Discussion
COVID-19-related stress, AD
REGRESSION
The present study investigated COVID-19-related stress in a sample of children with and without AD and their families. Only small differences emerged between families of children with and without AD or between children in out-of-home care and in adoptive/biological families: children with AD and children in out-of-home care were affected slightly more, but in few domains. Most families receiving therapy did not describe treatment-related changes. Perceived negative change in external conditions—particularly family conditions and leisure options—emerged as the most important risk factors for COVID-19-related stress across all models. When comparing families with and without AD and children in out-of-home care and in adoptive/biological families, no or only small differences emerged. Although some previous studies reported comparable findings (e.g. [The latter assumption is supported by the fact that families scarcely reported any negative treatment-related effects, which was surprising given that psychotherapeutic care has been disrupted or limited for most families during the pandemic [As initially hypothesized, we found an association between COVID-19-related stress and measures of AD in the correlation analyses. However, in the regression models, these variables were excluded in favor of other predictors. The strongest risk factors across all models were COVID-19-related perceived changes in external conditions. Negative changes in family conditions and leisure options proved to be particularly stable predictors across all models. Prior to the outbreak of COVID-19, family routines were mostly set by work and school schedules, and potentially also by leisure activities. However, since all these areas were affected by restrictions, families may have struggled to restructure daily routines. As the present sample consisted of families living in and around larger cities, alternative leisure options might have been especially limited due to the urban living conditions (e.g.; noise regulations for families living in apartments, less space, no garden for physical activities). Moreover, the increased amount of time spent together might have increased the potential for family conflicts. On the other hand, some families may have perceived benefits from the fact that they did not have to adhere to structures set by others and were able to spend more quality time together. These families might have therefore perceived the circumstances as a positive change in family conditions, consequently leading to decreased stress levels.Although we found small effects for the examined predictors in general, moderate effects emerged for the effect of family and childcare conditions on caregiver-rated stress in the AD group only, which may have led to the particularly large effect of the total model. Negative changes in both of these domains might place high demands on caregivers’ organizational skills and adaptability. As these demands may already be high in caregivers handling AD in daily life, the new external demands due to the pandemic may have exceeded the available resources more strongly in the caregivers in the AD group. Accordingly, external conditions should be considered when designing actions to support families to reduce stress, particularly regarding family conditions and leisure options, and additionally regarding childcare conditions for families with AD.Caregiver characteristics (mother’s country of birth, psychopathology of caregiver, and family adversity) emerged as additional meaningful risk factors for both caregiver-reported stress (No AD and AD group) and child-reported stress (No AD group). These results correspond to studies demonstrating a buffering or aggravating effect of caregiver characteristics on COVID-19-related stress in children [Some limitations of the present study should be mentioned. First, the interval for measuring COVID-19-related stress was rather long compared to other studies. While this enabled us to capture the prolonged stress reactions across different phases of COVID-19-related measures, it did not allow us to relate effects to specific pandemic-related measures (cf. [Nevertheless, several strengths of the study are also worthy of mention. First, we recruited a diverse sample of children with and without AD and a combination of screened community, clinical, and out-of-home care samples. Second, we included caregiver- and child-reported measures to assess COVID-19-related factors. Third, to assess caregiver and child characteristics as potential risk and protective factors, we used previously captured data, suggesting a causal link within the regression analysis. Finally, we included a variety of established reliable and valid child-rated, caregiver-rated, and clinician-rated instruments.Taken together, our findings indicate that the changes rated by children and caregivers were overall comparable between families of children with and without AD and between children in out-of-home care and in adoptive or biological families. The strongest and most stable predictors of increased stress overall were perceived negative changes in external conditions—particularly family conditions and leisure options. Actions to support families during the pandemic should, therefore, focus on these factors to reduce COVID-19-related stress.