The Relations among GI Symptoms, Mental Health, and Online Schooling for Youth with GI Conditions during the COVID-19 Pandemic

Abstract

Objectives:

For youth with gastrointestinal (GI) conditions, mental health symptoms can exacerbate GI symptoms. In a cyclical fashion, experiencing GI symptoms at school can contribute to depression, anxiety, and embarrassment. This study evaluated the impact of school instruction type on mental health and GI symptoms for youth with GI conditions during the COVID-19 pandemic.

Method:

Data were collected from caregivers and patients aged 8-17 years with inflammatory bowel disease, celiac disease, and irritable bowel syndrome (N = 146) from September-December 2020. Patients completed measures of depression, anxiety, anger, and GI symptoms; caregivers provided their child’s school instruction type (online, hybrid, or in-person). Analyses were conducted to examine the relations of mental health symptoms, GI symptoms, and school instruction type.

Results:

Participants generally had mild levels of depressive symptoms (T = 55.50), and anxiety (T = 53.02) and anger (T = 49.92) symptoms were within normal limits. Anxiety and GI symptoms were positively related (b = 0.14, p < .01), and if participants were attending school online, they had worse GI symptoms (b = 0.46, p < .05). However, there was no significant interaction between anxiety and instruction type. Depression and anger were not significantly related to GI symptoms and there were no significant interactions.

Conclusion:

For children with GI conditions during the pandemic, as their anxiety symptoms increased, so did their GI symptoms. Further research should examine the long-term effects of virtual learning for those with GI conditions.

Youth with gastrointestinal (GI) conditions, such as irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), and celiac disease (CD), often experience distressing gastrointestinal symptoms, such as diarrhea, constipation, abdominal pain, bloating, urgency, and bloody stools.^1–3 Despite these three GI conditions having different physiological etiologies, youth with these conditions may experience symptoms that can impact their mental health. Research demonstrates that youth with IBS,⁴ IBD,⁵ and CD⁶ have higher rates of mental health concerns (e.g., internalizing and externalizing symptoms) and worse quality of life compared to their healthy peers.

The gut-brain axis demonstrates there is a bidirectional relationship between mental health symptoms, such as anxiety and depression, and GI symptoms.⁷ There are many different pathways through which mental health and GI symptoms are interwoven. For example, psychological experiences, such as stress, can contribute to motility changes, inflammation, and abdominal pain.^8,9 Experiencing GI dysfunction may conversely lead to difficulty adjusting to these symptoms and potential treatments, which can further exacerbate mental health concerns.¹⁰ Biologically, serotonin (5-HT) signaling is a critical component of both gastrointestinal and psychological regulation in the body, meaning that disruption or dysregulation in one of these symptoms is directly related to the other.¹¹ This synergistic relationship between psychological symptoms and GI symptoms can be overwhelming when managed outside the home.

Youth spend much of their lives in academic environments. For youth with IBS, IBD, and CD, attending school can be particularly stressful. Due to GI symptoms, youth with IBS miss school, and some feel judged for their symptoms and school absences.^12–14 Children with IBD also miss more days of school than healthy peers and have poor peer acceptance.¹⁵ Youth with CD must maintain a strict gluten-free diet, which has a particular impact on social situations and can make children feel left out and different than other children.¹⁶ These unique challenges can make in-person school particularly challenging to navigate.

Prior to the COVID-19 pandemic, most youth received their instruction through in-person schooling environments. During the pandemic, however, over two-thirds of the largest school districts in the United States moved to remote or hybrid learning during the beginning of the 2020-2021 school year as a form of infection prevention.¹⁷ Given that most children prior to the pandemic were attending school in-person, there is limited data on the impact of virtual schooling on children with chronic conditions. Most literature focuses on children who are acutely ill with conditions such as cancer. Prior to the pandemic, Liu et al. (2015) found that patients with cancer, type 1 diabetes, asthma, and Friedreich’s Ataxia were able to maintain social connections with technology by joining their classrooms virtually.¹⁸ Additionally, Zhu and Winkel (2016) found that chronically sick adolescents were satisfied with virtual learning environments and found it helped them maintain social connection.¹⁹ During the pandemic, some caregivers reported that they were grateful online options were more available than before the pandemic.²⁰ There is very limited information on the impact of ubiquitous virtual and hybrid learning options on children with chronic conditions, particularly GI conditions and their related symptoms. It is important to understand how different school instruction types (i.e., in-person, virtual, hybrid) impact youth with GI conditions to inform on the experiences of these youth in a new academic landscape.

Data from this study have been previously published²¹ and examined the impact of pandemic-related social disruption (PRSD) on the well-being of children with GI conditions and their caregivers. Briefly, this study found that PRSD was related to worse well-being in children with GI conditions, but the parent-child relationship moderated the relationship between PRSD and well-being. In this study, the only significant differences by GI condition were school disruption (e.g., changes in type of instruction, parent satisfaction with school instruction), GI needs (e.g., more GI symptoms, greater healthcare utilization), and anxiety. Children with CD had more school disruption than those with IBD, and those with IBS had more GI needs than those with IBD and CD and more anxiety than those with IBD. The current paper expands on these findings by examining two aspects of PRSD: the change in GI symptoms and school type, which are often critical, intersecting aspects of these children’s lives.

For this study, we aimed to evaluate the impact of school instruction type during the COVID-19 pandemic on mental health and GI symptoms for youth with GI conditions. It was hypothesized that there would be significant positive relations between mental health and GI symptoms, given prior work on the gut-brain axis. Additionally, it was hypothesized that school instruction type would moderate this association such that the relationship between mental health and GI symptoms would be stronger for those attending school virtually.

Methods

Participants

Participants were youth 8-17 years old with a diagnosis of IBS, IBD, or CD in their medical chart and one of their caregivers. Potential participants were excluded if they had a significant developmental delay, exclusively spoke a language other than English, or had a reading disability that would impair their ability to complete the online surveys.

Procedures

This study was approved by Georgia State University’s institutional review board (IRB number: H20665). Potential participants were identified from the electronic medical record of a southern, private, pediatric gastroenterology clinic. Individuals that met inclusion criteria were contacted via email and phone to participate between September and December 2020. Details on recruitment and participation rate can be found in our previously published work.²¹

Individuals interested in participating received an email with a link to an online Qualtrics survey that they could complete at home. Caregivers provided consent for participation for themselves and their child. Youth provided assent. Participation was voluntary, and participants could stop the survey at any time without repercussions. Caregivers and youth participants each received a $30 Amazon gift card for participation.

Measures

Demographics

Caregivers completed a demographics measure (e.g., age, income) for themselves and their child, which included what type of school instruction their child was receiving (i.e., online, hybrid, or in-person) and if they could choose the method of school instruction for the year.

Mental Health Symptoms

Patient-Reported Outcomes Measurement Information System (PROMIS) short-form measures were used to assess self-reported youth mental health symptoms. Youth completed the PROMIS Pediatric Depressive Symptoms measure v2.0 short form²² with 8-items, PROMIS Pediatric Anxiety Symptoms measure v2.0 short form²² with 8-items, and PROMIS Pediatric Anger measure 2.0 short form²³ with 5-items. In the current sample, Cronbach’s alphas ranged from .91-.94 indicating strong reliability. These measures focus each question on the past 7 days, but this stem was changed to “since the COVID-19 pandemic” to capture a broader timeframe of change in symptoms since the pandemic had started. Higher scores indicating greater symptom severity (e.g., worse depression). Standardized norms with T-scores are used to evaluate clinical cut-offs: T-score between 55-60 indicates mild symptoms, 60-70 indicates moderate symptoms, and over 70 indicates severe symptoms.

GI Symptoms

The Child Somatic Symptom Inventory^24,25 was used to assess GI symptoms (e.g., pain, bloating, nausea). The measure was adapted to have youth report if and how the pandemic influenced each GI symptom on a 5-point Likert scale from “made it a lot better” to “made it a lot worse”. This measure had adequate reliability with Cronbach’s alpha .83.

Data Analysis

Data are available upon request to the corresponding author. IBM SPSS Statistics version 26 was used to examine demographic factors with descriptive statistics. Potential differences in mental health symptoms by GI condition were assessed using ANOVAs. Multivariable path analysis using Mplus (version 8.11) facilitated the examination of the impact of mental health symptoms on GI symptoms. Model-based multiple imputation in Mplus, as is recommended for analyses involving interactions, was used.²⁶ Missing data ranged from 8.8 – 22.3% across all analysis variables and moderation terms.GI symptoms were predicted by the main effects of depression, anxiety, anger, and a nominal indicator of school type (−1 = hybrid, 0 = in-person, 1 = online). An interaction term of school type by mental health symptoms was created to test for moderation. Exploratory analyses were conducted to test the model by GI condition with the assumption that the modeling was underpowered. GI condition was coded as −1= IBS, 0 = CD, and 1 = IBD. Exploratory analyses were also conducted to test the model by school choice.

Results

Participants (M age = 13.1, SD = 2.7) included 146 children with CD (n = 81, 44%), IBS (n = 51, 28%), and IBD (n = 44, 24%). There were more female participants (n = 95, 63%) than male participants (n = 51, 34%), and four (2.7%) participants identified as transgender, non-binary, or another gender identity. Most children identified as White (n = 162, 88%), followed by Black or African American (n = 16, 9%), Asian (n = 5, 3%), multiracial (n = 6, 3%), American Indian/Alaska Native (n = 3, 2%), Native Hawaiian (n = 1, .5%), and a racial group not listed (n = 4, 2%). Most children identified as non-Hispanic (n = 168, 91%). Most children (n = 75, 41%) were receiving online instruction followed by hybrid (n = 55, 30%), and in-person (n = 52, 28%). Most caregivers reported they were able to choose their child’s method of school instruction for the 2020 school year (n = 149, 80.1%). Caregivers mostly identified as female (94%), married (83%), and had similar racial demographics as the child participants. Full demographic information can be found in Robbertz et al. (2022).²¹

When examining the descriptive statistics for the main study variables (Table 1) participants had, on average, mild levels of depressive symptoms (T-score = 55.50), while anxiety (T-score = 53.02) symptoms and anger (T-score = 49.92) were within normal limits.

Table 1.

Descriptive statistics for main study variables and number/percentage of participants in clinical cut-offs

	M raw score (SD)	M T-score (SD)	WNL	Mild	Moderate	Severe
PROMIS Depressive symptoms	19.07 (7.67)	55.50 (10.13)	68 (45.6%)	24 (16.1%)	47 (31.5%)	10 (6.7%)
PROMIS Anxiety symptoms	18.42 (7.65)	53.02 (11.14)	84 (56.0%)	32 (21.3%)	23 (15.3%)	11 (7.3%)
PROMIS anger	11.56 (4.68)	49.92 (11.32)	92 (63.9%)	23 (16.0%)	25 (17.4%)	4 (2.8%)
GI Symptoms	1.51 (2.45)

Note. T-score between 55-60 indicates mild symptoms, 60-70 indicates moderate symptoms, and over 70 indicates severe symptoms; WNL = within normal limits

When comparing the main study variables by GI condition, anxiety (F = 3.82, p = .02) and GI symptoms (F = 7.88, p < .01) were significantly different by GI condition. Individuals with IBS (M = 20.51, SD = 8.03) had more anxiety than those with IBD (M = 16.00, SD = 8.43)). Additionally, participants with IBS (M = 2.49, SD = 2.75) had more GI symptoms than those with IBD (M = 1.03, SD = 2.34) and celiac disease (M = 0.88, SD = 1.60). Depression (F = 0.29, p = .75) and anger (F = 1.66, p = .19) were not significantly different by GI condition. There were no significant differences in school instruction type by GI condition (Table 2).

Table 2.

Number of Youth with each School Type and GI condition

	IBD	Celiac Disease	IBS
	Cramer’s V = .113, p > .05
Online	16	30	25
In-person	8	26	13
Hybrid	15	20	13

A multivariable path analysis showed anxiety (b = 0.14, p < .01) and school instruction type (b = 0.46, p < .05) significantly predicted GI symptoms. As children reported more anxiety symptoms, they also reported worsening of GI symptoms. Additionally, as children attended school online, they had worsening GI symptoms. Depression (b = 0.025, p > .05) and anger (b = −0.038, p > .05) did not predict reported changes in GI symptoms. When examining interaction terms of school instruction type by depression (b = −0.065, p > .05), anxiety (b = 0.069, p > .05), and anger (b = 0.046, p > .05), no interactions were significant.

An exploratory path analysis was conducted to examine whether the path above differed when including GI condition as a variable and with interaction terms. In this model, anxiety (b = 0.12, p <.001) and GI condition (b = −0.65, p < .01) were the only significant predictors of GI symptoms in the model. Similar to the first model, as children reported more anxiety symptoms since the pandemic started, they also reported worsening of GI symptoms. Additionally, children with IBS were more likely to have more GI symptoms. Depression (b = 0.038, p > .05), anger (b = −0.054, p > .05), and school instruction type (b = 0.35, p > .05) did not predict changes in GI symptoms. No interactions were significant. This model was likely underpowered.

An exploratory path analysis was conducted to examine whether the path above differed when including school choice as a variable and with interaction terms. In this model, no main effects or interaction terms were significant.

Discussion

The results of this study shed light on the mental health symptoms and academic experiences of youth with GI conditions during the COVID pandemic. On average, participants had mild depressive symptoms, and anxiety and anger symptoms were within normal limits. Without pre-pandemic data for comparison, we cannot assert that these findings are unique to the experience of the pandemic. Other GI samples during the pandemic also using PROMIS measures found comparatively lower levels of anxiety for children with IBD²⁷ and functional abdominal pain.^28,29 For example, in Italy, Fedele et al. (2022) found that only 3.3% of their pediatric IBD patients had T-scores above 50 in April 2020 when all patients were in virtual schooling and only 1% in April 2021 when 83.3% were in virtual schooling.²⁷ Also, Martinelli et al. (2024) found that 18.2% of their functional abdominal pain pediatric participants from Italy, the United States, and Israel had anxiety above a T-score of 50 in April 2020, and 17.2% in September-November 2021.²⁹ The reason for the discrepancy between our sample and others is not known, however, it is possible that urban areas of the United States experienced greater stress during the initial phases of the pandemic likely related to an increased population density and greater disruption in local systems,^30,31 though another study found no differences in stress between rural and urban populations during the pandemic.³² Another possibility relates to the diversity of our sample. It is known that minoritized individuals in the United States experienced greater mental health concerns and stress in the pandemic,³³ thus, the greater diversity in our study sample compared to those described above and more broadly in GI samples could be one factor contributing to the increased symptom rates in our study.

There was a significant positive relation between anxiety and GI symptoms in our study. School type was also related to GI symptoms, such that children who moved to online schooling had more GI symptoms. GI condition and school instruction type were also related to GI symptoms, with IBS and virtual schooling being related to more symptoms. According to our findings, parents ability to choose method of school instruction did not effect the relationship between mental health symptoms, school instruction, and GI symptoms. This may speak to the numerous other factors contributing to parents’ decision to send their child in-person to school or keep them home during the COVID-19 pandemic. Given the gut-brain connection,³⁴ it is typical that symptoms of depression and anxiety or emotional dysregulation would increase along with GI symptoms. A large sample from the United States found that older children who attended school in person had less mental health concerns during the pandemic,³⁵ and it is unsurprising that GI symptoms would follow this pattern as well given the known gut-brain relationship. One may have hypothesized that a home environment or virtual schooling would reduce anxiety and stress for youth. However, in-person schooling provides opportunities for youth to engage with peers, maintain routine and structure, and engage in pleasant activities and physical activity which are all critical to functioning especially for children with chronic conditions. The removal of this regularity and these outlets may place additional stress and anxiety on children. This is especially true in the context of the COVID-19 pandemic when multiple aspects of a child’s micro and mesosystems were interrupted, creating a lack of normalcy and routine across environments.

This study is the first of its kind to explore the relation between GI symptoms, mental health symptoms, and schooling type during the COVID-19 pandemic. This innovation is a strength of the research, as it represents a significant contribution to the literature and provides insight into the experiences of youth with chronic GI illness during a very challenging time period. Results should be interpreted in the context of the limitations of this research.

As the results are based on correlational data, it is important to further examine these relations with longitudinal data. Additionally, confirming the relations among sub-groups of children with differing GI conditions with a larger sample size is warranted. The study adapted validated questionnaires to assess pandemic-related questions; however, this could impact the validity of the questionnaire. Additionally, changing question prompts from “the past 7 days” to “since the pandemic started” can influence accuracy of participant recall. It is important to note there could be unmeasured confounding variables influencing the identified relationships.

These findings are relevant to healthcare providers who serve youth with GI conditions. Particularly related to school environment, families often wonder whether virtual learning environments would meet their academic and health-related needs. As described in previous literature,^36–38 having symptoms at school, navigating dietary restrictions, and school absences due to symptoms, treatment, and appointments, can make the in-person school environment challenging. Thus, it is logical that families would inquire about this virtual option to meet all their child’s needs. Clinically, it is common for behavioral health providers to recommend continuing in in-person school even with significant health needs given the clear benefits of the academic environment (e.g., social/emotional development, social support, routines, direct instruction). Our findings support this clinical approach. Additionally, in other populations, such as pediatric pain, research has shown that maintaining routines and structured environments to facilitate functioning, helps reduce symptoms.^39,40

Future research should elucidate the nature of this interaction between anxiety, GI symptoms, and schooling through qualitative inquiry. Patient interviews could provide understanding into how patients view these constructs as connected or related in their daily life, especially as schooling moves into an increasingly hybrid space. It is also possible that an additional variable (i.e., family conflict), either related to schooling or not, better explains the increase in GI symptoms for patients attending online schooling or that these results would not replicate outside of a worldwide pandemic. Future research should seek to determine if there are other relevant variables in this relationship.

Conclusions

To summarize, for youth with GI conditions during the COVID-19 pandemic, as anxiety increased, participants reported more GI symptoms. Additionally, children who were involved in virtual schooling had more GI symptoms. Given virtual schooling may be more readily available or seen as a more viable option since the COVID-19 pandemic, further research is needed to better understand the relationship between schooling environments, mental health symptoms, and GI symptoms.