Easing pandemic-related restrictions, easing psychosocial stress factors in families with infants and toddlers? Cross-sectional results of the three wave CoronabaBY study from Germany

The adverse experiences and profound structural changes related to the COVID-19 pandemic have resulted in severe psychosocial stress all over the globe.

There is a consensus that families have been particularly strained by the policies implemented to contain the virus, e.g., due to limited access to family support services [1] and daycare facilities/ nurseries or schools [2], which resulted in additional childcare responsibilities for parents while often having to work from home. While restriction measures have been gradually reduced or completely lifted, the long course of the crisis and the accumulation of stress factors such as existential fears and worries, loss and grief, economic disadvantages, negative personal and social changes in many life areas represent persistent stressors that can have adverse effects on e.g., mental health [3].

Accordingly, studies have found an increase in depression and anxiety symptoms among parents since the beginning of the pandemic [4, 5], with caregivers of young children at particular risk for these mental health issues [6]. There is also evidence for an increase of parenting stress [7‐9], which is closely related to the quality of parent–child-interaction [10] and both parental and child mental health [10‐12].

Child mental health soon became a matter of concern in the early stages of COVID-19. National and international studies found significant increases of psychological problems in children and adolescents [e.g. 13, 14] compared to pre-pandemic data. However, these studies largely focused on school-aged children or merely included younger children without highlighting their specific situation. Hence, comparable investigations of infants’ and young children’s mental health as well as their caregivers’ wellbeing are sparse- possibly due to this group being less directly affected by the structural restrictions (e.g., school closures) implemented to contain the virus. However, parental psychosocial stress during the different waves of the pandemic is likely to have impacted very young children: They depend almost exclusively on the physical and emotional care and protection of their parents in a phase of life characterized by rapid brain growth and development [15, 16], rendering them particularly vulnerable to stressful environmental influences [17] as evident during the pandemic—with severe possible implications for a healthy development [18, 19].

One of the very few investigations with a specific focus on infants and toddlers is the CoronabaBY study which surveys psychosocial stress factors such as parenting stress and parental and child mental health problems in families with 0–3 year olds in Germany [20]. First cross-sectional results from a high incidence phase in 2021 showed that infants and toddlers showed an overall similar level of mental health problems at this point compared to pre-pandemic studies. However, a substantial number of the surveyed parents struggled with affective symptoms and reported limited emotional resources for childcare due to high levels of parenting stress. Because young children’s mental health is generally closely linked to the psychosocial wellbeing of their caregivers [10, 11, 21‐23], there could still have been delayed detrimental effects of parental stressors in later stages of the pandemic. Given that children’s mental health is the foundation for healthy development [24], it is of particular interest to understand the extent to which potentially harmful stressors were present in this population at different stages of the pandemic in order to provide appropriate support services following the very recent crisis.

We therefore investigated psychosocial stress factors, namely perceived pandemic burden, parenting stress, and parent and child mental health outcomes in German families with children aged 0–3 years in a repetitive cross-sectional study during three different phases of the COVID-19 pandemic in 2021/22 (waves I and III = phases of high incidence rates and restriction measures and wave II = low incidence rates and relaxations). We aimed to answer the following research questions:

We expected a higher prevalence of perceived pandemic burden, parenting stress, parental anxiety and depression symptoms, infant crying, sleeping, and feeding problems, and toddlers’ emotional and behavioral problems among families in survey wave I, due to high incidence rates and lockdown measures compared with families surveyed in wave II during the summer with low incidence rates and restrictions, followed by a rise in the number of psychosocially stressed families during the wave III survey period with its renewed steep increase in infection rates (emerging Omicron variant).

In a comparison of the three survey waves of the CoronabaBY study, including a total of 2940 parents with their children aged 0–3 years, we cross-sectionally investigated the number of families experiencing psychosocial stress factors in relation to higher and lower COVID-19 incidences and restrictions in Bavaria, Southern Germany. Our results show that psychosocial stress factors in families with infants and young children remained highly prevalent over the course of the pandemic. While parental high pandemic burden mirrored incidence rates and respective restriction measures, the number of caregivers experiencing noticeable parenting stress increased irrespective of pandemic events. Parental mental health problems were highly evident, but remained more or less stable during the course of the pandemic. Similarly, toddlers’ mental health problems were highly evident in later stages of the pandemic but did not increase significantly during the course of the study. In contrast, the number of infants with mental health problems significantly increased from one high incidence phase to another. Of several sociodemographic and pandemic-related variables, we found the increase of familial conflicts during the pandemic to have the strongest negative influence on parenting stress, maternal, infants’ and toddlers’ mental health.

Looking at our results in detail, we found a perceived high pandemic burden in up to 65% of our sample, which appears to be a slightly higher rate than in a German comparison study (59% with high perceived pandemic burden) including parents of children younger than 14 years [34]. This result corroborates findings that parents of young children are particularly vulnerable to experiencing the pandemic as stressful (e.g., [2]). Partly as expected, the number of families with a high pandemic burden roughly mirrored the restrictions during the individual survey waves with a prevalence peak during survey wave I, a significant decrease in survey wave II but only a slight renewed increase in survey wave III. These findings are in line with another study showing a peak of disease-related distress early during the virus outbreak and a decrease as time proceeded [35].

A different picture emerged for parenting stress across the three survey waves: From the beginning of the study, with 38.2% of the families being affected, parenting stress was highly pronounced compared to pre-pandemic data (see [20]). Contrary to our initial assumption, the number of families with elevated parenting stress significantly increased in wave II despite lower COVID-19 incidences and fewer restrictions and only non-significantly rose to a peak in wave III. Although the effect sizes were small, overall more than half of the surveyed participants (51.2%) were affected by parenting stress.

While there are no studies that are fully comparable with regard to design, survey periods, and target group, a longitudinal study on parenting stress found an increase with a longer duration of the pandemic in the year 2020 [36]. In addition, a German longitudinal investigation of the general population found that psychological distress did not decrease between two high incidence phases in 2020 despite lesser restrictions during the second survey timepoint [37]. As parenting stress did not decrease despite relaxation of measures to contain the virus, it is likely to be a longer-term stress factor. Since it is closely related to parental [38‐40] and child mental health problems [10‐12] and negatively impacts the parent–child-relationship [38, 41], intervention efforts should aim at reducing parenting stress in families with young children in the aftermath of the pandemic.

Turning to parental mental health, we identified a peak of 28.3% of mothers and 28.4% of fathers with symptoms of depression and anxiety in survey wave III. The number of affected parents appeared to be higher compared to a pre-pandemic German study with approximately 20% of parents with children under the age of three experiencing affective symptoms [42]. Contrary to our assumptions, the number of parents with affective symptoms remained high almost irrespective of pandemic events, i.e., relaxation of measures. This result is roughly in line with an Austrian study on the general population showing a substantial persistence in mental health problems even 6 months after lifting of pandemic-related restrictions [43].

Taking a look at children’s mental health, the number of toddlers with borderline or noticeable emotional and/or behavioral problems rose from 18.4% in wave I to a maximum of 23.9% in wave III, however these increases were not significant. Still, while the number of toddlers with borderline and noticeable mental health problems almost exactly corresponded to the norm in survey wave I, this appears to be no longer the case in later periods of the pandemic [32, 44]. Prevalence rates for infants’ crying/sleeping, and feeding problems were already in the upper range compared to pre-pandemic data in survey wave I (compare [20]). The number of infants with excessive crying or feeding problems did not change significantly in relation to different survey periods. However, the proportion of infants with crying/sleeping problems was significantly higher in survey wave III than in survey wave I. One of the vanishingly small number of studies targeting infant crying, sleeping and feeding problems during the pandemic also used the CSF and found combined crying/sleeping but not feeding problems to be significantly higher prevalent in infants born during the pandemic [45]. While the small effect size in our study as well as differences in definition and operationalization of these problems have to be considered, with as much as 35.5% of infants affected, this rate is now higher than the ones found in pre-pandemic comparison studies [46]. These findings suggest a staggered negative impact of pandemic-related factors on young children’s mental health, and policy makers should be made aware that the needs of infants and toddlers are as relevant as those of e.g., school-aged children in the context of pandemic after-care.

In a second step, we explored possible influencing factors on parenting stress and mothers’ and child mental health problems. For all four outcomes, increased family conflicts had the highest predictive value, with a medium to large effect on parenting stress, a medium effect on maternal affective symptoms, a small to medium effect on toddlers’ emotional and behavioral problems and a small effect on infant crying/sleeping problems. This result highlights that also in the pandemic with its multiple external stressors, the family microclimate is particularly relevant for parental and child wellbeing and should be one focus when counseling burdened families, e.g., by providing conflict management strategies.

Individually, we found higher parental education to be predictive of higher parenting stress, which is in line with earlier findings of the CoronabaBY study and might be associated with higher educated parents worrying more about the pandemic (compare [20]). Survey wave and parental perceived pandemic burden also influenced parenting stress, however all effect sizes were small. Mothers’ symptoms of depression and anxiety were more pronounced with increasing child age. In contrast, a meta-analysis on moderating factors for maternal depression and anxiety during COVID-19 did not find child age to be influential [47]. As the found effect size in our sample of mothers was small, this result might not be of high practical relevance. Higher pandemic burden was also predictive for maternal mental health, again with a small effect size.

Infant crying/sleeping problems were predicted by survey wave and parental pandemic burden, whereas having a sibling was a protective factor. The latter result could be explained by parents’ greater experience in handling crying/sleeping problems when having more than one child and has also been shown by another study on infant crying/ sleeping problems during the pandemic in Germany [45]. Again, corresponding effect sizes in our study were small. Toddlers’ emotional and behavioral problems were slightly more pronounced for children with a chronic disease or a disability, which is line with earlier findings [48, 49].

There are several possible underlying causes for the trajectories of the surveyed psychosocial stress factors: First, the decreasing number of parents perceiving a high pandemic burden over time might reflect the reduced visibility of COVID-19 with the gradual relaxation of measures, but could additionally indicate the development of a habituation effect as a coping strategy. Second, given the permanence of COVID at the time of our survey, the increase in parenting stress over the course of the pandemic as well as the constantly high number of parents with mental health issues might be explained by lack of prospects, resulting in mental exhaustion—the so called ‘pandemic fatigue’ [37]. Third, with a longer duration of the pandemic—and again irrespective of pandemic events—the number of young children with deteriorated mental health has increased to a worrying level, while at the beginning of the study the numbers for both infants and toddlers still corresponded to the norm. As both parenting stress [10‐12] and parental mental health issues [21‐23] are known to be related to child mental health problems, the results corroborate the possibility of a staggered negative influence of high parental burden in this regard. However, these considerations remain theoretical as they cannot be answered on the basis of the data available in this study and will need to be addressed by future studies.

This study has strengths and limitations that have to be considered when interpreting the found results. The CoronabaBY study was the first and largest German investigation on psychosocial well-being during the pandemic specifically targeting families with children aged 0–3 years. Besides including a large number of participants, parenting stress and parental and child mental health were assessed with validated standardized psychological questionnaires without notable missing values. In addition, the individual survey periods as well as the whole study duration of 13 months were considerably longer than of many other comparison studies, enabling a broader perspective that goes beyond a momentary snapshot. Also, we investigated later stages of the pandemic while a majority of the pandemic-related research was conducted around the first outbreak of the virus.

We recruited a high number of financially well-off families with good education, German background, and mostly mothers (compare [20]). These aspects have to be considered with regard to the generalizability of our study results. Another limitation might be that the CoronabaBY study started a year after the initial outbreak of the virus and thus may not capture the most severe pandemic-related stress experiences. However, a significant proportion of the surveyed sample exhibited psychosocial stress factors, even if the crisis was no longer a new phenomenon, and the number of burdened parents and infants even increased during the course of the study. As the number of fathers in our sample was relatively small, we cannot provide specific results for them. Future studies should aim to shed light on fathers' mental health during and in the aftermath of the pandemic. Children’s mental health was assessed via parental report and we cannot rule out the probability that parents with higher stress levels perceive their child’s behavior as more troublesome. Finally, due to the cross-sectional nature of our data, we cannot draw causal conclusions with regard to the impact of the pandemic on the surveyed psychosocial stress factors. However, this study sheds light on trajectories of psychosocial stress in families with infants and toddlers in different stages of a global crisis and adds knowledge essential to provide adequate support for this vulnerable group.

Taken together, our results show that psychosocial stress factors in families with infants and toddlers remained highly pronounced or even increased with a longer course of the pandemic - despite relaxation of restrictions and lower incidences. Although the pandemic might start to fade into the background in public perception, the ongoing support needs of families with young children must not be allowed to fall out of focus. Because of their particularly high vulnerability and susceptibility to parental burden, promoting infants' mental health has to be a top priority for policy makers and health professionals in the aftermath of COVID-19. Future investigations need to explore the underlying causes of the trajectories found and specifically examine the relationship between parental and child outcomes in a longitudinal design. Support measures should focus on promoting a positive microclimate in the family, e.g., through conflict counselling, by reducing parenting stress and by strengthening parental resources so that they can be fully available for the signals and needs of their young children.