Effects of Coronavirus Disease 2019 (COVID-19) on Family Functioning

Abstract

More than a year and a half after the first clinical manifestations of coronavirus disease 2019 (COVID-19) were reported in Wuhan, China,1ProMED International Society for Infectious DiseasesUndiagnosed pneumonia—China (Hubei): Request for information. ProMED.https://promedmail.org/promed-post/?id=6864153Date: 2019Google Scholar,2Bloom J.D. Chan Y.A. Baric R.S. Bjorkman P.J. Cobey S. Deverman B.E. et al.Investigate the origins of COVID-19.Science. 2021; 372: 694Crossref PubMed Scopus (63) Google Scholar the magnitude of the pandemic across the globe and its related clinical and social effects3World Health OrganizationCoronavirus disease (COVID-19) outbreak.www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happenDate accessed: June 3, 2021Google Scholar remain unclear.4Alzueta E. Perrin P. Baker F.C. Caffarra S. Ramos-Usuga D. Yuksel D. et al.How the COVID-19 pandemic has changed our lives: a study of psychological correlates across 59 countries.J Clin Psychol. 2020; 77: 556-570Crossref PubMed Scopus (98) Google Scholar The pandemic has affected lives and sparked concerns about everything from health to job security. In high–Gross Domestic Product (GDP) countries, despite trillions in coronavirus aid released by governments, many families still struggle to pay for basic necessities like food and rent, and these difficulties worsened during the pandemic.5Jenco M. American Academy of Pediatrics (AAP) News. Study: COVID-19 pandemic exacerbated hardships for low-income, minority families.https://www.aappublications.org/news/2020/06/03/covid19hardships060320Date accessed: June 3, 2021Google Scholar,6Karpman M. Gonzalez D. Kenney G.M. Urban Institute. Parents are struggling to provide for their families during the pandemic.https://www.urban.org/sites/default/files/publication/102254/parents-are-struggling-to-provide-for-their-families-during-the-pandemic_2.pdfDate accessed: June 3, 2021Google Scholar The general social uncertainty caused by the pandemic seems to have also affected family resilience, weakening the ability of individuals to confront challenges, survive difficulties, and thrive in adversities as a group.7Killgore W.D.S. Taylor E.C. Cloonan S.A. Dailey N.S. Psychological resilience during the COVID-19 lockdown.Psychiatry Res. 2020; 291: 113216Crossref PubMed Scopus (243) Google Scholar,8Pettoello-Mantovani M. Pop T.L. Mestrovic J. Ferrara P. Giardino I. Carrasco-Sanz A. et al.Fostering resilience in children: the essential role of healthcare professionals and families.J Pediatr. 2019; 205: 298-299.e1Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar To reduce community spread of the virus, many countries adopted unprecedented confining measures, including the restriction of populations in their homes and reduction of interpersonal contacts. Confinement, quarantine measures for suspected COVID-19 cases, and social distancing were prolonged, and their effectiveness was debated at social, scientific, and political levels.9Song J.Y. Peck K.R. Korean Society of Infectious DiseasesA debate on public health responses to COVID-19: focused protection versus sustained suppression.J Korean Med Sci. 2020; 35: e433Crossref PubMed Scopus (3) Google Scholar However, although their prevention value in limiting viral spread is generally recognized,6Karpman M. Gonzalez D. Kenney G.M. Urban Institute. Parents are struggling to provide for their families during the pandemic.https://www.urban.org/sites/default/files/publication/102254/parents-are-struggling-to-provide-for-their-families-during-the-pandemic_2.pdfDate accessed: June 3, 2021Google Scholar it is also widely accepted that social isolation measures have upended family lives.4Alzueta E. Perrin P. Baker F.C. Caffarra S. Ramos-Usuga D. Yuksel D. et al.How the COVID-19 pandemic has changed our lives: a study of psychological correlates across 59 countries.J Clin Psychol. 2020; 77: 556-570Crossref PubMed Scopus (98) Google Scholar In particular, they have affected family functioning and parenting, which are significantly associated with the physical and psychosocial functioning of children and adolescents.10Lunkenheimer E.S. Olson S.L. Hollenstein T. Sameroff A.J. Winter C. Dyadic flexibility and positive affect in parent–child coregulation and the development of child behavior problems.Dev Psychopathol. 2011; 23: 577-591Crossref PubMed Scopus (123) Google Scholar This commentary, authored by the Working Group on Social Pediatrics of the European Paediatric Association/Union of National European Paediatric Societies and Associations, briefly discusses the effects of the confinement measures taken to combat the COVID-19 pandemic on family functioning. Our aim is to raise the awareness of pediatricians, social work professionals, and policy makers, as knowledge of the effects of social restrictions on family functioning may contribute to the efforts of national health systems to be effectively prepared to handle the social effects of future public health crises. Adopting a more mindful and coordinated approach may help overcome divergences across countries, particularly in terms of complex sociopolitical realities. The physical and psychosocial performance of children and adolescents challenged by adversities is significantly related to a number of family factors, including family functioning and parenting, which are typically embedded within the context of a family.10Lunkenheimer E.S. Olson S.L. Hollenstein T. Sameroff A.J. Winter C. Dyadic flexibility and positive affect in parent–child coregulation and the development of child behavior problems.Dev Psychopathol. 2011; 23: 577-591Crossref PubMed Scopus (123) Google Scholar Specific variables that characterize parent–child relations in each family also may play a role in maintaining balanced physical and psychosocial functioning in children struggling with external events affecting their families. Parent–child dyadic rigidity, together with the presence or absence and the magnitude of such variables as unstable family income, broken home, family mobility, parent mental health, number of children in the family, single-parent family, and parental past, may accelerate a deterioration of intrafamily relationships.10Lunkenheimer E.S. Olson S.L. Hollenstein T. Sameroff A.J. Winter C. Dyadic flexibility and positive affect in parent–child coregulation and the development of child behavior problems.Dev Psychopathol. 2011; 23: 577-591Crossref PubMed Scopus (123) Google Scholar In contrast, parent–child interaction processes of dyadic positive affect and flexibility may help prevent possible negative impacts on children's daily life and contribute to an effective parent–child coregulation.10Lunkenheimer E.S. Olson S.L. Hollenstein T. Sameroff A.J. Winter C. Dyadic flexibility and positive affect in parent–child coregulation and the development of child behavior problems.Dev Psychopathol. 2011; 23: 577-591Crossref PubMed Scopus (123) Google Scholar, 11Palermo T.M. Chambers C.T. Parent and family factors in pediatric chronic pain and disability: an integrative approach.Pain. 2005; 119: 1-4Abstract Full Text Full Text PDF PubMed Scopus (264) Google Scholar, 12Lewandowski A.S. Palermo T.M. Stinson J. Handley S. Chambers C.T. Systematic review of family functioning in families of children and adolescents with chronic pain.J Pain. 2010; 11: 1027-1038Abstract Full Text Full Text PDF PubMed Scopus (189) Google Scholar Family functioning is a multidimensional concept that refers to the dynamics and quality of family members’ relationships. This is based on the organization and level of conflict and cohesion internal to families and in large part on their adaptability and communication skills. In general, a family environment characterized by cohesion, clear communication ability, well-defined roles, and good emotional balance and regulation describes a positive family functioning.11Palermo T.M. Chambers C.T. Parent and family factors in pediatric chronic pain and disability: an integrative approach.Pain. 2005; 119: 1-4Abstract Full Text Full Text PDF PubMed Scopus (264) Google Scholar,12Lewandowski A.S. Palermo T.M. Stinson J. Handley S. Chambers C.T. Systematic review of family functioning in families of children and adolescents with chronic pain.J Pain. 2010; 11: 1027-1038Abstract Full Text Full Text PDF PubMed Scopus (189) Google Scholar Inadequate or defective family functioning refers to families showing disorganization characterized by unclear family roles, high levels of inner conflict situations, and poor affective and behavioral control.11Palermo T.M. Chambers C.T. Parent and family factors in pediatric chronic pain and disability: an integrative approach.Pain. 2005; 119: 1-4Abstract Full Text Full Text PDF PubMed Scopus (264) Google Scholar,12Lewandowski A.S. Palermo T.M. Stinson J. Handley S. Chambers C.T. Systematic review of family functioning in families of children and adolescents with chronic pain.J Pain. 2010; 11: 1027-1038Abstract Full Text Full Text PDF PubMed Scopus (189) Google Scholar Family structure also plays an important role in achieving balanced family functioning.13Fomby P. Cherlin A.J. Family instability and child well-being.Am Sociol Rev. 2007; 72: 181-204Crossref PubMed Scopus (465) Google Scholar Family functioning is widely used as an evaluation criteria for parents, caregivers, and families.14Beardslee W.R. Gladstone T.R.G. Wright E.J. Cooper A.B. A family-based approach to the prevention of depressive symptoms in children at risk: evidence of parental and child change.Pediatrics. 2003; 112: e119-e131Crossref PubMed Scopus (389) Google Scholar A variety of measures are available to assess functioning in families challenged by negative events and to evaluate family factors useful for identifying families most at risk for poor family functioning. It is important to properly assess family functioning for caregivers to provide informed support, tailor interventions, evaluate outcomes for individuals and the entire family,14Beardslee W.R. Gladstone T.R.G. Wright E.J. Cooper A.B. A family-based approach to the prevention of depressive symptoms in children at risk: evidence of parental and child change.Pediatrics. 2003; 112: e119-e131Crossref PubMed Scopus (389) Google Scholar,15Beardslee W.R. Hoke L. Wheelock I. Rothberg P.C. van de Velde P. Swatling S. Initial findings on preventive intervention for families with parental affective disorders.Am J Psychiatry. 1992; 149: 1335-1340Crossref PubMed Scopus (62) Google Scholar and ultimately develop programs and interventions that aim to improve family relationships and the overall family functioning. Five major theoretical models commonly used to assess family functioning are reported in Table (available at www.jpeds.com), which can be suitably selected and adopted as an assessment tool depending on the family context in which they are used. A variety of natural, economic, and public health crisis have affected families throughout the world, causing distress to family members, including mental health problems, interparental conflict, and relational instability, generating an increase in rough and abusive parenting.16Pettoello-Mantovani M. Namazova-Baranova L. Ehrich J. Integrating and rationalizing public healthcare services as a source of cost containment in times of economic crises.Ital J Pediatr. 2016; 42: 18Crossref PubMed Scopus (26) Google Scholar,17Hoey H. Mestrovic J. Vural M. Baranova L.N. Somekh E. Pettoello-Mantovani M. Children facing natural, economic and public health crisis in Europe: the risks of a predictable unpredictability.Turk Pediatri Ars. 2020; 55: 4-9PubMed Google Scholar During the COVID-19 pandemic, families have suffered severe financial and psychological hardships, which were particularly problematic in complex sociopolitical contexts18McIntosh E.D. Janda J. Ehrich J.H. Pettoello-Mantovani M. Somekh E. Vaccine hesitancy and refusal.J Pediatr. 2016; 175: 248-249.e1Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar characterized by important socioeconomic diversities, such as in Europe, making it difficult to establish coherent and consistent decision processes. In addition to the usual consequences of a public health crisis, including job instability and financial disruptions, families have experienced stress caused by social isolation, confinement within the household, rupture in the nature of school settings, concern for the future, and the need to make unprecedented health-related decisions for family members in a context of uncertainty.19Ferrara P. Corsello G. Ianniello F. Sbordone A. Ehrich J. Giardino I. et al.Internet addiction: starting the debate on health and well-being of children overexposed to digital media.J Pediatr. 2017; 191: 280-281.e1Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar Understanding the influence of the pandemic on family functioning is therefore essential to plan effective support interventions and preventive measures and allocate adequate resources to properly assist families during and after the pandemic. Recent studies in Europe and the US have provided evidence of a significant increase in overall mental distress in people tested before and during the pandemic20Pierce M. Hope H. Ford T. Hatch S. Hotopf M. John A. et al.Mental health before and during the COVID-19 pandemic: a longitudinal probability sample survey of the UK population.Lancet Psychiatry. 2020; 7: 883-892Abstract Full Text Full Text PDF PubMed Scopus (1261) Google Scholar and have shown a consistent deterioration in parent and child mental and behavioral health during the first months of the pandemic.21Feinberg M.E. Mogle J.A. Lee J.K. Tornello S.L. Hostetler M.L. Cifelli J.A. et al.Impact of the COVID-19 pandemic on parent, child, and family functioning.Fam Process. 2021; https://doi.org/10.1111/famp.12649Crossref Scopus (81) Google Scholar,22Jiao W.Y. Wang L.N. Liu J. Fang S.F. Jiao F.Y. Pettoello-Mantovani M. et al.Behavioral and emotional disorders in children during the COVID-19 epidemic.J Pediatr. 2020; 221: 264-266.e1Abstract Full Text Full Text PDF PubMed Scopus (612) Google Scholar In particular, increases in parent depression and children's internalizing and externalizing problems from before the pandemic were significant findings that normally are observed only infrequently in developmental and family studies.21Feinberg M.E. Mogle J.A. Lee J.K. Tornello S.L. Hostetler M.L. Cifelli J.A. et al.Impact of the COVID-19 pandemic on parent, child, and family functioning.Fam Process. 2021; https://doi.org/10.1111/famp.12649Crossref Scopus (81) Google Scholar,22Jiao W.Y. Wang L.N. Liu J. Fang S.F. Jiao F.Y. Pettoello-Mantovani M. et al.Behavioral and emotional disorders in children during the COVID-19 epidemic.J Pediatr. 2020; 221: 264-266.e1Abstract Full Text Full Text PDF PubMed Scopus (612) Google Scholar During the pandemic, these 2 factors increased by 2-fold and were more likely to score in the clinical range.21Feinberg M.E. Mogle J.A. Lee J.K. Tornello S.L. Hostetler M.L. Cifelli J.A. et al.Impact of the COVID-19 pandemic on parent, child, and family functioning.Fam Process. 2021; https://doi.org/10.1111/famp.12649Crossref Scopus (81) Google Scholar Preliminary reports on the social consequences of COVID-19 suggest that mental health problems and family conflicts generated by the pandemic may negatively impact family functioning, including the ability to develop resilience.7Killgore W.D.S. Taylor E.C. Cloonan S.A. Dailey N.S. Psychological resilience during the COVID-19 lockdown.Psychiatry Res. 2020; 291: 113216Crossref PubMed Scopus (243) Google Scholar,8Pettoello-Mantovani M. Pop T.L. Mestrovic J. Ferrara P. Giardino I. Carrasco-Sanz A. et al.Fostering resilience in children: the essential role of healthcare professionals and families.J Pediatr. 2019; 205: 298-299.e1Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar The ongoing COVID-19 pandemic offers an important opportunity to further investigate the implications of deterioration in parent and child psychological well-being during extraordinary public health events. They may in fact amplify intrafamily conflicts and compromise the capability of parents to implement and sustain protective health behaviors of family members, including social distancing, handwashing, mask-wearing, and preventive plans recommended by public health authorities.23Williams J. Namazova-Baranova L. Weber M. Vural M. Mestrovic J. Carrasco-Sanz A. et al.The importance of continuing breastfeeding during Coronavirus disease-2019: in support of the World Health Organization Statement on Breastfeeding during the Pandemic.J Pediatr. 2020; 223: 234-236Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Assessment of family functioning during a pandemic, as in the case of COVID-19, is important to maintain an adequate dynamic and quality of family members’ relationships. It is currently unclear whether and to what extent family instabilities due to the COVID-19 pandemic may recover during the months following the end of this public health emergency, and for how long the negative effects of this event will persist and affect parent and child well-being. However, experience from past crises suggests the strategic importance of establishing or potentiating preventive measures based on the promotion of individual and family resilience before a crisis8Pettoello-Mantovani M. Pop T.L. Mestrovic J. Ferrara P. Giardino I. Carrasco-Sanz A. et al.Fostering resilience in children: the essential role of healthcare professionals and families.J Pediatr. 2019; 205: 298-299.e1Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar,17Hoey H. Mestrovic J. Vural M. Baranova L.N. Somekh E. Pettoello-Mantovani M. Children facing natural, economic and public health crisis in Europe: the risks of a predictable unpredictability.Turk Pediatri Ars. 2020; 55: 4-9PubMed Google Scholar and to plan for providing support to families after the onset of a crisis.24Ferrara P. Guadagno C. Sbordone A. Amato M. Spina G. Perrone G. et al.Child abuse and neglect and its psycho-physical and social consequences: a review of the literature.Curr Pediatr Rev. 2016; 12: 301-310Crossref PubMed Scopus (30) Google Scholar Family support plans should include the promotion of coping skills, family relationship quality, and attitude management.25Ferrara P. Caporale O. Cutrona C. Sbordone A. Amato M. Spina G. et al.Femicide and murdered women's children: which future for these children orphans of a living parent?.Ital J Pediatr. 2015; 41: 68Crossref PubMed Scopus (30) Google Scholar Assisting families in recovering from pandemic periods and from crises in general requires a multidimensional and interdisciplinary approach including schools, pediatricians, social work professionals, mental health clinicians, counselors, family service agencies, and sport organizations.26Massachusetts Department of Mental HealthChapter 171: report and annual individual and family support plan.https://archives.lib.state.ma.us/handle/2452/839255Date accessed: June 28, 2021Google Scholar,27Bennet T. Developing individualized family support plans. Brookline Books/Lumen Editions, Northampton, MA1999Google Scholar