The Mental Health and Health-Related Behavior of Children and Parents During the COVID-19 Pandemic

The COVID-19 pandemic has negatively impacted the mental health of children and adolescents as well as their parents. This is shown by multinational meta-analyses and the German nationwide COPSY (COVID-19 and Psychological Health) longitudinal study (1). The COPSY study assessed mental health and health behavior longitudinally in three survey waves (W) so far (W1, May to June 2020; W2, December 2020 to January 2021; W3, September to October 2021).

Methods

A total of n = 1618 families with children aged 7 to 17 took part at W3 in the self-report (aged 11 to 17 years old, n = 1181) and parent report (of children aged 7 to 17 years old, n = 1618) (re-participation rate, 73.7%). Parents who took part in all three waves were on average older and tended to have a low level of education. No other significant differences were found with respect to sociodemographics or mental health well-being. The sample corresponds to the distribution of the German population according to the current microcensus (2018).

Screening was performed using internationally validated questionnaires on health-related quality of life (KIDSCREEN-10 Index), mental health problems (SDQ), generalized anxiety (SCARED), depressive symptoms (PHQ-2 and PHQ-8), and psychosomatic complaints (HBSC-SCL), as well as items covering health behavior. Data analyses were conducted using descriptive statistics, chi-square tests, and logistic regressions. Cramers-V (whereby V = 0.1/0.3/0.5 indicates a small/medium/strong effect, respectively) was used as an effect size measure for changes over the three survey waves and compared to pre-pandemic reference values from the German BELLA study (2).

Results

At W3, children and adolescents were on average 13.3 years old (52% girls, 17% with a migration background) and their parent, 44.5 years old (58% mothers, 59% with a medium level of education).

Even 1.5 years after the start of the pandemic, 82% of children and adolescents still felt burdened by the pandemic in autumn 2021 (W3) by the pandemic (table). Stress initially increased during the course of the pandemic and then stabilized at a high level.

Table. Experienced distress for children and parents before and during the COVID-19 pandemic.

	BELLA (pre-pandemic)	COPSY Wave 1	COPSY Wave 2	COPSY Wave 3	P*1	Cramer’s V *1
Children and adolescents
Stress due to pandemic*2		70.6 %	82.9 %	81.9 %	< 0.001	0.09
Reduced quality of life*3	15.3 %	40.2 %	47.7 %	35.1 %	< 0.001	0.14
Mental health problems*4	17.6 %	30.4 %	31.0 %	27.0 %	< 0.001	0.07
Anxiety symptoms*5	14.9 %	24.1 %	30.1 %	26.8 %	< 0.001	0.08
Depressive symptoms*6	10.0 %	11.3 %	15.0 %	11.1 %	0.001	0.03
Psychosomatic complaints*7 (at least 3 symptoms)	36.9 %	48.4 %	53.1 %	53.0 %	< 0.001	0.09
– Back pain*8 – Nervousness*8 – Stomach pain*8 – Feeling down or depressed*8 – Headache*8 – Problems falling asleep*8 – Irritability*8	25.9 % 23.6 % 21.3 % 23.0 % 28.3 % 39.2 % 39.8 %	26.4 % 27.9 % 30.5 % 33.8 % 40.5 % 43.3 % 53.2 %	33.0 % 33.3 % 36.4 % 43.4 % 46.4 % 47.4 % 57.2 %	32.8 % 35.3 % 39.2 % 41.2 % 48.7 % 46.0 % 57.0 %	< 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001	0.04 0.06 0.10 0.11 0.11 0.04 0.09
Physical activity (on at least 3 days/week)	76.1 %	45.8 %	29.5 %	46.9 %	< 0.001	0.19
Increased consumption of sweets		32.6 %	32.8 %	21.5 %	< 0.001	0.08
Increased media use		67.2 %	71.1 %	49.1 %	< 0.001	0.14
Parents
Burden due to pandemic*2		79.0 %	83.4 %	82.2 %	0.004	0.03
Loss of social contacts*9		45.0 %	47.4 %	36.0 %	< 0.001	0.07
Loss of leisure activities*9		56.3 %	61.2 %	51.1 %	< 0.001	0.06
Reduced physical activity*9		34.1 %	39.8 %	30.4 %	< 0.001	0.06
Problems organizing childcare/at-home schooling*9		44.4 %	35.8 %	37.5 %	< 0.001	0.05
Difficulty reconciling work and childcare*9		34.4 %	32.7 %	31.9 %	0.308	0.02
Tension at home or family conflicts*9		24.7 %	24.4 %	27.1 %	0.172	0.02
Depressive symptoms (parents)*10		17.4 %	23.8 %	20.9 %	< 0.001	0.05

*¹ Overall chi-squared tests across the studies BELLA und COPSY W1–W3; *² somewhat distressing/fairly distressing/extremely distressing; *³ KIDSCREEN-10; *⁴ SDQ; *⁵ SCARED; *⁶ PHQ-2; *⁷ HBSC symptom checklist; *⁸ at least once in the past week; *⁹ fairly distressing/extremely distressing; *¹⁰ PHQ-8

About one-third (35%) of the children and adolescents experienced a low quality of life at the time of the W3 survey, which is twice as many as before the pandemic. Mental health problems (SDQ) increased significantly during the course of the pandemic and decreased slightly at W3. A similar trend was found for anxiety and depression scores. The frequency of psychosomatic complaints was also significantly higher in W3 than before the pandemic; stomach pain, headaches, and nervousness increased again slightly in W3. A higher proportion of girls had an impaired quality of life, anxiety, depression, and psychosomatic complaints.

Children were significantly less active during the pandemic than before. One third of children ate more sweets in W1 and W2 and in autumn 2021, candy consumption was still increased for about one-fifth of the children. Media use was initially significantly higher but decreased somewhat in autumn 2021; nonetheless, almost half of the children still consumed more media than before the pandemic (i.e., more than 3 to 4 hours/day).

Children and adolescents experienced the pandemic as particularly stressful if they lived in a confined space (< 20 sqm living space/person), had a migration background, had parents with a low level of education, or suffered from mental illness. This risk group of children and adolescents (n = 292) showed a significantly increased risk in all three waves during the pandamic of having a lower quality of life (odds ratio [OR] W1: 2.1 95% confidence interval [1.5; 3.0], W2: 2.7 [1.9; 3.7], W3: 2.4 [1.7; 3.2]), mental health problems (OR W1: 2.7 [2.0; 3.7], W2: 2.8 [2.1; 3.7], W3: 3.0 [2.3; 4.1]), depressive symptoms (OR W1: 3.7 [2.4; 5.7], W2: 4.1 [2.8; 5.9], W3: 2.3 [1.5; 3.5]), and anxiety symptoms (OR W1: 2.2 [1.5; 3.2], W2: 1.7 [1.2; 2.4]), using the logistic regressions of age and gender and their interactions as covariates.

The majority of parents also felt distressed by the pandemic. While stress due to the loss of social contacts and reduced leisure activities decreased slightly in W3, problems such as the organization of childcare/at-home schooling and the reconciliation of work and childcare were stabilized at a high level. Tension at home and family conflicts increased again slightly in W3. The proportion of parents with depressive symptoms was 17% to 24%. Mothers and parents of younger children were significantly more distressed and had more depressive symptoms (see Table).

Discussion

The levels of distress in children, adolescents, and parents were still significantly higher in autumn 2021 than before the pandemic, even though the quality of life and health behavior of children and adolescents have slightly improved following the end of lockdown measures and low disease incidences. Mental health deterioration and problems stagnated at a high level. Overall, the effect size of changes is very small, but the effects of fundamentally existing risks are clearly pronounced (with an increased OR of up to 3.7). This is consistent with pediatric meta-analyses (3– 5), but the international study situation is still very heterogeneous. The COPSY study shows that parents as well as children and adolescents from certain risk groups are vulnerable. We recommend a heightened awareness of this in medical and psychotherapeutic practices as well as in educational institutions and providing support with low-threshold offers of prevention and intervention.