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Abstract
Background In late 2019, a new respiratory illness was detected in Wuhan, China and was later designated as COVID-19 by the WHO. Despite international efforts to impose restrictions and quarantine measures, the virus spreads rapidly across the globe. The pandemic has significantly impacted the mental health of both children and parents. This study investigates the relationship between parents’ anxiety, stress and depression, and Children’s Health-Related Quality of Life (CHQol) and externalised behavioural disorders during the COVID-19 pandemic.
Methods This is a cross-sectional study that included 396 parents who have children between the ages of 6 and 18 years old. Sampling was done by designing an online questionnaire that was distributed on social media (WhatsApp and Telegram and native social media, such as Eitaa, Soroush and E-Gap). Inclusion criteria were all citizens living in rural and urban areas of Rafsanjan, citizens living in Rafsanjan city for 1 year and having children aged 6–18 years old. We used a demographic information questionnaire, Depression, Anxiety, Stress Scale-21, CHQol and Achenbach System of Empirically Based Assessment to collect data.
Results We found a positive significant correlation between anxiety (r=0.334), stress (r=0.354), depression (r=0.324) and externalised behavioural disorder (p<0.001). Depression and anxiety predicted 22% of the variance of the CHQol (p<0.001) while age, stress, use of masks and gloves to prevent infection, and anxiety predicted 19% of the variance of externalised behavioural disorder (p<0.001).
Conclusion Parents experienced high levels of symptoms of anxiety, stress and depression during the COVID-19 outbreak, which can be associated with behavioural disorders in their children and negatively impact their health. Therefore, it is crucial to pay more attention to the mental state of parents and its complications for children.
- Adolescent Health
- COVID-19
- Nursing
- Child Psychiatry
Data availability statement
Data are available on reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
The outbreak of COVID-19 created extraordinary mental health problems in various regions.
The pandemic posed a serious challenge to mental health services.
Parent–child conflict during the pandemic introduced new challenges for families.
WHAT THIS STUDY ADDS
Investigated the symptoms of anxiety, stress and depression of parents during the COVID-19 outbreak and its effect on children’s mental health.
Found that parents experienced high levels of anxiety, stress and depression during the pandemic.
It was determined that parental mental health issues could be associated with behavioural disorders in children and decrease their overall health.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Identify factors causing mental health problems in children and adolescents to prevent serious and prolonged complications.
Mental health professionals should focus on the psychological state of parents and the parent–child relationship.
Special interventions are necessary to improve parents’ mental health during crises like the COVID-19 outbreak to prevent behavioural problems in children.
Introduction
In late 2019, a new respiratory illness was detected in Wuhan, China and was later designated as COVID-19 by the WHO. Even with global restrictions and quarantine to control COVID-19, the disease spreads rapidly throughout the world.1 This epidemic was associated with very complex events in various medical, social, political, economic, religious, cultural and civilisational aspects and had wide consequences at different levels.2 Despite governmental policies and strategies, the outbreak of COVID-19 created extraordinary mental problems in different regions and a serious challenge for mental health services.3 COVID-19 can affect the mental health of people at present and in the future4 and is the cause of some mental problems, such as acute stress disorder, depression and suicide.5 We should assess psychological and behavioural aspects in the community to identify the progress of the epidemic and risk-related strategic interventions.6 Studies conducted in China during the outbreak show that children and adolescents, as well as adults, were psychologically impacted, manifesting behavioural problems.7 Furthermore, other authors reported a high prevalence of depression among children during the COVID-19 outbreak8; depression in children and adolescents could be associated with substance abuse, academic problems,9 10 smoking, promiscuity, physical health problems, damaged social relations and increased suicide.11
We should pay special attention to the mental health of children. With the outbreak of COVID-19, authorities closed schools, so children and adolescents had to stay at home and faced significant challenges; they lost their daily activities and interpersonal and social interactions, which were potential risk factors for their mental health problems. The COVID-19 epidemic was serious and all adults were worried about the epidemic that might compromise children’s psychological health and cause their behavioural problems.12 Parents–children conflict brought about new challenges for families, and parents’ anxiety and stress affected children’s mental state and health.
Health-related quality of life is an important concept when evaluating children’s health status and well-being.13 Children and adolescents’ growth and health should be the main concern of any society because they are one of the most vulnerable age groups. Health-related quality of life can cause psychological challenges in children and adolescents. We rarely found studies that examined the evidence of COVID-19 on children’s mental health. Therefore, investigating mental problems and confounding variables in controlling the psychological complications of this disease can reduce its complications in children and adolescents. We should identify factors that cause problems in children and adolescents in the future and take measures to prevent their serious and prolonged complications. To the best of our knowledge, the complications of COVID-19 are unknown and require further studies.14 Therefore, we conducted the current study to determine the relationship between parents’ symptoms of anxiety, stress, and depression, and children and adolescents’ quality of life and behavioural problems during the COVID-19 outbreak.
Methods
Study design and setting
This cross-sectional study was conducted during the fourth wave of the COVID-19 outbreak in Iran from April 2021 to July 2022. Before completion of the online questionnaire, the participants were asked to complete the consent form if they wished to participate in the study and if they met the inclusion criteria. This form included study objectives, optional completion of the questionnaire and information confidentiality.
Patient and public involvement
No patients are involved.
Sampling and sample size
In this study, four questionnaires were used for data collection: (1) demographic information, (2) Depression, Anxiety, Stress Scale-21 (DASS-21), (3) the Children’s Health-Related Quality of Life (CHQol) (parent version) and (4) Achenbach System of Empirically Based Assessment (ASEBA) (parent version) (externalised behaviour problems scale). Sampling was done by designing an online questionnaire that was distributed on social media (WhatsApp and Telegram and native social media, such as Eitaa, Soroush and E-Gap). Inclusion criteria were all citizens living in rural and urban areas of Rafsanjan, citizens living in Rafsanjan city for 1 year and having children aged 6–18 years old. According to Shirzadi et al 15 (2020) (r=0.26) and the following formula, the sample size was 300 participants with 95% confidence and 90% test power.
Of 427 questionnaires, 31 were incomplete, so the response rate was 92.74%; the data of 396 participants were used in the final analysis.
Measurement
Data were collected using four questionnaires: demographic form, DASS-21,16 the CHQol and ASEBA.
Demographic and coronavirus information
Demographic information included age, sex, education level, the number of children, occupation, income, work experience in medical centres, infection with the coronavirus, acquaintances getting infected with the coronavirus, being at risk of contaminating with the coronavirus, taking precautions to prevent the coronavirus, using masks and gloves and washing hands for prevention, recommending healthcare to others and the most important concern.
Depression, Anxiety, Stress Scale-21
The DASS-21 was created to measure the psychological constructs of depression, anxiety and stress.16 This 21-item questionnaire includes three subscales of depression, anxiety and stress, designed in a 4-point Likert scale, with the options of never/low/medium/high. The lowest score for each question is 0, the highest score is 3 and the final score of the subscales should be doubled. The cut-off scores for severity labels are listed below: depression: normal (0–9), mild (10–13), moderate (14–20), severe (21–27) and extremely severe (28+). Anxiety: normal (0–7), mild (8–9), moderate (10–14), severe (15–19) and extremely severe (20+). Stress: normal (0–14), mild (15–18), moderate (19–25), severe (26–33) and extremely severe (34+). In Iran, Samani and Joukar examined the validity and reliability of this scale and the retest validity to be 0.80, 0.76 and 0.77 for depression, anxiety and stress, respectively. Cronbach’s alpha coefficient was reported to be 0.81, 0.74 and 0.78 for depression, anxiety and stress, respectively.17
Children’s Health-Related Quality of Life
CHQol designed by Landgrave and Abetz (1996)18 contains 28 items with 13 subscales. The questionnaire designed for children aged 5–18 is completed by parents. This questionnaire can be used for boys and girls of different ages and parents with various education levels and occupations.19 This questionnaire generally includes two domains of physical health (subscales of physical functioning, limitations in schoolwork and activities with friends, general health and bodily pain) and psychosocial health (subscales of emotional-behavioural social limitations, self-esteem, mental health and limitations in family activities).20 The scale is Likert-type, with some questions ranging from 1 to 4 and some ranging from 1 to 5; children with higher scores have better health. Golzarpour et al in Iran (2017) validated the 22-item questionnaire to measure CHQol in 7 factors with an internal consistency of 0.68–0.85.21
Achenbach System of Empirically Based Assessment
Achenbach Child Behaviour Checklist22 evaluates the emotional-behavioural problems as well as the academic and social abilities and competencies of children aged 6–18 from the perspectives of parents. The checklist evaluates children and adolescents’ anxiety/depression, isolation/depression, somatic, social, and thinking problems, attention/deficit problems, rule-breaking behaviour, and aggressive behaviour. Rule-breaking behaviour and aggressive behaviour are the second-order factors of externalising problems; this study used subscales of aggressive behaviour (19 items) and rule-breaking behaviour (17 items) of the Achenbach child behaviour checklist. The scale was Likert-type ranging from 0 to 2 (0 was given to behaviours that were not true about the child, 1 was given to situations and behaviours that were sometimes true about the child and 2 was given to behaviours that were very true about the child).
The overall reliability coefficients of the Achenbach Child Behaviour Checklist were 0.97 and 0.94 using Cronbach’s alpha and retest validity, respectively.23 Minaei in Iran (2015) reported internal consistency coefficients of 0.63–0.95 using Cronbach’s alpha, so it can be used to measure emotional-behavioural disorders in children and adolescents aged 6–18.24
Data collection
After obtaining permission and a code of ethics, the researchers designed and tested the online questionnaire with the help of computer experts and the designer of the online questionnaire. The online questionnaire included demographic information, the CHQol, the ASEBA and the DASS-21. The correct functioning and typesetting of the online questionnaire were verified during its design. The research team tested the questionnaire in terms of the highest practical rates of response and explained to respondents the research objectives, and how they could enter and complete the questionnaire or they could leave it without completion. The pilot study was conducted on 50 participants to check how many people completed the questionnaire, whether the online questionnaire was functioning well, as well as whether its typesetting was proper or not. Data collection lasted from May to January 2021 which coincided with the fourth wave of the COVID-19 outbreak in Iran. We had 437 online questionnaires, of which 396 remained for final analysis.
Data analysis
The data were analysed by using Statistical Package for the Social Sciences ‘SPSS’ V.23 (V.26, IBM). Descriptive statistics, including numbers and percentages, were used to describe the demographic characteristics and information related to variables such as symptoms of anxiety, stress and depression, CHQol and externalising behavioural disorders. The Pearson correlation coefficient was employed to assess the relationships between anxiety, stress, and depression variables, CHQol and externalising behavioural variables, with a significance level set at 0.05. Multiple linear regression was used to determine the effects of depression, stress and anxiety, in conjunction with demographic variables such as age and income, on the overall scores of children’s quality of life and behavioural disorders as two separate response variables. All assumptions related to multiple linear regression were validated in the data examined. The histogram of the overall quality of life score (dependent variable) and the overall behavioural disorder score (dependent variable) was symmetrical and resembled a normal distribution. The Kolmogorov-Smirnov test also indicated no significant deviation from normality (p=0.959). The histogram of residuals also had a normal distribution with zero mean. According to the Durbin-Watson statistic value of 2.524, which is in the range (1.5–2.5), therefore, the hypothesis of independence of errors was confirmed. By checking the values of the ‘specific value’ column, all the values were greater than 0, and by checking the values of the ‘status index’ column, all the values were less than 30. Therefore, there is no collinearity problem in using multiple linear regression. Also, by drawing the distribution chart of standardised predicted values against standardised residuals, no specific pattern was seen in the distribution chart, which indicates the uniformity of the data distribution around the regression line.
Results
Sociodemographic
The mean age of participants was 38.85±7.07 years (Min=20 and Max=57). The majority of the samples were female (n=273; 68.9%), employed (n=180; 45.5%) and with bachelor’s degree (n=153; 38.6%). COVID-19 contaminated 36.9% (n=146) of the participants and 92.2% of their relatives/friends (n=365) while 76% (n=301) considered themselves at risk of infection and 50% (n=198) received information about the coronavirus from social media (tables 1 and 2).
Demographic characteristics of the participants and their associations with anxiety, stress and depression (N=396)
The participants’ responses to some corona-related questions and their associations with anxiety, stress and depression (N=396)
The mean scores scale
The mean scores of symptoms of anxiety, stress and depression were 10.52±7.83, 16.69±9.36 and 12.07±9.26, respectively. 112 participants (28.3%) had intense/very intense anxiety, 73 (18.4%) had intense/very intense stress and 68 (17.1%) had intense/very intense depression. The mean score of the CHQol was 83.76±13.13, which was greater than the midpoint of the questionnaire (52.5). The mean score of externalised behavioural disorder was 12.41±8.87, which was lower than the midpoint of the questionnaire (36) (table 3).
Distribution of the anxiety, stress, depression, child health and externalised behavioural disorder in participants (n=396)
In the present study, a positive and significant correlation was seen between anxiety (r=0.334), stress (r=0.354), depression (r=0.324) and externalising behaviour disorder (p<0.001), but between anxiety (r=0.395) stress (r=0.421), depression (r=0.465) and health-related quality of life (p<0.001) have a significant negative correlation (table 4). Among the demographic variables, gender and work experience in medical centres had a significant relationship with anxiety, stress and depression (table 1).
Correlation among anxiety, stress, depression, Children’s Health-Related Quality of Life and externalised behavioural disorder in participants (n=396)
Results of regression
In the present study, multiple regression models with backward methods were used to investigate how the demographic variables of symptoms of anxiety, stress and depression can predict the CHQol and externalised behavioural disorder. As shown in table 5, depression and anxiety predicted 22% of the variance of CHQol, with depression being the best predictor (p<0.001) while age, stress, use of masks and gloves to prevent infection, and anxiety predicted 19% of the variance of externalised behavioural disorder, with age being the best predictor (p<0.001).
The multiple regression analysis summary for CHQol and externalised behavioural disorder in participants
Discussion
The present study aimed to investigate the relationship between parents’ symptoms of anxiety, stress, depression, and children and adolescents’ quality of life and behavioural problems during the COVID-19 outbreak. Our results indicated that 28.3% of the participants had intense/very intense anxiety, 18.4% had intense/very intense stress and 17.1% had intense/very intense depression; they are consistent with previous results. According to Zakeri et al, the prevalence of anxiety was 27.8% during the COVID-19 outbreak in Iran, indicating a 5–6 time increase in the prevalence of anxiety during this crisis.4 Literature reported that 25% of the parents had anxiety and depression during the COVID-19 outbreak.25
According to reports, many parents’ mental health has deteriorated due to stress, anxiety and depression caused by the corona epidemic.26 27 A study demonstrated that one in five parents had high stress and that parental stress increased significantly during the COVID-19 crisis and did not return to precorona levels.26 Similarly, another study found that more than 50% of the parents were under pressure due to social distancing and the closure of schools and kindergartens during the COVID-19 crisis, and their stress increased significantly during the epidemic.27 Common stressors affecting parents during the COVID-19 crisis included changes in children’s routine activities, concerns about COVID-19 and the demands of online school.26 These findings indicate the need for intervention, prevention, mental health support and the development of parental coping skills to reduce the symptoms of anxiety and stress caused by the crises. Public health interventions must focus on parents’ stressors and target strategies for managing parenting problems.
In our study, parents’ symptoms of anxiety, stress and depression were significantly associated with poorer health-related quality of life in their children. This finding is consistent with previous research, which also suggests an association between parents’ mental health and children’s health outcomes. Literature demonstrated that the psychological state of parents could be an important protective factor for the mental health of their children during quarantine, and children with more anxiety and depression, instability/negativity, and less emotional regulation had parents with more psychological distress.28 Another study in Latin America reported a correlation between parents’ mental health and their children’s anxiety during the COVID-19 pandemic that could affect their children’s health status.29 Families who had problems related to the COVID-19 pandemic show that the disease may cause changes in parenting. According to Calvano et al, 29.1% of parents reported an increase in children’s exposure to domestic violence, and 42.2% reported an increase in children’s verbal and emotional violence during the pandemic. The authors believe that parental stress is a crucial focus for interventions aimed at mitigating the negative consequences of the epidemic.
Furthermore, a study showed that the majority of parents had difficulty continuing parenting in the same way they did before the COVID-19 crisis.26 Some studies suggest a significant correlation between depression and more hostile, negative, and uncommitted parenting, which may be associated with poor parenting qualities30 and affect children’s health. There is a reported negative correlation between an increase in anxiety and depression in parents and the emotional regulation of their children during the pandemic; the spread of the coronavirus was a stressful factor that affected the mental health of parents and children.31 While general stress related to COVID-19 was decreasing, parental stress was increasing in many families.26 A study revealed that parents had more stress, anxiety and depression due to the COVID-19 pandemic.25 Prolonged stress in some parents affected significantly their mental health, including more depression, anxiety and poor quality of life,32 which is associated with substance abuse, eating behaviour changes and excessive alcohol consumption33; these behaviours may continue after their stress removal. These conditions can affect parents’ behaviours and communication with their children, and as a result, their children’s health. These findings confirm the psychological conditions and status of parents during this period and highlight the critical need to improve the psychological status of parents. To support parents, public health messages should promote healthy ways of coping and provide information about stress management for specific parental challenges. Health policy-makers must provide systemic changes to reduce the impact of crises, such as COVID-19 on parents and families.
The results of the present study showed a direct positive correlation between parents’ symptoms of anxiety, stress and depression on their children’s externalised behaviour disorder, which was in line with the findings of previous research. Consistent with the literature, it was revealed that parental depression and anxiety might affect children’s externalising behaviours.34 Similarly, another study reported mothers with severe depression might predict higher rates of externalising behaviour in children over time, and maternal chronic depression has predicted youth externalising symptoms over time as well.35 Another study also indicated a correlation between maternal depression and negativity and more withdrawal from the child; mothers with a history of depression and less effective interactions might affect the youth’s performance.36 Additionally, a study associated mother’s depression and anxiety with children’s emotional problems in middle age.37 The present study was conducted during the COVID-19 crisis and examined the short-term effects of this crisis; therefore, it is necessary to pay attention to the short-term and long-term effects of this disease on the relationship between parents and children during the coronavirus crisis. It is also necessary to pay attention to the type of psychological disorder in the parents. Gruhn et al showed an association between chronic depression and externalising symptoms through its destructive, persistent and disabling problems in parenting behaviour38 while shorter periods may have less disruptive problems in parent–child relationships. The challenges brought about by COVID-19 have disrupted children’s daily routines; many children typically grow up with predictable schedules that provide a sense of safety and security, leading to fewer externalising behaviours.39 Regular structures and routines help parents feel organised and in control and have less anxiety and stress in raising their children.40 Parents with a lot of anxiety and stress are unable to use a regular plan and routine to organise problems caused by the crises, which may have negative effects on their children’s behaviour. Therefore, healthcare professionals must guide parents on how to create a stable structure and routine in order to address their children’s mental health. Parents must learn how to adapt to crises, reduce symptoms of anxiety, stress and depression, communicate with their children and pay attention to their children’s emotional and psychological conditions.
The COVID-19 pandemic has provided an opportunity to study and examine clinical mental health responses among parents and their children. Studies, including ours, which examined data on parents and their children during the COVID-19 pandemic, provide a variety of practical implications for policy-making at various community levels and support potential public health targets and clinical interventions. To make informed decisions that protect vulnerable individuals, including parents and children, health policy-makers need to focus more on applied research related to mental health problems, their consequences and strategies for reducing them in these populations. This study provides practical implications for policy-making at the community level and supports potential public health goals and clinical interventions. Future studies are necessary to monitor prolonged mental health outcomes among parents.25
Our study had limitations. Information was collected through social media, which may not represent the views of individuals without access to these platforms. Additionally, we used a self-report questionnaire, so further research involving clinical examinations and face-to-face interviews is needed. Since this study was conducted on a sample from a community in Iran, caution should be taken when generalising the findings due to potential cultural and ethnic differences. The data were gathered through an online survey with voluntary participation, which may introduce biases and extreme values in key variables. Future studies should compare these findings with those from the general population of the region.
Conclusion
Our results indicated that parents experienced elevated levels of anxiety, stress and depression during the COVID-19 outbreak due to the stressful conditions and various measures implemented to control the disease. These issues could, in turn, impact their children. Therefore, addressing parents’ symptoms of anxiety, stress and depression is crucial for promoting their children’s health during crises. Health officials and managers should implement interventions aimed at reducing these symptoms in parents to enhance and support the health of their children.
Relevance statement
The COVID-19 pandemic has resulted in increasing mental health concerns in children and parents. Evaluating and recognising the relationship between the mental health status of parents and their children in crises can help in improving the mental health of children.
Data availability statement
Data are available on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and the researcher received the code of ethics from the Ethics Committee of Rafsanjan University of Medical Sciences (IR.RUMS.REC.1399.222). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
We would thank the authorities of the Social Determinants of Health Research Centre and Clinical Research Development Unit and Ali-Ibn Abi-Talib Hospital, Rafsanjan University of Medical Sciences, Rafsanjan, Iran.
References
Footnotes
Contributors MAZ, MD, and SS designed the study. MAZ, MD, and EK analyzed the data. YS, HP, MK, and MAZ drafted the manuscript. MD, PCC, and MAZ revised the manuscript for intellectual content. All authors read and approved the final version.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.