key: cord-0711542-u50m62vq authors: Berry, Anna; Burke, Tom; Carr, Alan title: The impact of the first wave of the Covid‐19 pandemic on parents of children with externalising difficulties in ireland: A longitudinal cohort study date: 2021-10-19 journal: Int J Clin Pract DOI: 10.1111/ijcp.14941 sha: ca030ac2bb66b46b7ae7b57ad90d4077cfa8cf3f doc_id: 711542 cord_uid: u50m62vq BACKGROUND: This longitudinal cohort study aimed to examine the impact of the first wave of the COVID‐19 pandemic in Ireland on parents of children with externalising difficulties, in comparison to parents of children without such difficulties. METHOD: Parents of 159 children completed online self‐report measures at three time points during the first wave of the COVID‐19 pandemic; (a) Delay and Mitigation Phase (March 2020 to May 2020), (b) Reopening of Society Phase (June 2020 to July 2020) and (c) Wave 2 Case Acceleration Phase (September 2020 to October 2020). Participants were allocated to the clinical group if they met the clinical cut off point on the Conduct or Hyperactivity/Inattention subscales of the Strengths and Difficulties Questionnaire at Time 1. RESULTS: Parents of children with externalising difficulties experienced significantly higher levels of stress, lower levels of wellbeing and engaged in higher levels of avoidant‐focused coping strategies longitudinally. There was a significant difference between outcomes at the different phases of the COVID‐19 pandemic, for stress related to parenting, personal/family stress related to the impact of the COVID‐19 and type of coping strategies employed. Children with externalising difficulties, in comparison to children without externalising difficulties, showed significantly greater adjustment over time for behavioural and emotional difficulties, as reported by their parents. CONCLUSIONS: Results provide important information regarding the trajectory of psychological outcomes in parents of children with externalising difficulties over the first wave of the COVID‐19 pandemic, highlighting the need for increased parental supports during, and after, the COVID‐19 pandemic. The first case of COVID-19 was detected in the Republic of Ireland on 26 February 2020, 1 Meta-analytic data from various countries [6] [7] [8] [9] suggest the prevalence of depression to be from 22.6% to 33.7%, anxiety to be from 22 .4% to 32.6%, and insomnia to be from 23.0% to 37.9%, during the COVID-19 pandemic. There is difficulty in accurately comparing these prevalence rates to pre-pandemic data, considering the use of varied outcomes measures and methodological factors. Longitudinal data from the UK suggests an overall increase in mental distress during the COVID-19 pandemic, in comparison with the year prior to the COVID-19 pandemic, in individuals aged 16 years and older, 10 however, a longitudinal study conducted in the Netherlands suggests no significant change in anxiety and depression occurred between prior to and during the COVID-19 pandemic. 11 Available evidence in an Irish population suggests that during the first week of the implementation of stay-at-home measures in March 2020, 27.7% of adults met the clinical cut off point on screening measures for GAD or depression, 12 with 17.7% of this sample also meeting diagnostic requirements for COVID-19related Post Traumatic Stress Disorder (PTSD). 13 A cross-sectional study, which involved retrospective report prior to the quarantine period, suggests the COVID-19 pandemic to be associated with statistically significant increases in levels of depression, anxiety and stress, 14 with the rate of depression increasing from 30% to 46 .3%, the rate of anxiety increasing from 30.7% to 32.5%, and the rate of stress increasing from 27.7% to 34%. People with an ongoing chronic health condition were also shown to have elevated psychological distress, and reduced wellbeing indices. 15 A longitudinal study, however, suggested there to be a significant reduction in major depression in an Irish population from a year prior to the COVID-19 pandemic and the early phases of the COVID-19 pandemic. 16 A cross-sectional study considering the relational path between COVID-19 distress and depression in the general population, in which a large proportion of respondents were living in Ireland, suggested the traumatic distress of COVID-19 to have a strong positive effect on depression, which was mediated by resilience, anxiety and hope. 17 With the closure of schools and child-care facilities, and implementation of stay-at-home orders in Ireland in March 2020, many parents had to adjust to increased levels of responsibility in supporting their children to access education through remote learning, and in many cases, simultaneously manage the demands of working from home. Longitudinal international data highlights the negative impact which the COVID-19 pandemic has had on parents. In a study conducted in the US, levels of parent depression and child externalising and internalising problems were significantly worse during the pandemic in comparison to pre-pandemic levels, to large effect. 18 Another US study reported that parent psychological well-being decreased during the post-COVID-19 restrictions period, with the number of COVID-19-related hardships found to be strongly associated with all psychological well-being measures. 19 When compared with pre-pandemic estimates, parents in Australia reported higher rates of parent depression, anxiety and stress, higher parenting irritability and lower family positive expressiveness. 20 In Singapore, 21 levels of parental stress were found to mediate the impact of COVID-19 on harsh parenting and parent-child relationship closeness during a period of stay-at-home orders, highlighting the importance of considering parental stress during periods of public health restrictions. Caring for a child with an externalising difficulty, such as the behavioural difficulties often exhibited by children with Attention Deficit Hyperactivity Disorder (ADHD), in pre-pandemic circumstances, has been associated with higher levels of parental stress, depression, and anxiety. 22, 23 This is of heightened concern during the COVID-19 pandemic, as there is a risk that additional stressors imposed by the COVID-19 pandemic may exacerbate pre-pandemic mental health difficulties. 24 As a bidirectional relationship has been proposed between parental stress and child The COVID-19 pandemic has been associated with negative psychological outcomes in the general population. Parents of children with externalising difficulties experience poorer outcomes than parents of children without such difficulties, in pre-pandemic circumstances. Over the first wave of the COVID-19 pandemic, parents of children with externalising difficulties experienced significantly higher levels of stress, lower levels of wellbeing and engaged in higher levels of avoidant-focused coping strategies. Children with externalising difficulties showed significantly greater adjustment over time for parent-reported Externalising difficulties are often prevalent for children who have autism, 26,27 ADHD, 28,29 children who have experienced complex trauma 30, 31 and/or children who have an intellectual disability (ID). 32, 33 Several aspects of the COVID-19 pandemic may have had a negative impact on parents of children with externalising difficulties. Restrictions imposed on social meetings are of concern, considering that poorer quality of life in parents of children with autism has been associated with child behavioural difficulties and lack of social support 34 and social support acts to reduce stress appraisals in parents of children with ADHD and autism. 35 In a cross- and parents of children diagnosed with a psychological or physical difficulty reported higher levels of parental burnout and less social support. 41 As services adjust to new ways of working, it is essential to consider the impact which the COVID-19 pandemic has had on this cohort of parents to inform paediatric practice and appropriate supports. Our study aimed to address the following five research Study information was disseminated online via Irish charities for children, school information platforms, and social media. Parents provided informed consent to be provided with a hyperlink via email to complete data entry at each time point. Each participant created an individual code to link their data from each time point. Individuals were eligible to participate if they were a parent of a child (4-18 years) and were living in the Republic of Ireland. The term "parent" in this study referred to any individual who engaged in the act of parenting, for example, biological parents, foster parents/carers, kinship carers, etc. Participants who completed all time points were entered into a draw to win one of three 50-euro retail vouchers. The study design was a longitudinal cohort study with 159 participants, divided into a clinical and a non-clinical group. Data were collected at three time points during the COVID-19 pandemic in Ireland. A power analysis, conducted with G*Power 3.1, 43 indicated that for one-tailed statistical tests with P values of .05 and power values of 0.80 to detect moderate differences (d = 0.50) between groups, a sample size of 102 study-completers (51 cases per cell) would be required. Demographic information was collected at Time 1 (Table 1) . Parentreported measures for assessing dependent variables, described below, were administered at all three time points. Cronbach alpha reliability coefficients of almost all measures at all time points exceeded 0.70, indicating acceptable levels of internal consistency reliability. There were two exceptions, discussed below. Questionnaire-Parent version (SDQ). 42 The SDQ is a 25-item screening instrument for assessing emotional and behavioural problems, which has been validated for use with children and adolescents aged 4-17 years of age. 42 Responses are The ECQ is a 29-item scale that evaluates perceptions of COVIDrelated stresses, as well as gratitude arising from the COVID-19 pandemic. This measure was developed for the current study by ing and approach-focused coping. 55 The Brief COPE Inventory has been utilised in studies investigating coping during the COVID-19 pandemic 56 and has been found to have satisfactory psychometric properties. 54 In the current study, Cronbach's alpha for the avoidantfocused coping subscale at all time points were from 0.64 to 0.66, indicating modest levels of internal consistency reliability. 58 The results below confirm the impressions given by the Panels in Figure 3 . The The The third research question concerned the effect of presence or ab- The The The aim of this study was to determine how the presence or absence Of concern is that parents in both groups in our study, exhibited a significant downward trajectory in the use of approach-focused coping strategies from Time 1 to Time 3, and that parents in the clinical group exhibited a significant increase in the use of avoidantfocused strategies from Time 1 to Time 3. In parents of children with externalising difficulties, an avoidant-focused coping style has been found to be involved in a process which predicts an increased level of parental depression. 67 Actively engaging in avoidant-focused coping strategies during the COVID-19 pandemic has been associated with mental health difficulties in adults. 68 These associations highlight the need for supports to assist parents in developing sustainable and helpful coping strategies. as tolerance, during stay-at-home orders has been reported by Australian families. 77 As parental responsiveness progressively supports the child's modulation, gradation, and containment of strong affect, 78 it is possible that children benefited from increased proximity to caregivers who could support this process. As highlighted above, it is possible that this result also may reflect regression to the mean. It is important to note that we are unable to make a comparison to pre-pandemic levels of externalising difficulties experienced by this cohort. Cross-sectional studies have suggested a deterioration in parental report of children's ADHD difficulties, such as inattention and hyperactivity, during the pandemic, in comparison to prior to the pandemic. 79 Limitations of the current study included that data collected was not compared with data collected in pre-pandemic circumstances, in addition to unequal group sizes. Additionally, a high level of attrition resulted in a reduction in sample size (N = 239-159) as only participants who provided >50% of data over the three time points were included in analyses, as it has been suggested that when imputing data, if proportions of missing data are very large on important variables, then results may only be considered as hypothesis generating. 80 Future research is recommended to examine mediating or moderating variables that may have impacted our results, for example, closure of schools, reduction of access to services, increased level of time spent at home, reduction of social interaction, and change in ing well-being and resilience. 84 Preliminary research has identified the positive impact of adopting a strengths-based intervention to managing externalising difficulties. 85 However, controlled trials in this area are required. This study provides important information regarding the trajectory of psychological outcomes in parents of children with externalising difficulties over the first wave of the COVID-19 pandemic. Results highlight the need for the provision of adequate supports to assist this cohort to manage stress, improve wellbeing, and to develop sustainable coping strategies. Results also demonstrate the ability of children with externalising difficulties to adjust and adapt during the COVID-19 pandemic. The authors would like to thank the participants, who took part in The data that support the findings of this study are available from the corresponding author upon reasonable request. First case of COVID-19 in Ireland COVID-19 -Statement from the Department of Education and Skills Roadmap for Reopening Society & Business. 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