Effects of Coronavirus Disease 2019 (COVID-19) on Family Functioning

More than a year and a half after the first clinical manifestations of coronavirus disease 2019 (COVID-19) were reported in Wuhan, China,^{1 , 2} the magnitude of the pandemic across the globe and its related clinical and social effects³ remain unclear.⁴ The pandemic has affected lives and sparked concerns about everything from health to job security. In high–Gross Domestic Product (GDP) countries, despite trillions in coronavirus aid released by governments, many families still struggle to pay for basic necessities like food and rent, and these difficulties worsened during the pandemic.^{5 , 6} The general social uncertainty caused by the pandemic seems to have also affected family resilience, weakening the ability of individuals to confront challenges, survive difficulties, and thrive in adversities as a group.^{7 , 8}

To reduce community spread of the virus, many countries adopted unprecedented confining measures, including the restriction of populations in their homes and reduction of interpersonal contacts. Confinement, quarantine measures for suspected COVID-19 cases, and social distancing were prolonged, and their effectiveness was debated at social, scientific, and political levels.⁹ However, although their prevention value in limiting viral spread is generally recognized,⁶ it is also widely accepted that social isolation measures have upended family lives.⁴ In particular, they have affected family functioning and parenting, which are significantly associated with the physical and psychosocial functioning of children and adolescents.¹⁰

This commentary, authored by the Working Group on Social Pediatrics of the European Paediatric Association/Union of National European Paediatric Societies and Associations, briefly discusses the effects of the confinement measures taken to combat the COVID-19 pandemic on family functioning. Our aim is to raise the awareness of pediatricians, social work professionals, and policy makers, as knowledge of the effects of social restrictions on family functioning may contribute to the efforts of national health systems to be effectively prepared to handle the social effects of future public health crises. Adopting a more mindful and coordinated approach may help overcome divergences across countries, particularly in terms of complex sociopolitical realities.

Family Functioning: a Social and Structural Asset of Global Family Environment

The physical and psychosocial performance of children and adolescents challenged by adversities is significantly related to a number of family factors, including family functioning and parenting, which are typically embedded within the context of a family.¹⁰ Specific variables that characterize parent–child relations in each family also may play a role in maintaining balanced physical and psychosocial functioning in children struggling with external events affecting their families. Parent–child dyadic rigidity, together with the presence or absence and the magnitude of such variables as unstable family income, broken home, family mobility, parent mental health, number of children in the family, single-parent family, and parental past, may accelerate a deterioration of intrafamily relationships.¹⁰ In contrast, parent–child interaction processes of dyadic positive affect and flexibility may help prevent possible negative impacts on children's daily life and contribute to an effective parent–child coregulation.10, 11, 12

Family functioning is a multidimensional concept that refers to the dynamics and quality of family members’ relationships. This is based on the organization and level of conflict and cohesion internal to families and in large part on their adaptability and communication skills. In general, a family environment characterized by cohesion, clear communication ability, well-defined roles, and good emotional balance and regulation describes a positive family functioning.^{11 , 12} Inadequate or defective family functioning refers to families showing disorganization characterized by unclear family roles, high levels of inner conflict situations, and poor affective and behavioral control.^{11 , 12} Family structure also plays an important role in achieving balanced family functioning.¹³

Family functioning is widely used as an evaluation criteria for parents, caregivers, and families.¹⁴ A variety of measures are available to assess functioning in families challenged by negative events and to evaluate family factors useful for identifying families most at risk for poor family functioning. It is important to properly assess family functioning for caregivers to provide informed support, tailor interventions, evaluate outcomes for individuals and the entire family,^{14 , 15} and ultimately develop programs and interventions that aim to improve family relationships and the overall family functioning. Five major theoretical models commonly used to assess family functioning are reported in Table (available at www.jpeds.com), which can be suitably selected and adopted as an assessment tool depending on the family context in which they are used.

Effects of COVID-19 Pandemic on Family Functioning

A variety of natural, economic, and public health crisis have affected families throughout the world, causing distress to family members, including mental health problems, interparental conflict, and relational instability, generating an increase in rough and abusive parenting.^{16 , 17} During the COVID-19 pandemic, families have suffered severe financial and psychological hardships, which were particularly problematic in complex sociopolitical contexts¹⁸ characterized by important socioeconomic diversities, such as in Europe, making it difficult to establish coherent and consistent decision processes. In addition to the usual consequences of a public health crisis, including job instability and financial disruptions, families have experienced stress caused by social isolation, confinement within the household, rupture in the nature of school settings, concern for the future, and the need to make unprecedented health-related decisions for family members in a context of uncertainty.¹⁹

Understanding the influence of the pandemic on family functioning is therefore essential to plan effective support interventions and preventive measures and allocate adequate resources to properly assist families during and after the pandemic. Recent studies in Europe and the US have provided evidence of a significant increase in overall mental distress in people tested before and during the pandemic²⁰ and have shown a consistent deterioration in parent and child mental and behavioral health during the first months of the pandemic.^{21 , 22} In particular, increases in parent depression and children's internalizing and externalizing problems from before the pandemic were significant findings that normally are observed only infrequently in developmental and family studies.^{21 , 22} During the pandemic, these 2 factors increased by 2-fold and were more likely to score in the clinical range.²¹

Preliminary reports on the social consequences of COVID-19 suggest that mental health problems and family conflicts generated by the pandemic may negatively impact family functioning, including the ability to develop resilience.^{7 , 8} The ongoing COVID-19 pandemic offers an important opportunity to further investigate the implications of deterioration in parent and child psychological well-being during extraordinary public health events. They may in fact amplify intrafamily conflicts and compromise the capability of parents to implement and sustain protective health behaviors of family members, including social distancing, handwashing, mask-wearing, and preventive plans recommended by public health authorities.²³ Assessment of family functioning during a pandemic, as in the case of COVID-19, is important to maintain an adequate dynamic and quality of family members’ relationships.

Conclusions

It is currently unclear whether and to what extent family instabilities due to the COVID-19 pandemic may recover during the months following the end of this public health emergency, and for how long the negative effects of this event will persist and affect parent and child well-being. However, experience from past crises suggests the strategic importance of establishing or potentiating preventive measures based on the promotion of individual and family resilience before a crisis^{8 , 17} and to plan for providing support to families after the onset of a crisis.²⁴ Family support plans should include the promotion of coping skills, family relationship quality, and attitude management.²⁵ Assisting families in recovering from pandemic periods and from crises in general requires a multidimensional and interdisciplinary approach including schools, pediatricians, social work professionals, mental health clinicians, counselors, family service agencies, and sport organizations.^{26 , 27}

Appendix

Table.

Five major theoretical models of family functioning

Stress and Coping Theory

Developed in the 1960s, this model is based on the notion that person and environment are in a dynamic, mutually reciprocal, and bidirectional relationship. Key elements are: a.Stress, defined as the relationship between the person and the environment that is appraised by individuals as exhausting, draining, or exceeding personal resources and as compromising their well-being b.Coping, identified as the thoughts and acts used by people to manage the demands of stressful circumstances.  The functioning of individuals is indissolubly related to their life context factors, and family functioning is viewed as the family's ability to adapt to stress and reduce the family and its members' overall vulnerability and susceptibility to stress.

Beavers System Model

Developed over the past 30-year period, this model is based on clinical observations of both dysfunctional and healthy families involved in treatment and research programs. Families are typified using 2 dimensions: a.Family competence: indicates the structure of the family, available information, and flexibility of the group to adapt to new circumstances. The ability of a family system to negotiate, function and deal effectively with stressful situations is directly related to its capability to intercept and use energy from the outside world to assist in maintaining its structure and flexibility. b.Family style: indicates the quality and style of family interaction and evaluate whether the families acquire most of their satisfaction by a centripetal way, from within the family, or, in a centrifugal way, from the outside world. According to these dimensions, family health is related to a curvilinear relationship, with optimal families falling in the middle of the continuum, experiencing satisfaction from both within the family and the outside world. In contrast, dysfunctional families are associated with both centripetal and centrifugal ends of the continuum. In this model, families are rated in these dimensions based on the structure and flexibility they display in such areas as autonomy, power, parental coalitions, family mythology, goal-directed behaviors, social intermediation ability, and family affect.

Circumplex Model of Family Functioning

Developed over the past 30 years, this model is based on clinical and research work with families and marital couples. Families are typified using 3 dimensions: a.Cohesion, defined as the emotional bonding that family members have toward one another. It encompasses the factors of emotional bonding, family boundaries, coalitions, time, space, friends, decision making, interests, and recreation. b.Flexibility: includes the quality and expression of leadership and organization, role relationships, and relationship rules and negotiations. c.Communication: indicates the positive communication skills utilized within a couple or a family system. It is considered a factor able to facilitate a positive modulation within the primary dimensions of cohesion and flexibility.  In a system of curvilinear continuum, optimal functioning is considered to be characterized by a balanced level of cohesion and flexibility, and is expected to fall in the middle of each continuum and dysfunction at the end of each continuum.

McMaster Model of Family Functioning (MMFF)

Thus systems-based model regards the family as an open system, characterized by a complex interaction between intrafamily subsystems, such as individual, marital and dyad, and the various external systems, such as extended family, schools, religion, or work. Instead of characterizing families through single dimensions, this model takes a whole-systems approach by evaluating the complex of family structure, organization, and transactional patterns. The assessment of family health or dysfunction is based on the ongoing articulated interplay between the individual relationships and the family system.  The approach to family functioning using this model implies the following guiding principles: parts of the family are related to each other; one part of the family cannot be understood in isolation from the rest of the system; family functioning is more than just the sum of its parts; a family's structure and organization are important in determining the behavior of family members; and transactional patterns of the family system are involved in shaping the behavior of family members. Family functioning is related to the accomplishment of essential functions and tasks grouped in 3 areas: a.Basic tasks b.Developmental tasks c.Hazardous tasks.  This model identifies 6 core areas that impact a family's ability to meet these functions and tasks: problem solving, communication, roles, affective responsiveness, affective involvement, and behavioral control.

Process Model of Family Functioning

This systems-based model investigates family functioning in the context of the ability of a family and its members to accomplish a multiplicity of tasks. The model distinguishes 7 basic dimensions to evaluate how successful a family is in confronting basic developmental and crisis tasks that can be recognized as central objectives to family life: task accomplishment, role performance, communication, affective expression, involvement, control, values, and norms.  The Process Model recognizes the importance of the larger social system and family history, as well as the intrapsychic interpersonal factors typical of the McMaster Model of Family Functioning. However, beyond these important factors of family system, the Process Model emphasizes the existence of a variety of additional influential factors. This model may be regarded not as a model of family therapy, but rather as a model for understanding families.