key: cord-0998687-237vu34q authors: Erfidan, Gökçen; Özyurt, Gonca; Arslansoyu‐Çamlar, Seçil; Özdemir‐ Şimşek, Özgür; Başaran, Cemaliye; Alaygut, Demet; Mutlubaş, Fatma; Kasap‐ Demir, Belde title: Is COVID‐19 Related Anxiety Higher in Children With Chronic Kidney Disease Than Healthy Children? date: 2021-06-16 journal: Pediatr Int DOI: 10.1111/ped.14887 sha: 46ff0ca5177a5a8cb6de08dd11c6f890d50c191c doc_id: 998687 cord_uid: 237vu34q BACKGROUND: Since the emergence and worldwide spread of the new Coronavirus pandemic(COVID‐19), it has caused people to be psychologically adversely affected. This study aimed to assess anxiety levels during COVID‐19 in children with chronic kidney disease(CKD), including nephrotic syndrome(NS) and kidney transplantation(Tx). METHODS: A case‐control, cross‐sectional study was conducted with children aged of 10 to 18 years, who had been followed with diagnosis of CKD,NS,Tx between April and July 2020. Healthy control group was recruited age and gender‐matched children. A questionnaire with printed and online version is designed in three parts: demographic characteristics, opinions about the pandemic, Turkish version of The Revised Child Anxiety and Depression Scale‐ Child Version (RCADS‐CV). RESULTS: Total of 88 children completed the questionnaire. The patient and control groups were similar by gender, age, household members and history of psychiatric treatment. Both groups stated that coronavirus is a risky disease for children(63.6%), they were afraid of contagion(69.3%). Only half of them were receiving realistic and informative answers from family members. In RCADS‐CV, 66% of them get high score from at least one subscale. Social Phobia(SP) scores of the control group was higher, although the high‐scoring ratios were similar. The ratio of high‐scored participants was higher in CKD patients for Panic Disorder, and was lower in immunosuppressive agent group for SP. CONCLUSION: The current COVID‐19 pandemic is a disaster that children encounter for the first time in their lives. It does not exclusively cause anxiety among children with chronic kidney diseases, but also healthy children. This article is protected by copyright. All rights reserved The new coronavirus, named Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), was first isolated in Wuhan, China, and was confirmed as the cause of the novel Coronavirus Disease 2019 . Lower respiratory tract involvement symptoms range from mild to severe, such as tiredness, muscle pain, sore throat, fever, cough, wheezing, dyspnea, and tachypnea. It may result in severe pneumonia and acute respiratory distress syndrome. Also, gastrointestinal manifestations and multiple organ failure may accompany, and the disease may even result in death 1, 2 . Severe cases and deaths are rarely seen in children, especially in those with chronic diseases such as malignancy, immunodeficiency, chronic lung diseases, heart diseases 3 . Since the World Health Organization (WHO) announced it in January 2020, the dramatic outbreak of COVID-19 has spread globally in months. The first case in Turkey was reported on March 11, 2020 . Since then, various precautions and restrictions have been implemented as the number of cases increased. High contagion rates, uncertain prognosis and lack of effective treatment cause fear and panic not only in Turkey but in all around the world. Media have reinforced this fear with information about daily numbers of infections and dead, overcrowded hospitals, and insufficient intensive care units. Also, social media causes the difficulty to access accurate information. In brief, widespread panic, desperation and hyperarousal have developed in people. Symptoms such as anxiety and sleep disturbances are being reported more frequently during COVID-19 pandemic 4 . Incidence of post-traumatic stress disorder and depression are reported between 8% to 32% of the population during COVID-19 5, 6 . In China, a cross-sectional study evaluating the general population's psychological responses to COVID-19 indicated that one-third of participants had moderate to severe anxiety. Female gender, student status, specific physical symptoms, low self-reported health status, and chronic illness were associated with higher stress levels, anxiety and depression 7 . Another extensive study in college students showed that 21.3% had mild, 2.7% had moderate, and 0.9% had severe anxiety 8 . The COVID-19 pandemic and restrictions have severe emotional impacts on vulnerable groups. Knowing the risk factors for COVID-19 mortality may cause patients with chronic diseases to exaggerate their fear of contagion and death. Children and adolescents, which are on emotional and social developmental stage, are vulnerable to the impacts of the danger of pandemic and social isolation due to quarantine 9 . In several studies during COVID-19 pandemic, it has been demonstrated that anxiety levels of children and adolescents have increased [10] [11] [12] [13] . Besides, some This article is protected by copyright. All rights reserved studies have been published on the psychological effects of COVID-19 in children with chronic diseases, especially in chronic lung diseases 14, 15 . However, there is no detailed study on the psychological effect of COVID-19 on children with chronic kidney disease. This study aimed to assess the anxiety levels and influencing factors during COVID-19 pandemic in children with chronic kidney disease, including nephrotic syndrome and kidney transplantation. It is a case-control, cross-sectional study. The children aged between 10-18 years, who had been followed with Chronic Kidney Disease (CKD) at Pediatric Nephrology Clinics of Izmir Tepecik Training and Research Hospital, Turkey, were invited the study between April and July 2020. We recruited a control group consisting of age and gender-matched healthy children This article is protected by copyright. All rights reserved GAD, SAD, PD, MDD, SP and OCD are meaningful above 7, 5, 6, 11, 9 and 7 points, respectively 16 . The data were analyzed in IBM SPSS Statistics 25.0 (IBM Corp., Armonk, New York, USA) statistical package program. Descriptive statistics were listed as the number of cases (n), percentage (%), mean ± standard deviation (x ± SD), median with lowest-highest values (M, min.max.). The distribution of the numerical variables was evaluated with the Kolmogorov Smirnov normality test and Q-Q graphics. The groups were compared using Student's T-test for variables with normal distribution, and Mann Whitney U test for variables without normal distribution. Categorical variables were compared using the Chi-square test. A value of p <0.05 was considered Tepecik Training and Research Hospital approved this study (Decision No: 2020 / 7-6). A total of 88 children completed the questionnaire. Female to male ratio was 0.63. The mean of the participants' age was 15.3 ± 2.6 years. Demographical characteristics of the patient and the control groups were summarized in Table I . These two groups were similar by gender, age, household members and history of psychiatric treatment (p>0.05). The answers of the participants to the coronavirus-related questions are listed in Table I. While 63.6% of the participants thought that coronavirus is a risky disease for children, this ratio increased to 70.5% in the patient group, although the difference was nonsignificant (p=268 >0.05). Total 69.3% of the participants degreed their concern about coronavirus transmission to themselves or their loved ones as "very" to "extreme". The control group also exhibited more concern about this situation (72.8%), although statistically similar to the patient group (p=0.592). Nearly 10% of the participants claimed that they were rarely or never talking about coronavirus at home. Finally, we ask "How do your family members answer your questions about coronavirus?", 52.3% of the participants thought they were receiving "realistic and informative answers". However, while 12.5% of the participants were getting evasive answers as "you do not need to worry about", 31.8% were scared by the family members, even banned to This article is protected by copyright. All rights reserved ask questions in 3.4% (Table I) . There was no relation between the answers to coronavirusrelated questions and high scoring rates. The proportion of high-scored participants from each subscore was evaluated. While 34% of the participants (n=30) did not get a high score from any subscale, 2.3% of them (n=2) had high scores from all six subscales. These two participants were in the patient group. The total of 28.4% participants had high scores in OCD, 25% in PD, 33% in GAD, and 12.5% in MDD, 26 .1% in SAD, and 38.6% in SP. The SP scores of female participants were higher compared to males (p=0.024<0.05), while other scores were similar in both genders. The ratio of high-scored participants was similar between genders. The comparisons of the RCADS-CV scores are shown in Table II , the proportion of the high-scored participants are in Table III . Only SP score of the patient group was lower compare to the control group (p=0.038 <0.05), while the other scores were similar (Table II) . However, the ratio of high-scored patients did not show any significant difference between the patient and control groups (Table III) . Three categories of primary kidney diseases, NS-Tx-CKD, were compared with each other and with the control group separately. The RCADS-CV scores were similar (Table II) , and the proportion of people with high scores was similar in subscales except for PD, which was higher in CKD than the control group (p=0.049<0.05) ( Table III) . The patients receiving immunosuppressive agents were also compared with patients who did not, and with the control group. Only the scores and high-scored ratio in SP subscale were found higher in the control group than the patients with an immunosuppressive agent (Table II and III) . In this study, it was shown that most of the participants had worried about the coronavirus infection and considered it as a risky disease for children. The healthy children had concerns about the pandemic as the children with chronic kidney diseases. Almost half of the participants had claimed that the family members had covered up the questions about coronavirus with evasive answers. The RCADS-CV scale, which is used for the evaluation of anxiety and depression in children, showed no difference between healthy children and children with chronic kidney disease except SP subscale. It was thought that SP score was higher in the control group was a coincidental finding. This article is protected by copyright. All rights reserved Depression and anxiety are the most common mental disorders seen in children and adolescents, causing significant functional impairment 17, 18 . These life periods are developmentally sensitive times, so they are highly vulnerable to the impact of chronic stressors 19, 20 . The mental health evaluation of children and young adults is a critical concern in disasters like pandemics. We hypothesized that children and adolescents with chronic kidney diseases might think they are at higher risk when they become infected, leading to increased anxiety and depression in these patients. Since the emergence of the new Coronavirus disease and its spread worldwide, knowledge about the disease has increased, risk factors affecting disease progression and mortality are described 21, 22 . New treatment strategies and vaccines are being developed 23, 24 . However, uncertain prognosis, lack of appropriate treatment, and the emergence of mutated strains still cause fear and anxiety. This study was carried out between April-July 2020. As of April 1, 2020, the total number of cases reported in Turkey was 15.679 with 277 deaths, while it rose to 230 billion with 5674 deaths at the end of July, despite the various measures and restrictions (Republic of Turkey Ministry of Health, 2020). Also, no vaccine had been developed yet during that time period. So, this situation may have exaggerated people's anxiety. The response to the pandemic and the mental health status of the population differs by time. This study was conducted in a time period of April 2020 to July 2020, which disease spread rate had increased and many measures were implemented in Turkey, such as closing schools, restrictions of children and elders to their home, closing workplaces. Pandemic has caused rapid changes in daily routines of children and young adults, with the closure of schools and attending classes remotely, restrictions of extracurricular activities and social interactions. These changes may put already vulnerable groups at greater risk for mental problems. Subsequently, these losses may worsen anxiety and depressive symptoms. Also, fear of contagion may exacerbate specific anxiety types, including specific phobias and obsessive-compulsive disorder. In this study, 66% of all participants had high scores at least one of the subscales of RCADS-CV. It is shown that 28.4% of the participants had increased risk for OCD, 25% had in PD, 33% had in GAD, and 12.5% had in MDD. Those findings were similar to the literature. Liu et al. 6 had shown that at least one-third of young adults had elevated levels of depression (43.3%), anxiety (45.4%), and PTSD symptoms (31.8%). Xie et al. 25 evaluated 2330 primary school students during home confinement due to COVID-19 in China This article is protected by copyright. All rights reserved and reported a total of 22.6% and 18.9% had depressive and anxiety symptoms, respectively. When we compared the patients with chronic kidney disease and healthy control groups, we found no difference in the RCADS-CV scales except SP subscale, which was higher in the control group. However, the ratios of high scored participants were also similar. Also, the category of the primary chronic renal disease and usage of immunosuppressive agent did not make any significant difference in terms of the scores and the ratio of high-scored people. Gender is an essential factor in analyzing the general mental health state. In some studies, conducted in the pediatric population, it is shown that adolescent girls are more likely to present anxiety and depressive symptoms 12, 13 . However, in our study, female and male participants had similar anxiety and depression scores except for SP, which was higher in females. Infection of children and adolescents with COVID-19 usually presents with milder symptoms, fewer hospital admissions, and a lower fatality rate than adults. However, in our study, 63.6% of the participants had answered "Yes" to the question of "Is coronavirus a risky disease for children?". Among the children with chronic renal diseases, it increased to 70%, although the difference was insignificant comparing with the healthy control group. The anxiety of children with chronic diseases may worsen during the pandemic because of increased parent anxiety, increased frequency of talking about the coronavirus at home, putting more protection pressure due to COVID-19, and the psychological problems of parents. We asked the participants the frequency of COVID-19 related conversations in their homes. The 35.2% of the participants answered "frequently" and "usually". The frequency of the conversations about the pandemic was similar in both healthy and patient groups. High scoring rates were also similar statistically. Therefore, in this study, we could not show any effect of frequently talking about the pandemic on anxiety and of having a child with chronic kidney disease on the frequency of these conversations. The COVID-19 pandemic has affected family interactions, which evidently influences child and adolescent mental health. Parenthood requires to help their children managing their emotions, coping with stress, interpreting their own experiences. However, for all of these, effective communication between two sides is essential. In this study, we try to evaluate the communication between children and their family members about the pandemic with a question ("How do your family members answer your questions about coronavirus?"). Only 31.8% of the children were having realistic and informative answers to COVID-related questions, while This article is protected by copyright. All rights reserved 52.3% were scared by their family members. These responses were similar in children with or without chronic kidney disease. Also, we found no significant effect of these answers on the RCADS-CV scores. Nevertheless, effective communication may become challenging for the parents due to their own demoralizing losses, such as loss of work, death of loved ones, the anxiety of contagion and exacerbation of their own psychiatric illnesses. Therefore, evaluation of the parents' mental status is also useful. The studies showed that anxiety and depression symptoms were more common in children with parents, who had a high risk on scales measuring mental health 26 . This study has some limitations. First, the study design is cross-sectional, so we cannot comment on causality. Second, it is conducted in a small group of participants in a single center, limiting the broader generalization of the results. Third, we couldn't evaluate the relationship between anxiety degrees of the parents and children. Finally, since the psychiatric status of the sample before the pandemic was not known, it was not possible to associate the findings only with the pandemic. The current COVID-19 pandemic is a disaster that children encounter for the first time in their lives. Due to the unpredictability and uncertainty of the pandemic, it caused high anxiety in children and adolescents as well as in adults. This study shows that the COVID-19 pandemic may not exclusively cause anxiety among children with chronic kidney diseases, but also healthy children. So, psychosocial support may needed for both grups. For evaluation of the long-term effects of the pandemic on children, further studies are needed. This article is protected by copyright. All rights reserved generalized anxiety disorder, MDD: major depressive disorder, CKD: chronic kidney disease, NS: nephrotic syndrome, Tx: renal transplantation ns: nonsignificant. p1 is obtained by comparison of the each primary disease category with control group, p2 is by comparison of these primary diseases with each other. p3 is obtained by comparison of the immunsuppressive agent receiving and non-receiving categories with control group, p4 is by comparison of these categories to each other. This article is protected by copyright. All rights reserved COVID-19): A Review of Clinical Features Clinical features of patients infected with 2019 novel coronavirus in Wuhan Epidemiology of COVID-19 among children in China The outbreak of COVID-19 coronavirus and its impact on global mental health Acute Posttraumatic Stress Symptoms during the COVID-19 Outbreak in Wuhan, China. medRxiv Factors associated with depression, anxiety, and PTSD symptomatology during the COVID-19 pandemic: Clinical implications for U.S. young adult mental health Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China The psychological impact of the COVID-19 epidemic on college students in China Coronavirus Disease 2019 (COVID-19) and Mental Health for Children and Adolescents Anxiety in Older Adolescents at the Time of COVID-19 How is COVID-19 pandemic impacting mental health of children and adolescents? Accepted Article This article is protected by copyright. All rights reserved Depression and anxiety among adolescents during COVID-19: A cross-sectional study Prevalence and socio-demographic correlates of psychological health problems in Chinese adolescents during the outbreak of COVID-19 Psychiatric and general health effects of COVID-19 pandemic on children with chronic lung disease and parents' coping styles Effect of the COVID-19 pandemic on anxiety among children with cystic fibrosis and their mothers Psychometric Properties of the Parent Version of the Revised Child Anxiety and Depression Scale in a Clinical Sample of Turkish Children and Adolescents Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication-Adolescent Supplement (NCS-A) Global burden of disease in young people aged 10-24 years: a systematic analysis The Impact of Stress on the Structure of the Adolescent Brain: Implications for Adolescent Mental Health How the timing and quality of early experiences influence the development of brain architecture A brief-review of the risk factors for covid-19 severity Covid-19: risk factors for severe disease and death Accepted Article This article is protected by copyright. All rights reserved Canakinumab as treatment for COVID-19-related pneumonia: a prospective case-control study One year update on the COVID-19 pandemic: Where are we now? Mental Health Status Among Children in Home Confinement During the Coronavirus Disease Psychiatric and general health effects of COVID-19 pandemic on children with chronic lung disease and parents' coping styles This article is protected by copyright. All rights reserved