Work

Corrigendum: Association of parent-child interactions with parental psychological distress and resilience during the COVID-19 pandemic

Year: 2023

Type: erratum

Abstract: COVID-19 associated effects on health, educational, economic, and social sectors have impacted children, families, and communities worldwide. New York City (NYC) was among the first metropolitan areas to experience the pandemic in the United States. The Bronx, in particular, reported the most severe COVID-19-related outcomes, with the highest hospitalization and death rates in NYC (1). Unemployment in the Bronx peaked at nearly 25% in May 2020, further devastating NYC communities with the highest pre-pandemic rates of poverty and food insecurity (2). Worldwide closures of daycares, schools and recreation centers resulted in an estimated 1.38 billion children shifting to remote learning (3,4). Many families experienced challenges with remote schooling, childcare, and professional obligations due to limited community- and family-level resources (5). Increased stress and adverse mental health effects were reported among parents (6,7), both during pregnancy and in the postpartum period (8-10). Hospital policies during the pandemic often forced pregnant women to give birth unaccompanied by their partners which further heightened psychological distress (10). The pandemic also worsened food and housing insecurity and poverty which particularly affect young children who are highly dependent on their primary caregivers for their physical and emotional needs (11). Although studies have found that young children’s exposure to early life stress impacts their development and overall health (12,13), parents can buffer these negative effects by externally regulating their children’s emotions (14) and supporting development of their intrinsic capacity for self-regulation (15). Positive parent-child interactions and engagement activities mitigate some of these negative factors and promote children’s socioemotional development (16-19) and resiliency to stress (19,20). Postpartum mental health symptoms during the pandemic may negatively impact maternal-infant bonding (21,22). Recent studies have shown that parents of children 10 months-17 years of age (mean age 8.84 years) more effectively buffer the negative effects of pandemic-related stress by supporting their children through negative emotions and more consistently maintaining household routines (23). Others have reported that lower quality parenting during the COVID-19 pandemic was associated with multiple household and pandemic risk factors, with caregiver depression linked to parent-child relationship disruptions among parents of children 1.5-8 years of age (24). However, few studies have examined parental psychological distress, resilience and regular engagement in parent-child/family activities during the COVID-19 pandemic, especially among parents of very young children and communities of color (23,24). Investigating the impact of COVID-19-related factors on parental mental health and parent-child engagement in activities is critical to identifying, informing, and planning services, education, and policies to support young children and families in the setting of high stress or adversity. Therefore, in children and their mothers enrolled in the “Bronx Mother Baby Health Study” (Bronx MomBa Health Study), an ongoing longitudinal study of epigenetic mechanisms underlying intrauterine growth restriction (IUGR)-mediated obesity from birth to two years of age, we sought to identify: 1) associations between parental psychological distress, resilience, parental perception of their child’s psychological distress, exposures to COVID-19-related events, and social-demographic factors, and 2) associations between psychological distress and resilience and parent-child engagement activities. Parents were also asked open ended questions to better understand the impact of the COVID-19 pandemic on families. We hypothesized that there would be a positive association between exposures to COVID-19-related events and parental psychological distress. Furthermore, positive engagement in parent-child activities would be negatively associated with parental psychological distress and positively associated with parental resilience. METHODSStudy sampleThe Bronx MomBa Health Study is an ongoing longitudinal study that aims to understand the pathogenesis of early childhood obesity (from birth to two years), by examining epigenetic mechanisms underlying IUGR-mediated alterations in DNA methylation of CD3+ T-cells. Infants of pregnant persons who received prenatal care and delivered at a large urban, private, non-profit hospital in the Bronx, NY were enrolled in the study. Inclusion criteria for this study include healthy term singleton pregnancy with no prenatal history of depression, smoking after the first trimester of pregnancy, or gestational/type 2 diabetes. Infants who were large for gestational age, and those with an Apgar score <7 at 5 minutes of age, chromosomal or congenital abnormalities, congenital infections, or inborn errors of metabolism were excluded. Infant anthropometric measurements, cord- and peripheral blood samples, and stool samples were obtained at multiple timepoints over the course of the first 2 years of life. From 9/2018-8/2021, 377 pregnant women were approached and 217 (57.6%) consented to study participation. Fifty-five of the consented participants (25.3%) were excluded from the study for the following reasons: cord blood sample not collected, infant large for gestational age or infant admitted to the intensive care nursery. In March 2020, the study was paused for new enrollment and in person visits because of the COVID-19 pandemic. Enrollment and study visits were resumed in September 2020. During the early stages of the pandemic, the original study protocol was amended in order to collect information related to the pandemic’s effects on our study cohort. A total of 105 parents whose children were scheduled for study-related visits between 6/2020 and 8/2021 participated in this amended study and provided information regarding their exposures to COVID-19-related events (Figure 1). Parents completed questionnaires regarding demographics, food and housing insecurity, psychological distress, resilience, and involvement in parent-child engagement activities. This study was approved by the Montefiore Medical Center/Albert Einstein College of Medicine Institutional Review Board (NCT03402139). Study MeasuresSince in-person study-related visits were halted during the height of the pandemic, some of the study participants completed the questionnaires either over the telephone or mailed the completed questionnaires to the study team whereas others completed the study questionnaires during the in-person study visits once on-site study-related activities resumed in September, 2020. All study questionnaires were available in both English and Spanish. Exposures to COVID-19-related events. Parents completed the COVID-19 Exposure and Family Impact Survey (CEFIS) (25), a questionnaire based on a trauma framework that aims to understand exposures as well as the impact of the COVID-19 pandemic on families and their children. Part 1 of the questionnaire focuses on COVID-19 related exposures/events, includes 25-items in six categories (designation as an essential worker, access to essentials, disruptions to living conditions, income loss and family caregiving and activities) with a yes/no answer. A higher Part 1 score indicates higher COVID 19-related exposures. Part 2 of the questionnaire focuses on the impact of the pandemic on families (personal well-being, family interactions, distress) and consists of 12-items, 10 of which use a 4-point Likert scale (made it a lot better; made it a little better; made it a little worse; and made it a lot worse). The last two questions in Part 2 of the questionnaire relate to COVID-19-related psychological distress experienced by the caregivers (Question 36) and their children (Question 37) and are rated on a 10-point Likert scale. Higher scores for Questions 36 and 37 indicate higher levels of psychological distress experienced by parents and their children, respectively. Part 3 of the scale includes an open-ended prompt for parents to share their positive and negative experiences during the pandemic. The COVID-19 Exposure and Family Impact Survey was registered on April 22, 2020 with the National Institutes of Health Disaster Information Management Research Center (https://www.niehs.nih.gov/research/programs/disaster/database/ cefis_covid_questionnaire_english_42220_final_508.pdf) and made widely available to the public. Here, we report on the results from Part 1 of the survey and questions 36 and 37 from Part 2 of the survey.Kessler 10 Psychological Distress Scale. Parents completed the Kessler 10 Psychological Distress Scale (K10), a questionnaire developed to yield a global measure of psychological distress based on questions related to anxiety and depressive symptoms in the most recent 4-week period (26). Each item is scored on a 5-point scale from 1 (none of the time) to 5 (all of the time), with a total sum ranging from 10 to 50. As few studies have collected normative data of psychological distress among a diverse group of parents of very young children (including postpartum mothers) (27), we elected to analyze psychological distress as a continuous outcome, with higher scores indicating greater levels of distress. This analytical strategy is consistent with Kessler’s recommendations against simple summing of items and use of cutoff scores (26). Parental Resilience. The 14-item Resilience Scale (RS14) is a validated, self-report scale evaluating the main characteristics of resilience and the ability to overcome adversity (28). Each item is scored on a 7-point scale from 1 (strongly disagree) to 7 (strongly agree) with a total sum ranging from 14 to 98; higher scores indicate higher resilience. Previous studies have shown good reliability of the scale in adults (29-33). Parent-child engagement activities. Parents reported on the frequency of positive engagement activities with their child including telling stories, playing games, and singing as well as household routines for meals and bedtime. These questions were based on national surveys from the Early Childhood Longitudinal Study, Birth Cohort which have been utilized previously by others (17). Activities were categorized and analyzed independently as present if children and caregivers engaged in: (1) family dinners >5 days/week, (2) sleep routines >5 days/week, (3) reading >3 times/week, (4) storytelling >3 times/week, (5) singing >3 times/week, or (6) playing >3 times/week (17). Food and Housing Insecurity. Food insecurity was assessed by parent report of a two-item screening questionnaire from the U.S. Department of Agriculture 18-item food security screening measure (34). The questions include: (1) “We worried whether our food would run out before we got money to buy more” and (2) “The food we bought just didn’t last and we didn’t have money to get more” (34). Each item was scored on a 4-point scale (often true; sometimes true; never true; don’t know). Food insecurity was categorized as present if parents reported either “Sometimes True” or “Often True” for either of the two questions. We also asked the following question: “Did your household participate in a food assistance program?” This question was scored on a 4-point scale (often true; sometimes true; never true; don’t know). Household participation in a food assistance program was categorized as present if parents reported either “Sometimes True” or “Often True” for this question.Housing insecurity was determined using the following question: (1) “Did you worry there would not be enough money to pay for rent?”(35). This item was scored on a 4-point scale (often true; sometimes true; never true; don’t know). Housing insecurity was categorized as present if parents reported either “Sometimes True” or “Often True” for this question. Other Patient Characteristics. Child characteristics included infant sex, race, and ethnicity. Ethnicity was categorized as Hispanic/Latino if either parent self-reported as being Hispanic/Latino. If multiple races were selected or if parents refused to self-identify as belonging to any race, this variable was categorized as “other.” Parent characteristics included language of survey completion and educational attainment. Statistical AnalysisAll analyses were performed using R package (https://www.r-project.org/; version 4.1.2) and SPSS version 29. This study has a sample size of 105 for our first study goal of identifying associations between parental psychological distress and resilience, with exposures to COVID-19-related events, family- and parent-level factors and 58-72 for our second study goal of identifying associations between these factors and parent-child engagement activities, which provides 80% power at significance level of 0.05 to detect a moderate correlation of r=0.27 and r=0.33-0.36, respectively. Spearman’s correlation was used to examine associations between COVID-19-related events, psychological distress and resilience and between psychological distress and resilience and parent-child engagement activities. Associations between maternal characteristics and psychological distress and resilience were analyzed using Spearman’s correlation, T-test or ANOVA as appropriate. Associations between categorical maternal characteristics and parent-child engagement activities were examined using Chi square test. We used an alpha level of 0.05 for all statistical tests. For the qualitative analysis, the content of parent responses to the open-ended COVID-19 Exposure and Family Impact Scales question were categorized under broad themes. RESULTSThere were no differences between study participants who either completed the questionnaires over the telephone or mailed the questionnaires to the study team and those who completed the questionnaires during the in-person study visit.Demographics of Study ParticipantsTable 1 describes characteristics of study participants. Overall, 73.3% of participants were Hispanic and 28.6% completed the surveys in Spanish; 52.4% and 31.4% were White and Black, respectively. Of the study participants, 29.4% graduated from high school, and 60.8% had more than high school education. After the pandemic start, almost one third (29.8%) of participants reported food insecurity, and almost one-half (46.9%) reported use of food assistance programs. Approximately one-half (47.6%) of our study participants reported that they were experiencing some level of housing insecurity. Exposures to COVID-19-related EventsThe mean COVID-19 Exposure and Family Impact Survey Part 1 score in our cohort was 8.3+4.2. Figure 2 illustrates the percent of participants who reported each of the COVID-19 Exposure and Family Impact Survey items. Notably, 60% reported a decrease in family income; 44% that a family had to that a family was to that a family was or with and that a family their Parental Psychological Distress In our the for for the scale was The mean score for psychological distress was Higher levels of psychological distress were associated with White Other and housing insecurity was no association between psychological distress levels and maternal age, education, and food insecurity. Parents who reported food insecurity were more to use food assistance Parents who reported use of food assistance had higher this association not statistical significance was a positive correlation between COVID-19 related exposures 1 of COVID-19 Exposure and Family Impact and parental psychological distress as by the questionnaire parental psychological distress as by 36 of COVID-19 Exposure and Family Impact Survey Part 2 and psychological distress in their children as by 37 of COVID-19 Exposure and Family Impact Survey Part 2 was a positive correlation between parental psychological distress as by 36 and psychological distress in their children as by 37 of COVID-19 Exposure and Family Impact Survey Part 2 our the for for the scale was The mean score for resilience was age, race, education, food and housing insecurity, and events were not associated with resilience as by the As shown in there was an relationship between parental resilience and psychological distress as by the questionnaire was no association between resilience and parental psychological distress and psychological distress in their children as by Questions 36 and 37 of the COVID-19 Exposure and Family Impact Survey Part engagement 3 the association between maternal and child characteristics and parent-child engagement activities. as a family times/week was associated with sleep was associated with higher maternal Although higher maternal was associated with more this association not statistical significance the surveys in English was associated with reading 3 a telling was associated with of the child was no correlation between parental psychological distress or resilience and engagement in any of the parent-child activities. However, parents with lower levels of psychological distress were more to in telling times/week this association not statistical parents with higher resilience scores were more to have family dinners times/week, this association not statistical significance and of COVID-19 as by parents the open-ended question regarding positive and negative effects of the pandemic. Parents reported on the effects of the pandemic including and with Parents to with one was to to prenatal participants of being during this Others for and family of COVID-19 who developed COVID-19 during pregnancy have an who for and for was pregnant and COVID or for COVID pregnant was very for with and for was to or During this was a parent of a and was through pregnancy with a child’s not have any or After was to that we food at with COVID during pregnancy was very and was if the had related to challenges in remote schooling, childcare, children’s social and activities, parental and professional and little parent on their experience have not to is more than and to on also the of the pandemic on the and educational of their children. Parents on their children’s of as well as due to COVID-19-related disruptions the to and being for young children to the very We physical in the to our for our one because there was no available than the it was not a especially young children, to and their The that all the adults in their are of and they have at their their is to as a have that and to run and Notably, participants on more family between and family was with some family others with family participants provided including in activities, and children to be more also to their children and they for their children’s resilience. of young children are particularly to COVID-19-related The effects of social can further this our this is the first study to examine associations between COVID-19-related and parental mental health, resilience, and parent-child engagement activities among parents of very young children in the Bronx, a that has been by related to health, and exposures. This as an of the COVID-19 pandemic and to experience In the Bronx MomBa Health Study participants, we that our study participants experienced COVID-19-related to the national study Parents also reported on they an open-ended question on the effects of the pandemic, the challenges and used by as has previously been reported high exposures to COVID-19-related events, some of our study participants on the positive of the pandemic including more family and children in activities. of the parents also the of their children and an experience that was made because of the pandemic and activities after the was our we have a positive association between exposures to COVID-19-related events and higher levels of parental psychological distress among parents of very young children. also was a positive association between COVID-19-related events and psychological distress in their young children. This is consistent with of distress in children during the COVID-19 pandemic, including anxiety and sleep and However, most of these studies have on school children and Although there was an relationship between resilience and parent psychological distress, parental resilience not or their children from psychological distress to COVID-19-related exposures. Of a recent of mental health symptoms of mothers with children under 5 years of age during the COVID-19 pandemic reported of and for depression and anxiety As there was an relationship between parental resilience and overall psychological distress as by the However, we that parent resilience not against COVID-19-related psychological distress, that the pandemic-related stress may have their parent resilience was to buffer the psychological distress experienced by their children. we that COVID-19-related psychological distress in parents and their children was highly Previous studies that have shown a association between the mental health of parents and their children recent studies have shown that parent psychological distress, depression and anxiety during the pandemic their children’s and emotional and is associated with psychological symptoms in children and is to that our cohort of parents of very young children than 2 years of age and child psychological distress was based on parent report than from the children In our housing insecurity, not food insecurity, was associated with psychological distress, the of identifying families with risk factors for early As food insecurity was associated with use of food assistance programs. is to that families with greater food needs are more to for food assistance parents who utilized food assistance had higher psychological this association was not Although studies have shown psychological stress with the use of food assistance more recent studies during the pandemic have shown that COVID-19 food insecurity and psychological distress in families using food assistance Previous studies have shown that maternal psychological distress is associated with positive parenting during early childhood However, we not any association between psychological distress or resilience levels and positive parenting in parents of very young children. Positive and consistent parenting after life have been shown to child mental health positive parenting have been shown to effectively buffer negative effects of COVID-19-related stress on children (23). Furthermore, more engagement of children in family routines was associated with lower rates of child depressive and during the pandemic in parenting among children under 5 years between and parents have previously been reported with these we that sleep routines and more reading were associated with higher parental education, and child was associated with parental we that family dinners were associated with ethnicity. This with which a to family to the in of Hispanic parents meals with their children to of parents Higher levels of exposures to COVID-19-related events were not associated with parent-child engagement activities, the of factors before the pandemic and in our that to parent-child In to the pre-pandemic reported families engaged in routines during the pandemic of our study include the and of our participants. our participants are parents of very young children, a group that is at greater risk of experiencing and adverse effects related to the pandemic. Study include a sample size which limited our ability to or include study of questionnaire data as parent and the use of one question a scale for the parent-child engagement activities which not as of or parents the COVID-19 Exposure and Family Impact Scales questions all their children, and not just their recent As family in experiences may in the COVID-19 Exposure and Family Impact Scales responses were may be if an is to that the COVID-19 Exposure and Family Impact Scales performed well in our cohort and high questionnaires to study can be and questionnaires COVID-19 Exposure and Family Impact Scales is to of The COVID-19 pandemic can be as a that may to stress effects during as the first of life. is critical to further the effects of the pandemic and on child and family factors to support families with young children during high stress events may mitigate some of the COVID-19 pandemic’s negative This study the for to examine the longitudinal effects of the COVID-19 pandemic on parental mental health and resilience. studies on positive parent-child engagement activities impact the mental and emotional health of both parents and their children during high stress

Source: Frontiers in Pediatrics

DOI: 10.3389/fped.2023.1245866