The Effects of Quarantine or Hospitalisation on Mental Health of Children and Parents with the COVID-19 Suspicion: A Case-Control Study
Background and Objectives: The aim of our study is to compare the children between the ages of 6 and 16 being in quarantine or hospitalised for at least 14 days with suspicion of COVID-19 and their parents and the children without suspicion of COVID-19 and their parents in terms of their mental exposure level. Methods: A list of questions, investigating post-traumatic stress disorder (PTSD) symptoms in children and parents and prepared by arranging DSM-5 diagnostic criteria, The Revised Child Anxiety and Depression Scale – Parent Form, DSM-5 Level 2 Sleep Disorder Scale 6-17 Age Parents Form and Hospital Anxiety Depression Scale, were answered by parents. Results: The mean score of DSM-5 Level 2 Sleep Disorder Scale (respectively 16.72±8.31, 14.34±6.37) and the rate of confrontation of DSM-5 PTSD diagnostic criteria (respectively 8.5%, 2.9%) were statistically significantly higher in the study group of children compared to the control group (p<0.05). Mean score of the depression scale (respectively 8.37±3.70 and 6.97±3.63) and the rate of confrontation of DSM-5 PTSD diagnostic criteria (respectively 16.3%, 7.9%) were statistically notably higher in the parents of study group compared to the control group (p<0.05). In addition to this, a statistically important positive correlation was found between anxiety and depression levels of the parents and anxiety, depression and sleep scores of the children for all of them (p<0.05). Conclusion: Direct exposure to the COVID-19 poses a higher risk for both children and their parents in the emergence of psychiatric symptoms than those without any direct exposure.
Keyword : COVID-19; Mental health; Pandemic; Quarantine
The COVID-19 outbreak has spread rapidly and widely since the first case was recorded. Studies suggest that children have a lower risk of severe symptoms formation after being infected with SARS-CoV-2 compared to adults.1 Many measures (such as lockdowns, suspension of schools) have been carried out worldwide to prevent the pandemic. Isolation and quarantine are also among these measures. Centers for Disease Control and Prevention (CDC) recommends that people with a suspicion of the disease should be isolated for at least 14 days. Those people hospitalising are required to be in quarantine at home to complete the remaining time after discharge.2
Studies has mentioned about the psychological effects related to negative life experiences in children. In a study of 1143 parents in Italy and Spain, 85.7% of the parents reported that their children experienced emotional and behavioural changes with closure during the pandemic period. The most common symptoms were stated as difficulty in focusing, boredom, irritability, restlessness, loneliness and anxiety.3 Parents, a group experiencing the direct and indirect effects of pandemic-related stress intensely, have to face the consequences of the pandemic on both their own health and the health of their loved ones. While many parents have been experiencing the stress especially about parenting roles even before the pandemic, this stress level may have increased in the pandemic.4 Meanwhile most of the studies on the COVID-19 outbreak examine the psychological effects on the general population, the number of studies investigating the effects on parents and their children is limited. The pandemic process can cause psychological difficulties for parents and their children. In addition to some cases, taking swabs from children and parents with the suspicions of COVID-19 during this period and staying in quarantine or isolation for at least 14 days with suspicion of disease and hospitalisation may have increased the difficulties experienced by both children and their parents. Also, the finding of post-traumatic stress disorder (PTSD) symptoms, which was 4 times higher in those who were quarantined supports this idea in a study comparing quarantined parents and children with those not in quarantine.5
The aim of this study is to compare children aged between 6 and 16 staying at home in isolation or quarantine for at least 14 days or treated by hospitalisation after taking a swab with suspicion of COVID-19 and their parents (study group) and again children in the same age range without any suspicion of COVID-19 and their parents (control group) according to their mental exposure level.
The control group, on the other hand, consists of children in the same age range, not suspected with COVID-19 and their parents. Parents of the children in the study group were reached through their phone numbers recorded in the hospital files. The cases in the control group were formed with children aged 6-16 years and their parents who first applied to departments other than child and adolescent psychiatry (such as paediatrics, eye disease, ear-nose-throat disease, orthopaedics, radiology) for any reason rather than the COVID-19 suspicion.
Questionnaires were answered by 282 participants. Fourteen participants with repetitive responses were excluded from the study. 48.1% (n=129) of the remaining 268 participants formed the study group, and 51.9% (n=139) of them were in the control group. 67.5% (n=181) of the responders to questionnaires were mothers and 32.5% (n=87) were fathers. The mean age of the parents was 40.6±5.65. 51.1% (n=137) of the children were male and 48.9% (n=131) were female with the average age of 10.8 (±3.37).
The Revised Child Anxiety and Depression Scale – Parent Version (RCADS-P) was used to determine the risk of anxiety and depression in children and DSM-5 Level 2 Sleep Disorder Scale 6-17 Age Parents Form was used to find out the level of sleep problems in children. Hospital Anxiety Depression Scale (HADS) was used to determine the risk of parents in terms of anxiety and depression. All forms were completed by parents. Measurement tools were made suitable for online application to be sent to the participants by e-mail or message because of face-to-face interaction with the public has been minimised due to restrictive measures taken by the Turkish Government for the COVID-19 outbreak. Ethical approval was received from Uludağ University Faculty of Medicine Non-Invasive Clinical Research Ethics Committee in accordance with the principles in the Declaration of Helsinki. Online informed consent was obtained from all participants.
The Revised Child Anxiety and Depression Scale – Parent Version (RCADS-P):
Hospital Anxiety Depression Scale (HADS):
Fifth Edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) Post-Traumatic Stress Disorder Question List Prepared in Consideration
In the study group 65.1% (n=84) of the parents work on the other hand this rate was found to be 74.8% (n=104) in the control group. While the occupations of the parents in the study group was reported that 28.7% of them were worker, 12.4% were health worker, 11.6% were officer and 19.4% were self-employment; 35.3% of the parents in the control group were healthcare workers, 24.5% were officer, 8.6% were worker and 8.6% were self-employed. 57.4% (n=74) of the parents have high school and higher education level in the study group and the education levels of the parents 92.0% (n=128) in the control group were high school or higher education. There was no psychiatric disease before the epidemic in 91.5% of the children in the study group and 93.5% of the control group. No statistically significant difference was found between two groups in the aspects of child age, child gender, mother or father filled out the questionnaire, whether the parents work in any job or not, the presence of a psychiatric disease in their children before the pandemic and whether there was a change in the course of the psychiatric disease when the study group and the control group were compared according to sociodemographic variables (p>0.05) (Table 1).
In the study group, being a worker and having a secondary school or lower education level were statistically significantly higher than the control group (p<0.05).The average age of parents in the control group was higher than the study group (p<0.05) (Table 1).
It was specified that 33.3% of the children (n=43) had positive test results, 45.7% (n=59) of them had a member with positive COVID-19 test result except the child in the family, the most frequent positive results were reported by mothers (61.0%) and fathers (59.3%) when the data related to the diagnosis of COVID-19 and the disease process were examined in the study group. While 87.6% of the children (n=113) had symptoms of the illness, the most common symptoms were fever (63.7%) and weakness (45.1%). 76.7% of the children after the swabbing were followed at home in quarantine or under isolation measures and medicine treatment was started for 74.4% of the children. In 2.3% of the children, it was found that a family member died of COVİD-19 (Table 3).
Sleep problem was reported in 70.9% of all children (n=190) unlikely these rates were 73.6% in the study group and 68.3% in the control group. The mean score of DSM-5 Level 2 Sleep Disorder Scale in the study group was 16.72 (±8.3) as well it was 14.34 (±6.37) in the control group. The mean score of DSM-5 Level 2 Sleep Disorder Scale was statistically significantly higher in the study group compared to the control group (p<0.05) (Table 2).
A list of questions consisting of DSM-5 PTSD diagnostic criteria was directed to parents in order to investigate the risk of PTSD in their children. 5.6% of all children provided the DSM-5 PTSD diagnostic criteria as this rate was statistically significantly higher in the study group compared to the control group (respectively 8.5%, 2.9%) (p<0.05) (Table 2).
The mean score of RCADS-P anxiety was 24.30 (±12.35) in all children meantime this rate was higher in the study group compared to the control group (respectively 24.65±12.75 and 23.97±12.01). The rates of children above the cut-off value for anxiety were 42.2% of all children, 43.4% in the study group, 41.0% in the control group. No statistically significant difference was found between two groups in terms of anxiety score and cases above the cut-off value for anxiety (p>0.05) (Table 2).
The mean depression score of RCADS-P was 5.87 (±3.96) in all children at the same time this rate was higher in the study group compared to the control group (respectively 6.00±4.09 and 5.75±3.85).The rate of children above the cut off value for depression was 18.7% of all cases while this rate was higher in the study group than in the control group (respectively 21.7%, 15.8%). No statistically significant difference was attained between two groups in terms of depression score and the number of cases above the cut-off value for depression (p>0.05) (Table 2).
A list of questions consisting of DSM-5 PTSD diagnostic criteria was directed to research the risk of PTSD in parents. While 11.9% of all parents provide the DSM-5 PTSD diagnostic criteria, this rate was statistically significantly higher in the study group compared to the control group (respectively 16.3%, 7.9%) (p<0.05) (Table 2).
The anxiety and depression symptoms of the parents were questioned by using HADS in our study. The mean score of HADS anxiety was 8.52 (±3.73) for all parents also it was higher in the study group compared to the control group (respectively 8.62±3.88 and 8.44±3.61). The rate of responses above the cut-off score for anxiety was found to be 37.7% in all cases and this rate was higher in the study group compared to the control group (respectively 38%, 37.4%). There was no statistically significant difference between two groups in terms of total anxiety score and rates of responds above the cut-off score for anxiety(p>0.05) (Table 2).
The mean score of HADS depression for all parents was 7.64 (±3.72). The mean depression score was statistically significantly higher in the study group compared to the control group (respectively 8.37±3.70 vs 6.97±3.63) (p<0.05). The rate of responds above the cut-off score for depression was 56.7% in all cases meanwhile this rate was higher in the study group compared to the control group (respectively 58.1%, 55.4%).There was no statistically significant difference in the rate of responses above the cut-off score for depression (p>0.05) (Table 2).
Statistical analyses were also made for the study group. There was no statistically significant difference between the situation of the COVID-19 swab result was positive or negative in the child, having a member with positive COVID-19 test except the child at home, presence of disease symptoms in the child and following-up at the hospital or at home during disease and anxiety and depression levels in children and parents (p>0.05) (Table 3).
In our study, the relationship between the levels of anxiety and depression in the parents of all cases and the scores of anxiety, depression and sleep in the children was examined. A statistically significant positive correlation was found between the anxiety and depression levels of the parents and the anxiety, depression and sleep scores of the child (p<0.05) (Table 4).
The number of studies, researching whether there is a difference in the mental exposure levels between children and their parents feeling the threat of COVID-19 directly (hospitalised after taking a swab with suspicion of disease or undergone isolation and quarantine measures at home for at least 14 days) and children and their parents not directly affected by the pandemic (no swabs taken from them or their relatives with the suspicion of disease, not isolated at home with the suspicion of disease or not hospitalised) is very limited.
Our study is one of the first studies analysing the prevalence of anxiety, depression, PTSD symptoms and sleep problems in these two groups and also makes comparisons between them.
Sleep Problems in Children
Post Traumatic Stress Disorder Symptoms in Children
Anxiety and Depression Levels in Children
Anxiety and Depression Levels in Parents
Parental Post Traumatic Stress Disorder Symptoms
The Effects of Parental Anxiety Depression Levels on Mental Health of Children
Statistical analyses were also done for cases (study group) followed up with the suspicion of COVID-19 in our study. There was no statistically significant difference between COVID-19 swab result of children, members with positive results of the COVID-19 except the children at home, presence of symptoms, follow-up period during the disease and the levels of anxiety and depression in children and parents (p>0.05). Some of the reasons of significant difference deficiency can be lack of severe pain in symptoms of children compared to adults, lack of life threatening in most of them and short hospital stays in also hospitalised children.
The findings of our study show that direct exposure to the COVID-19 (getting the disease or isolation measures with the suspicion of disease) creates a higher risk for both children and their parents in the emergence of psychiatric symptoms than those not directly exposed. For this reason, the mental health needs of children directly exposed to the disease and their families should be considered while planning the measures related to the pandemic.
The author(s) has/have received no financial support for the research, authorship, and/or publication of this article.
Availability of Data and Material
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Baris GULLER designed the study, wrote the protocol, and conducted the survey. FerhatYalaciy performed statistical analysis, and wrote the first draught of the manuscript. All the authors read and approved the submitted version of the manuscript.
Compliance with Ethical Standards
Conflict of Interest
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