiences, such as natural disasters or accidents leading up to individual tragedies.

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