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| ORIGINAL ARTICLE |
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| Year : 2021 | Volume
: 3
| Issue : 1 | Page : 30-35 |
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Parental Stress and Parenting during COVID-19 Pandemic in Pakistan
Nazish Imran1, Muhammad Imran Sharif1, Somia Iqtadar2, Afzal Javed3, Muhammad Waqar Azeem4
1 Department of Child and Family Psychiatry, Mayo Hospital, King Edward Medical University, Lahore, Pakistan
2 Department of Medicine, Mayo Hospital, King Edward Medical University, Lahore, Pakistan
3 Psychiatry Department, University of Warwick, Coventry, England, UK
4 Department of Psychiatry, Sidra Medicine, Weill Cornell Medicine, Doha, Qatar
| Date of Submission | 06-Sep-2020 |
| Date of Decision | 03-Dec-2020 |
| Date of Acceptance | 03-Dec-2020 |
| Date of Web Publication | 29-Apr-2021 |
Correspondence Address:
Dr. Nazish Imran
Department of Child and Family Psychiatry, Mayo Hospital, King Edward Medical University, Lahore
Pakistan
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/wsp.wsp_73_20
Objectives: As COVID-19 spreads around the globe, parents are being presented with new challenges to meet their children needs. We investigated parental stress and its impact on their parenting practices during COVID-19 outbreak in Lahore, Pakistan. Methods: Following ethical approval, using web-based cross-sectional survey, data were collected in April 2020–May 2020. Symptoms of depression and anxiety were assessed among parents by the patient health questionnaire and generalized anxiety disorder scale. Respondents also reported on parenting practices and emotional and behavior changes noticed in their children. Results: Three hundred and fifty-five parents participated in the survey with a mean age of 35.3 years (standard deviation = 8.2) with 55% having at least one child between the ages of 1 and 5 years and 9% had children with special needs. The prevalence of depressive symptoms and anxiety was 25.6% and 21.6%, respectively. A significant proportion (77%) of parents were concerned about the outbreak fearing about family/self-being infected, losing love ones, and financial difficulties. Fifty percent of participants reported more than usual use of consequences (shouting at children, taking privileges away, and slapping child) in the past 1 month. However, the positive impact of parents spending more time with their children was also reported. Unhealthy eating and sleeping patterns (24.5%), irritability (21.1%), anxiety (16.3%), and aggression (14.6%) were the most common behavior and emotional problems noticed in children. Conclusions: Parental stress observed during COVID-19 outbreak can adversely impact the parenting practices and child's mental health. Provision of effective strategies to support parents to care for children is urgently needed.
Keywords: Anxiety, children, COVID-19, depression, parental stress, parenting
How to cite this article:
Imran N, Sharif MI, Iqtadar S, Javed A, Azeem MW. Parental Stress and Parenting during COVID-19 Pandemic in Pakistan. World Soc Psychiatry 2021;3:30-5 |
| Introduction | |  |
The unprecedented COVID-19 pandemic has upended family life, and parents around the world are struggling with navigating new challenges daily. Although recent literature suggests many adverse psychological outcomes of quarantine and other illness containment measures such as loneliness, fears, anxiety, and depression, the demands and psychological impact are likely to be greater for parents and children.[1] Parents are caring for their children in stressful conditions, under a high degree of economic uncertainty, attempting to work remotely with childcare responsibilities, keeping children busy, and managing demands of home-based schooling with no clarity on how long the situation will last.[2] Furthermore, looking after a child with special needs is an established risk factor for parental stress.[3] Parental stress (i.e., the experience of distress or discomfort that results from demands associated with the role of parenting) is associated with an increase in parental mental health needs. There is a high risk of developing psychiatric illness among parents as well as for children which ultimately leads to adverse parenting outcomes.[4]
Parenting contributes significantly to the course and outcome of child development. Supportive parenting with encouragement and companionship has been linked to higher self-esteem and academic achievement, while poor parent–child relationships and harsh parenting lead to adverse parenting outcomes contributing to parental stress.[5],[6] There is considerable evidence that large-scales events such as wars and natural disasters can be detrimental to parental mental health and parenting.[7],[8] Preliminary research on COVID-19 indicates a significant increase in psychological distress for expectant mothers.[9],[10] With an increase in parental stress during these conditions, there are reports of increased domestic violence impacting the families negatively.[3]
Given the significant psychological impact of COVID-19 around the globe and indications from literature that parents' mental health and parenting may be negatively impacted, there is a critical need to assess it. This can help in developing effective strategies to support the parents and strengthen the families. The current study intends to yield a better understanding of the effects of COVID-19 on parents and their parenting practices in Lahore, the capital of Punjab province of Pakistan, which is one of the most severely COVID-19 affected cities in the country.
| Methods | | |
Ethical approval was obtained from the Institutional Review Board (Ref no: 271/RC/KEMU dated April 4, 2020). This was a cross-sectional, web-based study (to avoid transmission of the COVID-19 through droplet or contact) done in Lahore, the capital city of Punjab province of Pakistan from April 15, 2020, to May 15, 2020. This web-based study was anonymous, voluntary and confidentiality of information was assured. Information to access confidential psychological support was also provided during the study. Parents having at least one child or adolescent below the age of 18 years residing with them at home were invited to participate in the study. Exclusion criteria included parents who refused to consent and parents with intellectual disability.
After informed consent, all participants reported their demographic data and details about the number and ages of children at home as well as any history of special needs and medical and psychiatric issues in children. The questionnaire asked respondents to report on their concerns and worries during COVID-19 pandemic, their mental health and well-being (by using patient health questionnaire [PHQ-9] and generalized anxiety disorder [GAD-7] scale), and impacts on parenting alongside emotional and behavior changes noticed in children during quarantine.
PHQ-9 is a self-reporting questionnaire that diagnoses depression using criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).[11] The score range is 0–27 with an interpretation of severity as follows: normal (0–4), mild (5–9), moderate (10–14), and severe (15–21) depression. It has also been translated into Urdu language and found to be a valid and reliable tool to screen, rate, and monitor outcomes of depressive illness in Pakistan.[12] The PHQ-9 was found to have good reliability (Cronbach's alpha = 0.86). For the purpose of this study, we defined PHQ-9 total score of 8 points or greater as significant for the presence of depressive symptoms.
GAD-7 is also a self-reporting scale designed to identify cases of anxiety and to assess symptom severity; the seven items are arranged according to the DSM-IV criteria.[13] GAD-7 cutoff score of 7 or greater is recommended to identify a person suffering from GAD. The score range is from 0 to 21. Interpretation of GAD-7 scores is as follows: normal (0–4), mild (5–9), moderate (10–14), and severe (15–21) anxiety.
SPSS statistical software version 26.0 (SPSS Inc., Chicago, IL, USA) was used for data analysis. Descriptive analysis was done to assess demographic characteristics of the patients, their concerns and worries, parenting practices, and children emotional and behavioral changes. Data for each level of symptoms for depression and anxiety are presented as numbers and percentages. Chi-square test was used to compare the severity of each symptom between the groups. An independent sample t-test was used to test for differences in continuous variables between the groups (gender; parents having children with special needs). All tests were two tailed and the significance level was set at α = 0.05.
| Results | | |
The sample consisted of 355 parents, with a mean age of 35.3 years ±8.2, and 229 (64.3%) were mothers. Eighty-six percent of parents had at least bachelor's degree and 66% had at least one child under the age of 5 years at home. Thirty-five (9%) parents had children with special needs [Table 1].
Parental concerns and psychological impact
On average, parents rated their COVID-19 related concern as a 7.4/10, suggesting a high but not urgent level of concern. When asked about worries associated with pandemic, 77% of parents said that they worry about self/family getting infected and 52% had fear of losing loved ones due to pandemic; 29% were worried that money will run out and 26% were afraid of isolation/quarantine.
The overall prevalence of depressive symptoms (PHQ-9 ≥8) and anxiety (GAD-7 >7) among parents was 25.6% and 21.6%, respectively. Parents of children with special needs had higher mean scores on depression and anxiety, but they were not statistically significant. Compared to fathers, mothers in our sample had statistically significant higher mean scores on anxiety (P < 0.05) but not for depression. [Table 2] describes the severity of depression and anxiety in the total cohort and stratified by gender. There was no statistically significant difference in depression and anxiety among parents of children with or without special needs in our sample, although there were very few parents of children with special needs in the current study to have a meaningful comparison. | Table 2: Severity categories of depression, anxiety, insomnia, and stress measurement in total cohort and stratified by gender
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Impact of COVID-19 pandemic on parenting
Positive parenting and activities with children
About 92.7% (330) of parents reported that they are spending more time with their children, with 67% reporting feeling very or extremely close to their children since lockdown. They were engaged in various activities since the coronavirus pandemic such as watching movies/television together (65.4%), educational activities (52%), exhibiting more physical affection (51%)), playing sports (47%), and playing with toys (45%).
Parental stress and worries since COVID-19 pandemic and adverse impact on parenting
[Figure 1] shows parental perceptions of how COVID-19 has adversely impacted their parenting. Seventy percent of parents reported that worries were “sometimes” or “often” getting in the way of their parenting. Social isolation and social distancing were also contributing to the parental practices.
Twenty-five percent of parents stated that they had received criticism from their close contacts (spouse/partner, mother or father, in-laws, and friends) about their parenting during coronavirus. Even though parents reported high levels of closeness and engagement in activities with their children since the coronavirus pandemic, they also admitted to a high level of discipline and verbal and physical punishment of their children. Since the coronavirus pandemic, parents reported more than usual use of consequences; 72% “shouted, yelled, or screamed” at their children, took away privileges (58.2%), and used time out (45.2%). Nearly 35.4% of parents spanked or slapped children at least once in the past 1 month.
In response to a question about changes in their children's behavior since the COVID-19 outbreak, unhealthy eating and sleeping patterns (24.5%), irritability (21.1%), anxiety (16.3%), aggression (14.6%), and sleep difficulties (12.7%) were the most common behavior and emotional problems noticed by the parents [Figure 2]. | Figure 2: Behaviour and emotional problems of children observed during the COVID-19 pandemic
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Parents provided responses to open-ended questions about what steps if offered can reduce their stress which illustrated that regular online school teaching, being able to take children outside to park, having support at home, therapy sessions for special need children, activities to engage children at home, and financial support can make a huge positive difference to parental worries and stress.
| Discussion | | |
The current article describes the psychological impact on parents and their parenting practices during COVID-19 pandemic, which remains a salient and largely unexamined issue. The results showed that parents perceived a higher level of stress, depression, and anxiety. Infectious disease outbreaks like COVID-19 constitute a humanitarian emergency causing widespread human, economic, and environmental losses. Daily life changes have resulted in an unprecedented situation for families worldwide. Parents experience greater psychological distress related to worries regarding infection, financial insecurity and unemployment, burden of round the clock caregiving, and quarantine-related stress (e.g., changes to routines, schools' closure, and overcrowding), similar to the worries noted in our study.[1],[2] There is a well-documented literature of negative psychological outcomes of adults exposed to health-related disasters including elevated risk for stress, depression, anxiety, anger, and posttraumatic stress disorder.[14],[15],[16] Some preliminary studies during COVID-19 have indicated an increase level of stress among parents and disruptions in parent–child relationships.[10],[16] Various family factors can affect parents' ability to cope with health-related disasters and quarantine including number of children at home, their ages, support system, children with special needs or psychiatric problems as well as parents own history of mental health problems prior to the crisis.[17] Although parents of children with special needs had higher mean scores on depression and anxiety in our sample, they were not statistically significant. Parental mental health, in particular maternal depression, is identified in the literature as a negative predictor of children's psychosocial functioning.[18]
In addition to threats to parents' well-being, COVID-19 pandemic has also increased demands on parent–child relationships. Studies show that parental psychosocial functioning and psychological response to potentially distressing situations including pandemics directly impact their parenting practices and children outcomes.[19] A significant proportion of parents (70%) in our study felt that COVID-19-related worries are impacting their parenting and they admitted to more than usual use of consequences to discipline their children during these times. In another survey in the USA, parents have reported increased incidents of yelling, shouting, and even slapping their children.[10] This has serious implications as evidence suggests that children are very vulnerable during infectious disease outbreak and violence usually increases for young people during quarantine. Parents' depression and distress may lead to more negative parenting behaviors like harsh and neglectful parenting. Frustrated parents display aggression (such as more yelling and spanking) and as a result of modeling, children are also likely to resort to aggression when frustrated.[20] In line with previous studies, an increase in child abuse and domestic violence complaints during COVID-19 outbreak is also noted.[21],[22] Exposure of children to direct and indirect violence may lead to serious emotional and behavioral problems including posttraumatic stress disorder.[22] Parents in our study reported many emotional and behavioral issues among children during the current pandemic including unhealthy eating and sleeping habits, irritability, anxiety, aggression, and sleep difficulties. These results are consistent with previous studies highlighting that children are not indifferent to the dramatic impact of health-related disasters.[15],[22],[23] A recent study in China carried out a preliminary investigation on the psychological impact of COVID-19 among 330 children and noticed increased clinginess, inattention, and irritability. Children residing in areas with a higher number of COVID-19 cases reported more fear and anxiety.[24] Sixty-seven percent of parents in another recent study reported difficulties in managing their children during the pandemic.[25] Children with special needs including autism spectrum disorder and intellectual disability are more likely to get frustrated easily and can throw temper tantrums due to disruption of their routines and limited access to support networks. This can lead to further parental stress.
Despite challenges of home confinement and social distancing measures during COVID-19 outbreak, it also allows an excellent opportunity to build stronger positive interactions between parents and children. A vast proportion of parents in our study reported spending more time with their children and feeling very or extremely close to them, a finding noted in other recent research as well.[10] The use of media entertainment, reading together, and physical exercise are different strategies used by parents to relieve children's distress and also build positive relationships.
Many online resources in different languages are accessible to help parents to manage their stress, and children behaviors.[23],[26] Evidence for web-based parent training to reduce parental distress, improve child behavior, and reduce psychological impact on families during COVID-19 needs to be explored further and can be an effective method to support parents during these unprecedented times.[27]
It is important that there is continuity of care by pediatricians and other health-care professionals to support parents and risk monitoring should be part of interactions between various stake holders. Parents and children with special needs and preexisting psychiatric difficulties need to be monitored closely.
Findings from this study need to be considered in the context of several limitations. Data collection through web-based forms during quarantine although suitable but has drawbacks due to less representation from uneducated parents or those who are unable to access the questionnaire due to lack of smartphones. Furthermore, there was very little response from the rural population. The purpose of the child questionnaire was to screen for emotional and behavior disorders, not to establish a final diagnosis of psychiatric disorder. Participants were provided information about resources which they can access for support, but it is not possible to know how many parents accessed services. Parents' own stress may lead to reporting bias as they struggle to recognize symptoms in children.
| Conclusions | | |
COVID-19 pandemic has brought many challenges for families and children which can be easily overlooked and need to be addressed. There should be urgent efforts to implement public mental health approach leading to building networks involving governmental agencies, health organizations, hospitals, schools, and community centers to support families, parents, and children. Evidence base for interventions which can be delivered effectively to families at risk during COVID-19 crisis is urgently needed. A collective response to COVID-19 needs to include being sensitive and responsive to the needs of families, parents, and children, as the impact of this pandemic will be long lasting.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet 2020;395:912-20.  |
| 2. | Cluver L, Lachman JM, Sherr L, Wessels I, Krug E, Rakotomalala S, et al. Parenting in a time of COVID-19. Lancet 2020;395:e64. |
| 3. | Lee J. Mental health effects of school closures during COVID-19. PLoS One 2020;15:e0243528. |
| 4. | Alipour Z, Kheirabadi GR, Kazemi A, Fooladi M. The most important risk factors affecting mental health during pregnancy: A systematic review. East Mediterr Health J 2018;24:549-59. |
| 5. | Jeynes WH. The effects of parental involvement on the academic achievement of African American youth. The J Negro Educ 2005;74:260-74. |
| 6. | Jackson AP, Choi J. Parenting stress, harsh parenting, and children's behavior. J Family Med Community Health 2018;5:1150-8. |
| 7. | Eltanamly H, Leijten P, Jak S, Overbeek G. Parenting in times of war: A meta-analysis and qualitative synthesis of war exposure, parenting, and child adjustment. Trauma Violence Abuse 2021;22:147-60. |
| 8. | Gunn BJ, Schneider W, Waldfogel J. The great recession and the risk for child maltreatment. Child Abuse Neglect 2013;37:721-9. |
| 9. | Lebel C, MacKinnon A, Bagshawe M, Madsen TL, Giesbrecht G. Elevated depression and anxiety among pregnant individuals during the COVID-19 pandemic. J Affect Disord 2020;277:5-13. |
| 10. | Lee SJ, Ward KP. Parenting in context research brief Stress and parenting during the coronavirus pandemic. Research Brief, Parenting in Context Research Lab. Available from: https://www.parentingincontext.org. [Last accessed on 2020 Apr 18]. |
| 11. | Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. Primary care evaluation of mental disorders. Patient health questionnaire. JAMA 1999;282:1737-44. |
| 12. | Ahmad S, Hussain S, Akhtar F, Shah FS. Urdu translation and validation of PHQ-9, a reliable identification, severity and treatment outcome tool for depression. J Pak Med Assoc 2018;68:1166-70. |
| 13. | Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med 2006;166:1092-7. |
| 14. | Sprang G, Silman M. Posttraumatic stress disorder in parents and youth after health-related disasters. Disaster Med Public Health Prep 2013;7:105-10. |
| 15. | Koller DF, Nicholas DB, Goldie RS, Gearing R, Selkirk EK. When family-centered care is challenged by infectious disease: Pediatric health care delivery during the SARS outbreaks. Qualitative Health Res 2006;16:47-60. |
| 16. | Wang G, Zhang Y, Zhao J, Zhang J, Jiang F. Mitigate the effects of home confinement on children during the COVID-19 outbreak. Lancet 2020;395:945-7. |
| 17. | Danese A, Smith P, Chitsabesan P, Dubicka B. Child and adolescent mental health amidst emergencies and disasters. Br J Psychiatr 2020;216:159-62. |
| 18. | Dix T, Meunier LN. Depressive symptoms and parenting competence: An analysis of 13 regulatory processes. Dev Rev 2009;29:45-68. |
| 19. | World Health Organization. The Importance of Caregiver-Child Interactions for the Survival and Healthy Development of Young Children: A Review. Geneva: World Health Organization; 2004. |
| 20. | Humphreys KL, Myint MT, Zeanah CH. Increased risk for family violence during the COVID-19 pandemic. Pediatrics 2020;146:1. |
| 21. | Taub A. A new Covid-19 Crisis: Domestic Abuse Rises Worldwide. The New York Times: The New York Times Company; 2020. p. 6. |
| 22. | Imran N, Zeshan M, Pervaiz Z. Mental health considerations for children & adolescents in COVID-19 Pandemic. Pakistan J Med Sci 2020;36:S67. |
| 23. | Pisano L, Galimi D, Cerniglia L. A qualitative report on exploratory data on the possible emotional/behavioral correlates of Covid-19 lockdown in 4-10 years children in Italy. [preprint published online April 13, 2020]. PsyArXiv. [doi: 10.31234/osf.io/stwbn]. |
| 24. | Jiao WY, Wang LN, Liu J, Fang SF, Jiao FY, Pettoello-Mantovani M, et al. Behavioral and emotional disorders in children during the COVID-19 epidemic. J Pediatr 2020;221:264-60. |
| 25. | Cui Y, Li Y, Zheng Y, Chinese Society of Child & Adolescent Psychiatry. Mental health services for children in china during the COVID-19 pandemic: Results of an expert-based national survey among child and adolescent psychiatric hospitals. Eur Child Adolesc Psychiatry 2020;29:743-8. |
| 26. | |
| 27. | Riegler JL, Raj SP, Moscato EL, Narad ME, Kincaid A, Wade SL. Pilot trial of a telepsychotherapy parenting skills intervention for veteran families: Implications for managing parenting stress during COVID-19. Psychol Int 2020;30:290. |
[Figure 1], [Figure 2]
[Table 1], [Table 2]
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