The global outbreak of Coronavirus Disease 2019 (COVID-19) significantly impacted the mental health of individuals across all age groups. The Co-SPACE (COVID-19: Supporting Parents, Adolescents, and Children during Epidemics) study conducted in South Africa aimed to explore the impact of the COVID-19 lockdown on the mental health of parents/carers and their children. The online survey involved 257 parents/carers of children (aged 4 to 10 years) and adolescents (aged 11 to 18 years) attending school in Grades R (pre-formal schooling) to 12. The survey assessed the stressors faced by parents/carers, evaluated children’s anxiety levels using the Pandemic Anxiety Scale (PAS), created to measure specific pandemic-related mental health factors, and gathered information on children’s concerns and time allocation. Study findings revealed that the COVID-19 lockdown had a detrimental effect on both parents/carers and their children. The top three sources of stress reported by parents/carers were their work, their child’s future, and their child’s education. Children and adolescents had average anxiety levels of 11.60 ± 6.14 and 14.62 ± 5.56 on the PAS, respectively. Factors such as the child’s age, household income, and family composition were associated with higher anxiety levels. This study highlights the experiences and stress levels faced by parents/carers during the pandemic, as well as the concerns of their children and adolescents. It underscores the importance of identifying vulnerable groups and understanding the factors contributing to their mental health difficulties. This knowledge is crucial for developing effective strategies to address the mental health challenges arising from COVID-19 and future crises. By recognizing and addressing these issues, society can better support families and promote overall well-being.
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The global outbreak of the Coronavirus Disease 2019 (COVID-19) has presented unprecedented challenges worldwide. In South Africa, since the initial COVID-19 outbreak in March 2020, effective strategies for epidemic prevention and control were implemented. These measures included lockdowns, restrictions on public gatherings, and limitations on physical commercial activities, with exceptions made for essential items such as food and medicine (Spaull & van der Berg, 2020). The lockdown restrictions were implemented in a five-level approach based on risk assessment, starting from level 5 with high COVID-19 transmissions and low healthcare readiness, and gradually decreasing to level 1 with low transmissions and high healthcare readiness (October et al., 2021). Schools re-opened during level 3 of the lockdown, which allowed in-person attendance. Education policies included guidance on online teaching and access, but this was severely limited by access to technology (both by the schools and households) in different provinces of the country, and implementation was guided by individual school districts.
The COVID-19 pandemic has brought about significant changes and challenges globally. Families had to adopt practices such as home-schooling and remote work. Amidst their work responsibilities, parents have had to provide care and support for their children at home (October et al., 2021). This period may have posed greater challenges for parenting due to increased uncertainty, stress, and economic hardships (Cluver et al., 2020). Families and children have had to adapt to numerous new challenges, including sharing limited resources and spaces, and adjusting daily routines (Cluver et al., 2020). Although research from South Africa indicates that COVID-19 did not impose significant physical risks on most children and adolescents, evidence suggests that they were more affected by the indirect negative consequences of the pandemic and its restrictive containment measures (Imran et al., 2020; Spaull & van der Berg, 2020; Tomlinson et al., 2021a). The global pandemic has had an impact on stress reactions and posed a threat to the mental health of children, with factors such as fear of infection, social isolation, and financial difficulties playing a role (Luijten et al., 2021; Raw et al., 2021; Spaull & van der Berg, 2020).
The mental health of children and adolescents has been affected by the pandemic in various ways, including disruptions to normal developmental stages, educational achievements, pre-existing mental health conditions and disabilities, socioeconomic status, and care arrangements (Nguse & Wassenaar, 2021; Tomlinson et al., 2021b). Previous studies on the effects of pandemics have shown that social isolation and quarantine can lead to symptoms of anxiety, stress, and fear in children and adolescents (Luijten et al., 2021; Magson et al., 2021; McElroy et al., 2020; Soland et al., 2020). In South Africa, existing under-resourced mental health services, coupled with economic hardships and poverty, have further compromised access to mental healthcare, resulting in poorer mental health outcomes (Nguse & Wassenaar, 2021; Tomlinson et al., 2022). Children with special education needs were particularly vulnerable, as disrupted school routines and limited access to mental health services may have negatively impacted their coping mechanisms (Lee, 2020).
While some studies have examined the effects of COVID-19 on the mental health of children and adolescents (Cluver et al., 2020), there has been limited investigation into the specific sources of increased anxiety among this population. The present study aims to identify the mental health challenges faced by children and adolescents during the first year of the COVID-19 pandemic. Additionally, we aim to explore parental responses and actions that can protect children and adolescents from deteriorating mental health, as perceived by parents/caregivers, and examine the relationship between these responses and child and family characteristics. Specifically, our objectives are to (1) identify the primary sources of stress for parents/caregivers, children, and adolescents, and (2) investigate how children spent their time during the lockdown and the concerns they encountered.
Methods
This study employed a cross-sectional research design to examine the mental health difficulties experienced by children (aged 4 to 10 years) and adolescents (aged 11 to 18 years) in South Africa during the initial year (2020) of the COVID-19 outbreak.
Participants
A total of 257 participants were included in this study. The participants consisted of parents/carers of school-age children from Grade R (equivalent to preschool/pre-kindergarten and kindergarten) to Grade 12 (aged 4–18 years) residing in South Africa. Each participant represented a distinct household. Among the participants, 193 (76.0%) lived in urban regions, while the remaining participants resided in rural areas. The data were collected through an online survey conducted between May 4, 2020, and February 18, 2021, during alert levels 4 and 3 of the South African COVID-19 lockdowns. Alert level 4 indicated a moderate to high COVID-19 spread with a low to moderate health system readiness, while alert level 3 indicated a moderate COVID-19 spread with a moderate health system readiness (Department of Health, 2020).
Recruitment
The survey was distributed across the nine provinces of South Africa through various channels, including social media platforms and organizations such as the South Africa Depression and Anxiety Support Group, South African Society of Psychiatrists, South African Association of Child and Adolescent Psychiatrists, Allied Health Professionals, Occupational Therapy Association of South Africa, and The Psychological Association of South Africa. Additionally, non-governmental organizations, charities, and TV/radio interviews with the research team were used for recruitment. Parents and carers were invited to participate in the survey on behalf of one of the children under their care.
Procedure
The online survey was administered using REDCap software. Ethics approval for this study was obtained from Stellenbosch University’s Health Research Ethics Committee (Reference number: 14968). Participants provided informed consent before accessing the survey link to complete the questionnaire electronically. In cases where participants had more than one child within the specified age range, they were asked to complete the survey separately for each child.
Measurements
The data were collected using a self-report questionnaire that took approximately 20 minutes to complete. The questionnaire was made up of four sub-sections, namely: socio-demographic questionnaire, Pandemic Anxiety Scale, COVID-related stressors, and child-specific questions.
Socio-Demographic Questionnaire
Participants provided information about their age, gender, ethnicity, and the same demographic details for their children. They also shared details about their lifestyle, family structure, place of residence, and employment status (Bloom et al., 2022). Age at baseline was categorized into two groups: 4–10-year-olds (children) and 11–18-year-olds (adolescents) in accordance with Waite and colleagues (Waite et al., 2021). Household income was classified as low (under R30,000 per month), middle (between R30,000 and R100,000 per month), or high (above R100,000 per month). Participants were also asked if their child had been diagnosed with special educational needs or a neurodevelopmental disorder and whether they experienced difficulties in various areas, and if so, if they had difficulties with their emotional, mental and social health, communication and interacting, cognitive and learning abilities, and sensory and/or physical needs (Bloom et al., 2022).
Pandemic Anxiety Scale (PAS)
The PAS is a reliable measure that captures two distinct types of anxiety related to the COVID-19 pandemic: disease anxiety and consequence anxiety. The measure was created during the COVID-19 pandemic to measure parent and child pandemic-specific mental health factors (McElroy et al., 2020). For children (aged 4–10 years), parents/carers completed the PAS questions on behalf of their children. Adolescents were able to self-complete the PAS questions of the survey. The scale consists of seven items, reduced from nine-items following psychometric evaluation factor analysis (McElroy et al., 2020), with respondents rating each item on a 5-point Likert scale ranging from 0 (strongly disagree) to 4 (strongly agree). The scale assesses concerns about the disease itself, i.e., disease anxiety (e.g., contagion, transmission) and short- and long-term outcomes associated with the public health response (e.g., current income, economic prospects) and concerns about the consequences (consequence anxiety) of the pandemic and the lockdown (e.g., I’m worried about the long-term impact this will have on my job prospects and the economy). The total score on the PAS ranges from 0 to 28 (McElroy et al., 2020). In this study, the PAS demonstrated good internal consistency, with a Cronbach’s alpha coefficient of 0.822.
COVID-related Stressors
Participants were asked to indicate their level of stress experienced in the past week regarding various potential stressors, including finances, personal plans, work, child(ren)’s education, and child(ren)’s future (Waite et al., 2021). Response options ranged from “not at all” to “a great deal”, where participants who selected ‘a little’, ‘quite a lot’, and ‘a great deal’ were noted as experiencing stress.
Child-specific Questions
Parents and caregivers provided information about how their child spent their time during the COVID-19 outbreak, such as the average time spent on schoolwork, communicating with friends through social media, and outdoor activities (Waite et al., 2021). They were also asked to assess their child’s feelings regarding COVID-19, including perceptions of seriousness and worries about contracting the virus or their loved ones being affected. Response options for these questions ranged from “strongly disagree” to “strongly agree”.
Parent/carer Need for Support
Participants were asked to indicate their need (yes/no) for support in managing their child or adolescent’s emotions, behaviours, educational demands, adherence to government guidelines, and transitioning out of self-isolation, as well as their family relationships.
Data Analysis
Descriptive statistics were used to summarize the socio-demographic characteristics of the sample. The data were analysed using SPSS version 27. Independent sample t-tests were conducted to compare mean scores on the PAS and its subscales (disease anxiety and consequence anxiety) based on age (child/adolescent), family composition (single parent or not), and the presence or absence of special educational needs or a neurodevelopmental disorder, predictors of pandemic-associated mental health factors previously identified (Bloom et al., 2022; Waite et al., 2021), as well as the area of residence (rural/urban) and parent/caregivers gender (female/male) and employment status (employed/unemployed). One-way Analysis of Variance (ANOVA) was performed to compare PAS total scores and subscale scores across three levels of household income (low, middle, and high), parent/caregiver level of education (did not finish formal schooling, matriculated, undergraduate degree, postgraduate degree), and parent/caregiver ethnicity (Black/African, Coloured/Mixed race, Indian, White). Independent sample t-tests were also employed to compare mean scores between alert level 3 and alert level 4 of the COVID-19 lockdown. Furthermore, a one-way Analysis of Covariance (ANCOVA) was conducted to assess the influence of child’s age, family composition, household income, area of residence, as well as the parents/carer’s ethnicity, highest level of education, and employment status on anxiety levels (PAS) while adjusting for lockdown alert level. Multiple linear regression models for PAS and its subscales were performed, where variables associated during univariate analyses were included in each model to determine which variables significantly predicted PAS scores. Overall, missing data were few and data imputation was not undertaken. For each set of analyses, only participants with complete observations were included. Level of significance was set at p < 0.05.
Results
Sample Characteristics
A total of 257 parents/carers completed the online survey. Most respondents 220 (85.6%) were from two-parent households, while 23 (8.95%) were from single-parent households (Table 1). Among the participants, 228 (88.7%) were females, and 219 (89.0%) were between 31 and 64 years of age. In terms of the children and adolescents, 128 (49.8%) were aged 4–10 years, and 129 (50.2%) were aged 11–18 years. Regarding household income, 81 (31.5%) parents/caregivers reported low income, 99 (38.5%) reported middle income, and 39 (15.2%) reported high income. A total of 26 (10.1%) parents/carers indicated that their family had a child with special educational needs or a neurodevelopmental disorder such as autism or attention deficit hyperactivity disorder.
Table 1
Demographics of participants (parents/carers) and their children
Characteristics
Children (4–10 yrs)n = 128 (49.8%)
Adolescents (11–18 yrs)n = 129 (50.2%)
Full samplen = 257
n
%
n
%
n
%
Province
Eastern Cape
10
8.4
18
14.2
28
11.4
Free State
1
0.8
2
1.6
3
1.2
Gauteng
37
31.1
26
20.5
63
25.6
Kwa-Zulu Natal
9
7.6
8
6.3
17
6.9
Limpopo
3
2.5
7
5.5
10
4.1
Mpumalanga
6
5.0
14
11.0
20
8.1
Northwest
2
1.7
7
5.5
9
3.7
Western Cape
51
42.9
44
34.6
75
38.6
Parent age
Early adulthood (18 – 30 years)
2
1.7
0
0
2
0.8
Mature adulthood (31 – 64 years)
107
89.9
112
88.2
219
89.0
Old age (65 years and above)
1
0.8
0
0
1
0.4
Parent gender
Female
114
89.1
114
88.4
228
88.7
Male
13
10.2
14
10.9
27
10.5
Other/Unknown
1
0.8
1
0.8
2
0.8
Parent ethnicity
Black/African
26
20.3
43
33.3
69
26.8
Indian
21
16.4
11
8.5
32
12.5
Mixed ancestry/Coloured
8
6.3
7
5.4
15
5.8
Mixed race – other
1
0.8
1
0.8
2
0.8
White
63
49.2
61
47.3
124
48.2
Prefer not to say
9
7.0
6
4.7
15
5.8
Parent/carer education
No qualifications
1
0.8
3
2.3
4
1.6
Completed primary school (13 yrs)
0
0
4
3.1
4
1.6
Completed secondary school (16 yrs)
1
0.8
10
7.8
11
4.3
Completed high school (18 yrs)
21
16.4
27
20.9
48
18.7
Undergraduate degree/professional qualification
42
32.8
32
24.8
74
28.8
Postgraduate degree
60
46.9
53
41.1
113
44.0
Child mean age (SD)
7.77
(1.67)
13.91
(2.32)
10.96
(3.68)
Child gender
Female
53
41.4
62
48.1
115
44.7
Male
72
56.3
67
51.9
139
54.1
Child has special educational needs or a neurodevelopmental disorder
8
6.3
18
14.0
26
10.1
Household income
High income
24
18.8
15
11.6
39
15.2
Middle income
47
36.7
52
40.3
99
38.5
Low income
36
28.1
45
34.9
81
31.5
Prefer not to say
21
16.4
17
13.2
38
14.8
Family composition
Single adult household
6
4.7
17
13.2
23
9.0
Multiple adult households
116
90.6
104
80.6
220
85.6
Prefer not to say
6
4.7
8
6.2
14
5.4
SD standard deviation
Parent/carer Stress
Main Causes of Stress
Parents/carers reported experiencing higher levels of stress during the COVID-19 pandemic. The most prevalent sources of stress reported were work (162, 56.8%), their child’s future (136, 53.8%), their child’s education (131, 51.6%), finances (135, 51.4%), and their own future (119, 47.1%) (Fig. 1).
Fig. 1
The main stressors among parents in the total sample
×
Working Status
Among the participants, 75 (29.2%) were not working, 51 (19.8%) were working part-time from home, and 63 (24.5%) were working full-time from home. Additionally, 18 (7.0%) worked part-time outside the home, and 50 (19.5%) worked full-time outside the home. When analysing sources of stress by work status, a greater proportion of parents who worked part-time compared to full-time endorsed COVID-related stressors. For example, more than 70% of parents/carers who worked part-time outside the home reported work, finances, and their children’s education as notable stressors (Fig. 2). Parents/carers who worked full-time outside the home expressed concerns about work, their child’s future, and their children’s education. Those who worked from home had higher stress levels related to work, their child’s future, and finances.
Fig. 2
The main stressors reported by parents/carers, grouped by employment status (full-time, part-time, unemployed) and work location (home or outside)
×
Parent/carer Stress in Relation to Children with Special Educational Needs or a Neurodevelopmental Disorder
Parents/carers of children with special educational needs or a neurodevelopmental disorder experienced different sources of stress compared to parents of children without. All stressors, except work (even if you feel your job is safe), finances, and future plans were endorsed by a greater proportion of parents of children with special educational needs or a neurodevelopmental disorder than parents without children with special educational needs or a neurodevelopmental disorder. Parents of children with special educational needs or a neurodevelopmental disorder reported their child’s future, education, screen-time and household chores, behavior, and loss of support as the main stressors during COVID (Fig. 3). On the other hand, a smaller proportion of parents of non-special educational needs or a neurodevelopmental disorder children endorsed difficulty with their children’s behavior.
Fig. 3
The proportion of parents with children having Special Educational Needs and Neurodevelopmental Disorders who reported feeling more stressed compared to parents without such children
×
Children and Adolescents
Child Worries Related to COVID-19
A majority of parents (229, 89%) reported that their children considered COVID-19 to be a very serious issue. Children and adolescents expressed concerns about their family or friends catching the virus ((70, 27.3%) and (83, 32.4%) respectively), catching the virus themselves ((63, 24.6%) and (73, 28.5%) respectively), and missing school ((44, 17.3%) and (71, 28.0%) respectively) (Table 2). The seven-item measure (PAS) capturing concerns about COVID-19, parents overall indicated that adolescents expressed more concerns than children (Table 2).
Table 2
Pandemic Anxiety Scale (PAS) variable responses by child’s age
PAS variable
Children (4–10 years)
Adolescents (11–18 years)
n
%
n
%
My child is worried that they will catch Covid-19
63
24.6
73
28.5
My child is worried that friends and family will catch Covid-19
70
27.3
83
32.4
My child is afraid to leave the house right now
35
13.7
41
16.0
My child is worried they might transmit the infection to someone else
27
10.7
37
14.7
My child is worried about missing school
44
17.3
71
28.0
My child is worried about the amount of money we have coming in
13
5.1
38
15.0
My child worried about the long-term impact this will have on their job prospects and economy
12
4.7
58
22.8
How Children and Adolescents Spent their Time
Approximately 31 (13%) children and adolescents failed to complete daily schoolwork. On average, adolescents spent more than two hours on schoolwork per day, while children spent around two hours. Communication with friends and family primarily occurred through WhatsApp and text messages (119, 48.1%), followed by telephone conversations (78, 35.3%) and daily video chats (74, 30%). The majority (249, 97.6%) of children and adolescents had access to outdoor space.
Balancing Work and Child’s Needs
Around 100 (54.4%) parents/carers reported struggling to meet both their work responsibilities and their child’s needs, compared to 79 (43%) who said they were meeting both their work and their child’s needs ‘a lot’ or ‘completely’.
Association of Pandemic Stress with Socio-Demographic Factors
Child’s Age
Adolescents exhibited higher levels of pandemic fear (Mean Difference (MD) = 3.02, p < 0.001) compared to children, according to reports from parents/carers (Table 3). In terms of fears of contracting and transmitting the virus, there was no difference between children and adolescents (MD = 0.7, p = 0.15). Furthermore, adolescents were more afraid of the pandemic’s consequences than children (MD = 2.28, p < 0.001). After accounting for lockdown levels, there was no significant association between child age and (i) PAS (F (1, 218) = 0.022, p = 0.883), and (ii) consequence anxiety (F (1, 216) = 0.303, p = 0.583).
Table 3
Association of socio-demographic factors with PAS score
Special educational needs or a neurodevelopmental disorder
Yes (n = 26)
11.20
6.47
0.094
t (247) = 1.68
0.034
7.00
4.01
0.083
t (254) = 1.74
0.35
4.16
3.01
0.260
t (252) = 1.13
0.25
No (n = 225)
13.33
5.96
8.38
3.81
4.93
3.24
Lockdown level
Level 3 (n = 72)
16.48
5.64
0.87
t (253) = 6.64
0.910
9.82
3.42
0.090
t (253) = 4.63
0.62
6.67
2.90
0.36
t (253) = 6.66
0.90
Level 4 (n = 171)
11.45
5.51
7.51
3.83
3.99
3.02
M mean, SD standard deviation
Bold denotes significance at p < 0.05
Household Income
Household income was significantly associated both with the PAS score and children’s perceptions of contracting and transmitting the virus, as well as their concerns about the consequences of the pandemic as reported by their parents/carers. There was more fear of the pandemic reported among children in low-income households compared to those in middle-income households (MD = 5.74, p < 0.001), and high-income households (MD = 7.00, p < 0.001) (Table 3). Children in low-income households reported more fears of contracting or transmitting the virus compared to those in middle-income (MD = 3.12, p < 0.001) and high-income households (MD = 2.99, p < 0.001). Children in low- (MD = 2.61, p < 0.001) and middle-income households (MD = 1.15, p < 0.019) were reported to be more concerned about the consequences of the pandemic compared to those in high-income households. There were no significant differences between middle- and high-income households in terms of total PAS scores (MD = 1.26, p = 0.673), or fear of contracting or transmitting the virus (MD = 1.14, p = 1.00). The associations between household income and (i) PAS (F (3, 218) = 5.12, p = 0.002), (ii) worries about catching or transmitting the disease (F (3, 218) = 2.42, p = 0.67), and (iii) consequence anxiety (F (3, 216) = 6.85 and p < 0.001), were significant even after adjustment for lockdown level.
Family Composition
Parents/carers from single-parent households reported that their children were more fearful of the pandemic than those in two-parent households (MD = 3.62, p = 0.006), as well as more fearful of the consequences of the pandemic than those in households not headed by one parent (MD = 2.62, p < 0.001) (Table 3). There were no differences between single-parent households and households where more than one parent/carer was present with regard to fears of contracting and transmitting the virus (MD = 1.14, p = 0.17). The associations between family composition and (i) PAS (F (1, 218) = 1.01, p = 0.32) and (iii) consequence anxiety (F (1, 216) = 1.42 and p = 0.24), were not significant after adjustment for lockdown level.
Area of Residence
Parents/carers living in rural areas reported that their children were more fearful of the pandemic (MD = 3.44, p < 0.001), as well as more fearful of contracting and transmitting the virus (MD = 2.64, p < 0.001) than those living in urban areas. There were no differences between rural and urban living and the consequences of the pandemic (MD = 0.8, p = 0.068). The associations between the area of residence and (i) PAS (F (1, 242) = 15.34, p < 0.001) and (ii) worries about catching or transmitting the disease (F (1, 242) = 11.68, p < 0.001) remained significant after adjustment for lockdown level.
Parents Ethnicity
Parents/carers ethnicity significantly influenced both the PAS score and the children’s perceptions of contracting and transmitting the virus, but not their concerns about the consequences of the pandemic as reported by their parents/carers (Table 3). There was more fear of the pandemic reported among children with parents/carers of Black/African ethnicity compared to those of White ethnicity (MD = 2.73, p = 0.001). Children with parents/carers of Black/African ethnicity also reported more fears of contracting or transmitting the virus compared to those of White ethnicity (MD = 2.75, p < 0.001). The associations between parents/carers ethnicity and (i) PAS (F (3, 229) = 2.92, p = 0.035) and (ii) worries about catching or transmitting the disease (F (3, 229) = 4.88, p = 0.003) were significant even after adjustment for lockdown level.
Parents Education Level
Parents/carers highest level of education influenced their children’s concerns about the consequences of the pandemic but not their PAS score or their children’s perceptions of contracting and transmitting the virus (Table 3). There was more fear of the consequences of the pandemic reported among children with parents/carers who had an undergraduate degree/professional qualification compared to those with a postgraduate degree (MD = 1.18, p = 0.034). The association between parents/carers education level and (i) concerns about the consequences of the pandemic (F (3, 240) = 3.33, p = 0.020) remained significant after adjustment for lockdown level.
Parents Employment Status
Parents/carers who were employed reported that their children had more fear about the consequences of the pandemic (MD = 1.04, p = 0.026) compared to parents/carers who were unemployed (Table 3). Parents/carers employment status did not influence the PAS score (MD = 0.09, p = 0.917) or their children’s perceptions of contracting and transmitting the virus (MD = 0.97, p = 0.110). The associations between the parents/carers employment status and (i) concerns about the consequences of the pandemic (F (1, 242) = 5.41, p = 0.021) remained significant after adjustment for lockdown level.
Lockdown Levels
There were no differences between alert level 3 and alert level 4 of lockdown with regards to fears of the pandemic (MD = 5.03, p = 0.87), contracting and transmitting the virus (MD = 2.31, p = 0.090), and consequences of the pandemic (MD = 2.68, p = 0.359) (Table 3).
Linear Regression Models for Associated PAS Variables
The total PAS score regression model was statistically significant (R2 = 0.104, F (5, 195) = 5.626, p < 0.001), and included the variables family composition, household income, child’s age, area of residence, and parents/carers ethnicity (Table 4). Of the variables included, only the area of residence remained statistically significant (B1 = 2.632, p = 0.010). The PAS disease anxiety subscale regression model was statistically significant (R2 = 0.137, F (3, 200) = 11.715, p < 0.001) and included the variables household income, area of residence, and parents/carers ethnicity. Of the variables included, area of residence (B1 = 1.936, p = 0.009) and parents/carers ethnicity remained statistically significant (B1 = −0.684, p = 0.005). The PAS consequence anxiety subscale regression model was statistically significant (R2 = 0.070, F (7, 193) = 5.626, p = 0.003) and included the variables family composition, household income, child’s age, area of residence, parents/carers ethnicity, parents/carers level of education, and parents/carers employment status. Of the variables included, only parents/carers employment status remained statistically significant (B1 = −1.192, p = 0.022).
Table 4
Multiple linear regression models for associated PAS variables
Model
Unstandardized Coefficients
Standardized Coefficients
t
p
95% CI
B
SE
Beta
LL
UL
Total PASa
(Constant)
25.310
3.412
7.417
<0.001
18.581
32.040
Family composition
−1.429
1.051
−0.095
−1.360
0.175
−3.501
0.643
Household income
−0.185
0.520
−0.028
−0.356
0.722
−1.210
0.840
Child’s age
−0.179
0.672
−0.018
−0.266
0.791
−1.504
1.146
Area of residence
2.632
1.006
0.231
2.617
0.010
0.649
4.616
Parents ethnicity
−0.399
0.328
−0.107
−1.216
0.225
−1.047
0.248
PAS – disease anxiety scoreb
(Constant)
12.887
1.602
8.045
<0.001
9.728
16.046
Household income
0.286
0.386
0.056
0.741
0.460
−0.475
1.046
Area of residence
1.936
0.734
0.221
2.637
0.009
0.488
3.384
Parents ethnicity
−0.684
0.243
−0.238
−2.811
0.005
−1.164
−0.204
PAS – consequence anxiety scorec
(Constant)
13.175
2.186
6.028
<0.001
8.864
17.486
Household income
−0.254
0.322
−0.065
−0.788
0.432
−0.888
0.381
Area of residence
0.714
0.598
0.107
1.192
0.235
−0.467
1.894
Parents ethnicity
0.283
0.200
0.129
1.415
0.159
−0.111
0.677
Child’s age
0.546
0.402
0.096
1.359
0.176
−0.247
1.339
Family composition
−1.125
0.632
−0.129
−1.778
0.077
−2.372
0.123
Parent level of education
−0.456
0.243
−0.150
−1.876
0.062
−0.935
0.023
Parents employment status
−1.192
0.517
−0.164
−2.306
0.022
−2.211
−0.172
SE standard error, CI confidence interval, LL lower limit, UL upper limit
Bold denotes significance at p < 0.05
aR = 0.355, R2 = 0.126, Adjusted R2 = 0.104. F (5, 195) = 5.626, p < 0.001; bR = 0.387, R2 = 0.149, Adjusted R2 = 0.137. F (3, 200) = 11.715, p < 0.001; cR = 0.321, R2 = 0.103, Adjusted R2 = 0.070. F (7, 193) = 5.626, p = 0.003
Parent/carer Need for Support
Among those who felt they would benefit from support, the majority expressed a need for support in managing their child(ren)’s emotions, followed by support in managing their academic needs, behaviour, adherence to government rules, and transitioning out of self-isolation (Fig. 4). Parents who were more fearful of the pandemic were more likely to request support for managing their child’s emotions (MD = 2.37, p < 0.001), child’s behaviours (MD = 2.41, p < 0.001), ensuring that their child followed government guidelines (MD = 3.84, p < 0.001), exiting self-isolation (MD = 2.66, p = 0.003), and managing family relationships (MD = 3.67, p < 0.001) (Table 5). Similar results were seen for parents who were more fearful of contracting and transmitting the virus (significant across all support needs). In contrast, parents who were more fearful of the consequences of the pandemic only requested more support for managing their child’s emotions (MD = 2.82, p = 0.004) (Table 5).
Fig. 4
The proportion of parents/carers seeking help in various areas to support their child(ren) during challenging times
Table 5
Association of parent/caregiver need for support with PAS score
Variables
Total PAS
Disease Anxiety
Consequence Anxiety
M
SD
p
t(247)
Cohen’s d
M
SD
p
t
Cohen’s d
M
SD
p
t(247)
Cohen’s d
Managing children or young people’s emotions
No (n = 164)
23.08
4.78
<0.001
−3.73
−0.50
7.89
4.03
0.009
t (247) = −2.617
−0.35
3.17
2.88
0.004
−2.881
−0.39
Yes (n = 85)
25.45
4.70
8.59
3.63
5.99
3.16
Managing children or young people’s behaviours
No (n = 188)
23.30
4.79
<0.001
−3.42
−0.50
13.28
3.75
0.002
t (247) = −3.17
−0.47
10.02
2.86
0.092
−1.70
−0.25
Yes (n = 61)
25.71
4.72
14.97
3.18
10.74
2.93
Managing children or young people’s educational demands
No (n = 175)
23.50
4.91
0.055
−1.92
−0.27
13.29
3.86
0.003
t (173.35) = −2.98
−0.38
10.22
2.83
0.864
0.171
0.02
Yes (n = 74)
24.80
4.70
14.65
3.03
10.15
3.03
Ensuring my child follows government guidelines (e.g. handwashing, staying home)
No (n = 208)
23.26
4.73
<0.001
−4.81
−0.82
13.15
3.66
<0.001
t (83.40) = −7.36
−0.95
10.11
2.84
0.263
−1.12
−0.19
Yes (n = 41)
27.10
4.36
16.44
2.36
10.66
3.11
Managing family relationships
No (n = 208)
23.28
4.63
<0.001
−4.57
−0.78
13.17
3.60
<0.001
t (247) = −5.26
−0.90
10.11
2.84
0.289
−1.06
−0.18
Yes (n = 41)
26.95
4.99
16.32
2.94
10.63
3.12
Children or young people coming out of self-isolation
No (n = 210)
23.47
4.74
0.002
−3.18
−0.55
13.31
3.60
<0.001
t (247) = −3.90
−0.68
10.16
2.86
0.659
−0.44
−0.08
Yes (n = 39)
26.1
5.04
15.74
3.51
10.39
3.04
M mean, SD standard deviation
Bold denotes significance at p < 0.05
×
Discussion
The present study was conducted with the aim of identifying the mental health challenges faced by children and adolescents during the first year of the COVID-19 pandemic. Additionally, the study sought to examine the parental responses and actions that can help protect children and adolescents from experiencing a decline in their mental health. This was achieved by 1) identifying the main sources of stress for parents/carers and 2) identifying how children spent their time during the lockdown and the anxiety and worries they encountered.
Parental stress during the pandemic was influenced by various factors, with work being the most prevalent source of stress. It is not surprising that parents were particularly stressed about work during the pandemic, given the economic uncertainty and job losses that many families experienced (Spaull & van der Berg, 2020). This finding is consistent with previous research highlighting the challenges faced by parents in balancing work responsibilities with childcare and home-schooling obligations (Adams et al., 2021; Masten & Motti-Stefanidi, 2020; McElroy et al., 2020). The results also indicate that parents who worked part-time outside the home experienced more sources of stress and thus higher stress levels compared to those working from home. This may be attributed to the added burden of health and safety concerns associated with working outside the home during the pandemic, as well as the challenges of managing work and childcare simultaneously (van Tilburg et al., 2020; Zandifar & Badrfam, 2020).
Parents of children with special educational needs or neurodevelopmental disorders reported more sources of stress, including household chores, loss of support systems, friends or family living outside their home as well as their child’s behaviour, screen time, education, and future. This finding aligns with previous studies highlighting the increased caregiving demands and stress experienced by parents of children with special needs during the pandemic (Tomlinson et al., 2021a).
Children and adolescents exhibited significant worries related to COVID-19, with concerns about family or friends catching the virus, their own susceptibility, and the impact on their education being prominent. Adolescents tend to experience more fear due to the increasing pressures and responsibilities that come with age, such as academic expectations, social pressures, and future planning. These findings are consistent with studies highlighting the psychological impact of the pandemic on children, including anxiety, fear, and disruptions to daily routines and social connections (Tomlinson et al., 2022). The study also revealed that a significant portion of children struggled to complete daily schoolwork, emphasizing the challenges of remote learning and the need for additional support and resources to ensure educational continuity during such crises.
In regression analyses, the socio-demographic factors analysed in this study revealed significant associations with pandemic stress. Lower household income, living in a rural area and parent/carer ethnicity were found to be associated with higher levels of fear related to the pandemic, concerns about contracting or transmitting the virus, and worries about the consequences of the pandemic for children. Findings from our study confirm those from research in Kenya and Uganda that suggest that COVID-19’s impact on adolescents’ mental health is greater if they come from low-income households since low-income households are more vulnerable to income shocks and financial instability and insecurity can cause anxiety for both parents and their children (Kansiime et al., 2021; Solantaus et al., 2004). Children from low-income households may face additional challenges, including limited access to resources for remote learning, increased financial strain on the family, and potential exposure to higher levels of stress within the household (Cusinato et al., 2020).
Living in a rural area was also found to be associated with increased COVID-19 stress levels and concerns about contracting or transmitting the virus. This finding is supported by studies from China, where adolescents who lived in rural areas reported higher levels of psychological health problems during the pandemic compared to their counterparts who resided in urban areas (Zhou et al., 2020) and where living in an urban area was shown to reduce the risk of developing anxiety in Chinese university students during the pandemic (Cao et al., 2020). People living in rural areas in South Africa have reduced access to healthcare services (Morris-Paxton et al., 2020) and could be considered marginalised, previously shown to increase youth risk for negative pandemic-associated outcomes (van Lancker & Parolin, 2020).
Parents/carers ethnicity was also found to influence children’s stress levels, where children with parents/carers of Black/African ethnicity reported increased concerns about contracting or transmitting the virus compared to children with parents/carers of White ethnicity. This is in line with most research which has shown that marginalised and minority race groups have not only been disproportionately impacted by the pandemic but they also experience more stress (Brown et al., 2010; Grace & García, 2024; Kamp Dush et al., 2022; Perry et al., 2021).
The study also highlighted the role that family composition plays on children’s stress levels, with children from single-parent households reporting higher levels of fear and concern about the consequences of the pandemic. Single-parent households may face unique challenges in managing multiple responsibilities, limited support systems, and potential financial strain (Cusinato et al., 2020; Masten & Motti-Stefanidi, 2020).
It is worth noting that the study did not find significant differences in stress levels between children and adolescents with and without special educational needs or neurodevelopmental disorders. This may suggest that the pandemic’s impact on stress and mental health is not solely influenced by the presence of special educational needs or a neurodevelopmental disorder but rather by a combination of various factors such as individual coping mechanisms, access to support systems, and overall family functioning (Greenway & Eaton-Thomas, 2020).
The study findings also emphasize the importance of providing support to parents and carers. A considerable proportion of parents expressed a need for support in managing their child(ren)’s emotions, academic needs, behaviour, adherence to government rules, and transitioning out of self-isolation. Support systems that address these specific needs can play a vital role in alleviating parental stress, promoting positive parenting practices, and supporting children’s well-being during challenging times.
There were several limitations for this study, including the recognition that using an online survey creates a selection bias. Many South Africans may not have had internet access to participate, and the sample represents those in the population with access to online media and data. Another limitation is that parents/carers responded on behalf of their children (under 11 years old) and, as such, this survey does not reflect the direct ‘voices’ of the children reported on. While we have categorized children broadly based on their ages (children: 4–10 years and adolescents: 11–18 years), another limitation of this study is that COVID-19 may have impacted young children differently based on their age and developmental stage (children aged 4–5 years vs. those aged 9–10 years) which was not explored here. Furthermore, while PAS showed good internal validity in this study, at the time of its use it still lacked long-term reliability data. It was however the only available measure for pandemic-specific mental health factors. Another limitation is that there are no psychometric data available for the ‘COVID-related stressor-’ or the ‘Child-specific’ questions used in this study. However, these questions as used by Waite et al., (2021) were adapted to the South African setting. We could also not account for the influence of different schools on children’s PAS scores given that the breadth and diversity of schools included was guided by access granted by individual school districts during the lockdown. Our sample may also not be representative of the geographic, ethnic, and economic diversity of the South African population. However, we believe that an online survey was the best mode of delivery at the time considering the state of the national lockdown and the risks inherent in face-to-face/physical contact interviews. Increased access to the internet and lowering of data costs in South Africa will allow for greater representation of low-income communities thereby ensuring that children and adolescents from a spectrum of socioeconomic backgrounds can participate in online surveys and access mental health resources online.
Conclusion
In conclusion, the COVID-19 pandemic and subsequent lockdowns appeared to have played a role in the stress levels of both parents/carers and children. Parents/carers were particularly concerned about their work and their children’s education, while adolescents were particularly worried about the consequences of the pandemic. The study also found that children and adolescents were resilient and used physical activities and virtual social connections to cope with the situation. In general, the findings emphasize the importance of providing support and resources during times of crisis for families to help ease stress and promote resilience.
Author contributions
E.G., J.B., A.L., E.L.D., L.T., J.P., and S.S. contributed to the study conception and design. material preparation, data collection and data analysis were performed by E.G., J.B., M.S., and S.S. The first draft of the manuscript was written by E.G. and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Compliance with ethical standards
Conflict of interest
• The authors have no relevant financial or non-financial interests to disclose. • The authors have no competing interests to declare that are relevant to the content of this article. • All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript. • The authors have no financial or proprietary interests in any material discussed in this article.
Ethics approval
Ethics approval for this study was obtained from the Stellenbosch University Health Research Ethics Committee (Reference number: 14968).
Consent to participate
Informed consent was obtained from all individual participants included in the study.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
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