How Pandemic-Related Stress Affects Families, Parenting, and Child Mental Health
COVID & MENTAL HEALTH – from Brain & Behavior Magazine, September 2021 issue
In 2020 alone, the COVID-19 virus killed 375,000 Americans, making it the 3rd-leading cause of death in the country, after heart disease and cancer, according to government statistics. An additional 240,000 Americans died of the virus in the first 7 months of 2021, estimates indicate. By any standard, the pandemic represents an immense threat to public health.
The implications for mental health may be somewhat less obvious on the surface but are no less serious, according to a team of researchers led by BBRF Scientific Council member Kathleen R. Merikangas, Ph.D., a senior investigator at the National Institute of Mental Health. In a recent paper appearing in Scientific Reports, Dr. Merikangas and colleagues note that “the pernicious mental health effects of the pandemic may result from death of loved ones, disease severity, social isolation and quarantine, unemployment, financial hardship, domestic violence, and educational disruptions.” Each of these factors, they stress, has been “independently associated with psychological comorbidities.”
Members of the team, including the paper’s first author, 2018 BBRF Young Investigator Aki Nikolaidis, Ph.D., of The Child Mind Institute, say the pandemic may pose distinctive risks due to its prolonged nature, compared with other well-studied disasters such as terrorist attacks, natural disasters, or acute exposures to environmental dangers such as radiation leaks or oil spills. These well-defined events have been associated with increases in depression, PTSD, substance use, and generalized anxiety disorder, among other psychiatric illnesses—as measured by investigators in their aftermath. “Much less is known about the risk and protective factors for well-being during and after prolonged threats like the pandemic, which continues to unfold,” the researchers point out.
Dr. Merikangas’ team specifically set out to address this gap in knowledge, with the aim of testing a survey instrument that can be easily and rapidly deployed to help experts gauge, and address in real time, pandemic-related injuries to the psyche, to relationships between people—in short, to mental health generally, across the population. They created the Coronavirus Health and Impact Survey, or CRISIS, and conducted a pilot study, testing it over an 11-day period in April 2020 in 5,646 volunteer respondents in the U.S. and UK.
Among their chief goals was to identify, based on the answers to survey questions, factors in individuals that would reliably predict who was at greatest risk of acute and longer-term mental health issues due to pandemic conditions. Another goal was to identify which factors in the CRISIS survey appeared to have a protective effect.
The CRISIS survey asked questions about the following matters: household composition and crowding; physical and mental health of household members 3 months prior to the pandemic; COVID-19 exposure and infection status; life changes due to the pandemic; concerns and worries associated with COVID-19; current self-assessment of “wellbeing”; and what the team calls “behavioral factors,” which include media use, sleep, physical activity, and substance use. Long and short versions of the survey were developed, both deployed via the internet.
Results of the pilot test of CRISIS revealed that individuals’ perceptions of COVID-19 risk, their prior mental health status, and changes in lifestyle were key predictors of current mood state during the pandemic.
“Fear and worry about COVID and resulting changes in routines and daily life” were “significant drivers of adverse mental health outcomes associated with the pandemic,” Dr. Merikangas and colleagues reported.
Interestingly, among children whose data were captured in the CRISIS survey (which was supplied by their parents) “current mood” during the pandemic was more strongly related to changes in life routines or circumstances than worries about COVID. This finding was consistent, the team said, with past research stressing the importance of regular, predictable daily routines for pediatric mental health. The findings “suggest that attending to changes in children’s lives may be key to predicting those at greatest risk for negative psychological impact.” Specifically, “current mood” was more negative in respondents reporting family and social-isolation stress in both adults and children. The team also noted that subgroups of children with greater family and social isolation stress also experienced greater stress due to financial and food security. “This underscores the impact of multifactor physical, educational, emotional, interpersonal, social and financial stressors which converged during this pandemic,” the team said.
PARENTAL BEHAVIOR CAN HELP OR HURT
In a study seeking to understand more about how COVID-related stress affected children in a family setting, a team of investigators led by 2015 BBRF Young Investigator Dylan Gee, Ph.D., of Yale University, focused on the impact of “buffering” behaviors by parents, as well as parental behaviors that potentially exacerbated the effect of children’s exposure to pandemicrelated stress.
As noted by Dr. Gee and colleagues, “nearly all aspects of family life were disrupted during the spring of 2020,” when they conducted their study via a carefully designed internet-based questionnaire. “Parents were required to work remotely without access to childcare or to work in essential roles while risking disease transmission for themselves and their families. Children transitioned to online schooling, with an increased burden for managing learning falling on parents. Many families faced additional concerns related to job loss and food and housing insecurity, as well as long-term effects of isolation on family members’ mental and physical health.”
The team gathered data from a sample of 200 parents, average age in the late 30s, 85% married and 52% female. Over a several-day period in April 2020 they sought to assess the impact of parental stress and behaviors on “internalizing” and “externalizing” symptoms in children. Examples of internalizing problems are anxious and depressive symptoms, loneliness, sadness, as well as social withdrawal. Externalizing problems often take the form of aggressive, oppositional, and delinquent behaviors that are manifested outwardly.
The study generated preliminary evidence for a linkage between a “wide range of COVID-19-related stressors and heightened internalizing and externalizing symptoms” in children, the team reported in Research on Child and Adolescent Psychopathology.
The results suggested to the investigators that specific parental factors “may buffer or exacerbate” the impact of COVID-related stress on children. “Specifically, parents who reported engaging in relatively higher levels of emotion coaching of children’s negative emotions and who reported that they were able to more stably maintain children’s home routines were more likely to effectively buffer the effects of pandemic-related stress.” Conversely, buffering was less common in parents who reported higher stress levels and anxiety due to the pandemic.
Dr. Gee and colleagues said their study “underscores the importance of considering parent-level factors and parents’ potential to either buffer or exacerbate children’s stress” in any attempt to deal with the effects of an event like the pandemic across large populations. “Public health efforts should consider the importance of targeting parental wellbeing, thereby promoting parents’ capacity” to shield their children from the potentially harmful effects of ongoing stress.
The investigators cited a number of measures taken along these lines during the pandemic: recommendations for parents to increase communication with children about the pandemic and to continue to maintain children’s typical home routines to the extent possible during a time of disruption.
STRESS, BRAIN FUNCTION, AND PARENTING
In a similar vein, another recent study in which Dr. Gee participated, published in American Psychologist and co-led by BBRF Scientific Council member Amy F. T. Arnsten, Ph.D., of Yale University, focused on the impacts of “an unanticipated and uncontrollable chronic stressor” such as the pandemic on the behavioral health of children and families. Such continually stressful events, which, they said, have disproportionately impacted families that are disadvantaged or marginalized, have “consequences on parent-child functioning.”
Based on neuroscience and clinical evidence, the researchers presented evidence that “sensitive parenting is a vital avenue of intervention against the toxic effects” of a stressor such as the pandemic. Dr. Arnsten, a neuroscientist, is also a 2015 BBRF Goldman-Rakic Prize winner, a 2008 BBRF Distinguished Investigator and 1998 Independent Investigator. She and colleagues noted a strong body of evidence demonstrating that exposure to uncontrollable stress “rapidly impairs the functioning of the prefrontal cortex (PFC),” which performs higher cognitive functions including the guidance of flexible, goal-directed behavior, as well as topdown regulation of emotion, attention and action.
The prefrontal cortex is engaged during a pandemic, the team noted, “in using abstract reasoning to imagine the potential harm in once-habitual behaviors like hugging a friend.”
Prefrontal circuitry is also needed for effective, sensitive parenting, “as it supports mentalizing functions that allow a parent to understand their child’s state of mind in response to new challenges such as disruptions in family routines and planning of effective strategies to help children cope with restrictions in learning and socializing.
The PFC is also engaged in operations in the brain which mediate attachment and empathy, as well as self-regulation that comes into play in trying to cope with frustration caused by disruptions in work and social life. The researchers noted that the PFC accomplishes these multiple functions via extensive connections throughout the brain, and can inhibit brain areas such as the amygdala and basal ganglia which are involved in reactive, emotional responses like shouting and aggression.
One way the PFC accomplishes its higher-order functions is via excitatory circuits that rely upon neurotransmitters such as glutamate, acting at NMDA receptors. These receptors are blocked by kynurenic acid, the precursor for which has been found to be highly elevated in the plasma of COVID-19 patients, particularly in men, the researchers noted. Blockade of NMDA receptors “could potentially weaken functions such as working memory and inhibitory control that depend on the PFC.”
Similarly, “high levels of norepinephrine and dopamine are released in the brain upon exposure to uncontrollable stressors like COVID- 19,” and can weaken critical PFC connections needed for cognitive functions and top-down control. In contrast, they note, high levels of such neurotransmitters in the amygdala and basal ganglia “simultaneously strengthen the more primitive, emotional responses, shifting the brain from a more reflective state to a more reflexive one, which could be maladaptive” when coping with a remarkable enduring stressor like the evolving pandemic.
Written By Peter Tarr, Ph.D.