Caregiving Responsibilities and Mental Health Outcomes in Young Adult Carers during the COVID-19 Pandemic: A Longitudinal Study

Round 1

Reviewer 1 Report

- Please add drawings showing the methodology used and the results of the study. Present the data from Table 2 and Table 3 in the figures.

- Conclusions should be formulate in more clearly way.

Author Response

- Please add drawings showing the methodology used and the results of the study. Present the data from Table 2 and Table 3 in the figures.

RESPONSE: Figure 1 already depicts the methodology with respect to participants’ enrollment in the study. It is not possible to present data from Table 2 and Table 3 in figures as the correlation coefficients and the standardized beta coefficients in the regressions need to be displayed in a table. The combination of Figure 1 and Tables 2 and 3 provide the clearest and most readable display of the relevant data.

- Conclusions should be formulate in more clearly way.

RESPONSE: We have edited the conclusion section to make the conclusions clearer, including numbering the three major findings along with their key implications.

Author Response File: Author Response.docx

Reviewer 2 Report

The current study sought to investigate relationships between COVID-19/lockdown factors, caregiving responsibilities, and mental health outcomes among young adult carers during the COVID-19 pandemic. Strengths of the paper include quality of writing, importance of subject matter, and novelty of findings. Please see below suggestions to further improve the manuscript.

Abstract/Title:

1)    Because the authors did not experimentally manipulate caregiving responsibilities, the authors cannot claim causality in saying “their effects on the mental health of…” Please change this language throughout the manuscript to focus on associations rather than effects. For instance, the authors might change this sentence to “This study investigated caregiving responsibilities and associated mental health outcomes…” I think “effects” should be changed to “outcomes” in the title as well, perhaps changed to “A Longitudinal Investigation of COVID-19 Lockdown Factors, Caregiving Responsibilities, and Mental Health Outcomes in Young Adult Carers during the COVID-19 Pandemic.”

2)    Please include results about the specific mental health outcomes when reporting that “caregiving responsibilities were longitudinally related to poorer mental health outcomes.” For instance, “caregiving responsibilities were longitudinally related to poorer mental health outcomes, including higher fear of COVID-19, anxiety, and depression, and lower wellbeing.”

3)    Please change “whole of family” to “whole family” in both places where it appears this way.

4)    I think the sample sizes are somewhat misleading in the abstract for Aim 3 because for this question, authors are only looking at a much smaller subsample with available data at Time 3. Please specify the sample sizes for each set of analyses in the abstract.

Introduction:

1)    Please change this sentence to not imply causality due to its cross-sectional nature: “We conducted a cross-sectional study during the second lockdown in Italy  which revealed that compared to non-carers, the mental health of young adult carers was more adversely impacted.”

2)    Please change this sentence to be easier to comprehend: “We have previously argued that given parents typically assume the primary caregiving role in relation to their children, a reversal of this role is likely to create more caregiving demands than caring for a non-parent family member.”

Methods:

1)    For the analytical plan for Aim 2, how were Time 1 and 2 Covid-19 variables combined to be used as one variable in the analyses?

2)    For the analytical plan, please discuss whether these data met assumptions for multivariate linear regression, including correlations among independent variables and among dependent variables (mental health outcomes). I am concerned specifically that the mental health outcomes are so highly correlated that the model is compromised. It may be more beneficial to conduct four separate linear regression models with each of the four outcomes.

Results:

1)    Please reduce the discussion of Table 1 in the text to reduce redundancy. Please only highlight anything particularly notable in the text of the result section.

2)    Please remind the reader of the sample size (with a breakdown of sample size of each group included as well) in each set of analyses addressing each Aim.

3)    Please include a section on power to detect effects in each aim.

4)    For the first study aim, please conduct a comparison between PI and OIFM to determine if these two groups are significantly different in caring responsibilities. 

Discussion:

1)    When speaking about the results related to aim 1, the manuscript focuses on how young adults have more care responsibilities than children. However, because this study did not compare young adults to children, the results cannot speak directly to this comparison. I think that a discussion of the potential differences between young adults caring for a parent vs. non-parent family member would be more relevant here.

2)    This sentence is long and confusing. Please revise: “Spending more time at home working or undertaking distance learning where the living space is perceived as insufficient, is also likely to result in less opportunities for the young adult to escape caregiving tasks and hence, the associations between these factors and higher caregiving responsibilities.”

3)    I wonder if insufficient home space and time spent distance working and learning are both related to the severity of illness/disability of the ill family member. If a family member requires more assistance and funds to manage the illness, this could lead to both insufficient home space (due to income problems and potentially due to equipment related to illness) and need for the carer to be closer to the family member to take care of them. Relatedly, please include not measuring severity of illness/disability for the ill family member as a limitation.

4)    I think there is a paragraph missing in the discussion section in which authors provide insight into potential mechanisms of how/why caregiving responsibilities may affect mental health (supported by relevant literature), and potentially how these mechanisms may affected by the context of the pandemic.

5)    Please provide more detailed description of the “whole family” approach, as well as citations about the efficacy of this approach.

6)    Please address the limitation of not being powered to look at differences in mental health outcomes between carers for ill parents (n = 45) and carers for ill non-parents (n = 16). Relatedly, I would not include large sample size in the list of strengths, especially due to lower numbers for Aim 3.

7)    Please address the limitation that while these measures were technically longitudinal, authors could not test for bidirectional effects because the study design only measured mental health factors at one time point after other measures. Some of the mental health factors may also affect a carers’ perception of their caregiving responsibilities. 

8)    It is not clear to me what this means in the list of strengths: “the contextualizing of young adult carer mental health in the COVID-19 pandemic.”

9)    Please number strengths for readability.

Author Response

The current study sought to investigate relationships between COVID-19/lockdown factors, caregiving responsibilities, and mental health outcomes among young adult carers during the COVID-19 pandemic. Strengths of the paper include quality of writing, importance of subject matter, and novelty of findings. Please see below suggestions to further improve the manuscript.

Abstract/Title:

1)    Because the authors did not experimentally manipulate caregiving responsibilities, the authors cannot claim causality in saying “their effects on the mental health of…” Please change this language throughout the manuscript to focus on associations rather than effects. For instance, the authors might change this sentence to “This study investigated caregiving responsibilities and associated mental health outcomes…” I think “effects” should be changed to “outcomes” in the title as well, perhaps changed to “A Longitudinal Investigation of COVID-19 Lockdown Factors, Caregiving Responsibilities, and Mental Health Outcomes in Young Adult Carers during the COVID-19 Pandemic.”

RESPONSE: Throughout the manuscript, we have now replaced the terms that suggest causality (e.g., “effect”) with the language of association. We have also edited the title to reflect this change as suggested. The new title now is: “Caregiving Responsibilities and Mental Health Outcomes in Young Adult Carers during the COVID-19 Pandemic: A longitudinal study”.

2)    Please include results about the specific mental health outcomes when reporting that “caregiving responsibilities were longitudinally related to poorer mental health outcomes.” For instance, “caregiving responsibilities were longitudinally related to poorer mental health outcomes, including higher fear of COVID-19, anxiety, and depression, and lower wellbeing.”

RESPONSE: Amended.

3)    Please change “whole of family” to “whole family” in both places where it appears this way.

RESPONSE: Amended.

4)    I think the sample sizes are somewhat misleading in the abstract for Aim 3 because for this question, authors are only looking at a much smaller subsample with available data at Time 3. Please specify the sample sizes for each set of analyses in the abstract.

RESPONSE: We have now included information on participants at each of the three Time points in the abstract. As it is costumery in longitudinal studies, we have specified attrition rates in the manuscript. The sample for this study is the same for Aim 1 and Aim 3, as we have conducted the analyses in Mplus using the Full Information Maximum Likelihood estimator to address missing data. Because the percentage of missing data was only 14.12%, the complete baseline sample (N=1,048) was retained for data analyses and the Full Information Maximum Likelihood estimator available in Mplus was used to handle missing data. We used this approach in Landi et al. (2022). We have now specified this in the “data analysis approach” sub-section of the Method section.

We re-ran the analyses keeping only participants that responded to two assessments (n=804, 76.72% of participants), rather than retaining the complete baseline sample, and the results of the analyses are the same.

We thank the reviewer for raising this issue. Using correlations conducted in SPSS to address aim 2 was not the best analytic strategy. We have now conducted correlations in Mplus using the Full Information Maximum Likelihood estimator as well and we have noted this in the Methods section.

Reference

Landi, G., Pakenham, K. I., Crocetti, E., Tossani, E., & Grandi, S. (2022). The trajectories of anxiety and depression during the COVID-19 pandemic and the protective role of psychological flexibility: A four-wave longitudinal study. Journal of Affective Disorders, 307, 69-78. https://doi.org/10.1016/j.jad.2022.03.067

Introduction:

1)    Please change this sentence to not imply causality due to its cross-sectional nature: “We conducted a cross-sectional study during the second lockdown in Italy  which revealed that compared to non-carers, the mental health of young adult carers was more adversely impacted.”

RESPONSE: We have changed the sentence as follows “We conducted a cross-sectional study during the second lockdown in Italy which revealed that compared to non-carers, young adult carers had poorer mental health.”

2)    Please change this sentence to be easier to comprehend: “We have previously argued that given parents typically assume the primary caregiving role in relation to their children, a reversal of this role is likely to create more caregiving demands than caring for a non-parent family member.”

RESPONSE: We have changed the sentence as follows “We have previously argued that given parents typically assume the primary caregiving role in relation to their children, a reversal of this role is likely to create more caregiving demands for youth caring for a parent than for those caring for a non-parent family member.”

Methods:

1)    For the analytical plan for Aim 2, how were Time 1 and 2 Covid-19 variables combined to be used as one variable in the analyses?

RESPONSE: As indicated in the Method section in the “COVID-19 and Lockdown context variables” sub-section, “the mean time spent in a ‘red’ zone was calculated by averaging the scores across these two items”, while for the categorical COVID-19 context variables assessed at both Times 1 and 2 (i.e., COVID-19 infected, COVID-19 hospitalized, family member infected, family member hospitalized, family member death, and COVID-19 vaccine), the variable “was scored as 1=yes, and no endorsement at the two time points was scored as 0=no.”

2)    For the analytical plan, please discuss whether these data met assumptions for multivariate linear regression, including correlations among independent variables and among dependent variables (mental health outcomes). I am concerned specifically that the mental health outcomes are so highly correlated that the model is compromised. It may be more beneficial to conduct four separate linear regression models with each of the four outcomes.

RESPONSE: As suggested, we have now conducted four separate linear regression models with each of the four mental health outcomes and reported the results of these analyses.

Results:

1)    Please reduce the discussion of Table 1 in the text to reduce redundancy. Please only highlight anything particularly notable in the text of the result section.

RESPONSE: Amended.

2)    Please remind the reader of the sample size (with a breakdown of sample size of each group included as well) in each set of analyses addressing each Aim.

RESPONSE: As indicated above (point 4, abstract/title), we have retained the complete baseline sample (N=1,048) for all data analyses.

3)    Please include a section on power to detect effects in each aim.

RESPONSE: We have now included information on posteriori power analyses in the Results section under each aim as follows:

Aim 1:

“Results were subjected to posteriori power analyses for linear multiple regressions. Results of these analyses revealed that given a sample size of 1,048, an α of 0.05, and the effect sizes obtained in caregiving responsibilities for the PI and the OIFM groups (i.e., 0.016 and 0.010, respectively), the resulting power (1-β) calculations were 0.94 for the PI group, and 0.78 for the OIFM group, respectively.”

Aim 2:

“Significant correlations were subjected to posteriori power analyses. In the OIFM group, given a sample size of 87, an α of 0.05, and the obtained significant correlation coefficients of 0.41, and 0.29, respectively, the resulting power (1-β) calculations were 0.98 for the relationship between age and caregiving responsibilities, and 0.87 for the relationship between working or studying from home and caregiving responsibilities. In the total young adult carer group, given a sample size of 235, an α of 0.05, and the obtained significant correlation coefficient of 0.18, the resulting power (1-β) calculation was 0.88 for the relationship between insufficient home space and caregiving responsibilities. Finally, in the non-carers group, given a sample size of 813, an α of 0.05, and the obtained significant correlation coefficient of 0.10, the resulting power (1-β) calculation was 0.88 in the relationship between low socio-economic status and caregiving responsibilities.”

Aim 3:

“Results were subjected to a posteriori power analyses for linear multiple regressions. Results of these analyses revealed that given a sample size of 1,048, an α of 0.05, and the effect sizes obtained for caregiving responsibilities of 0.02 for fear of COVID-19, 0.04 for anxiety, 0.03 for depression, and 0.05 for wellbeing, the resulting power (1-β) calculations were 0.96, 0.99, 0.97, and 0.99, for fear of COVID-19, anxiety, depression, and wellbeing, respectively.”  

4)    For the first study aim, please conduct a comparison between PI and OIFM to determine if these two groups are significantly different in caring responsibilities. 

RESPONSE: It is not possible to conduct ANOVAs in Mplus, and, as we did in our previous published manuscripts (i.e., Landi et al., 2022; Pakenham & Cox, 2015) and as indicated in the “data analysis approach” sub-section of the Method section “because the non-carer group was represented as a score of 0 on both dummy variables, the regression intercept equalled the mean score on the outcome variable for the non-carer group. The regression coefficients for the PI and OIFM dummies provide a test of the mean differences between the two young adult carer groups and non-carers, while controlling for the presence of OIFM or PI, respectively.”

References

Landi, G., Pakenham, K. I., Grandi, S., & Tossani, E. (2022). Young adult carers during the pandemic: the effects of parental illness and other ill family members on COVID-19-related and general mental health outcomes. International Journal of Environmental Research and Public Health, 19(6), 3391. https://doi.org/10.3390/ijerph19063391

Pakenham, K. I., & Cox, S. (2015). The effects of parental illness and other ill family members on youth caregiving experiences. Psychology & Health, 30(7), 857-878. https://doi.org/10.1080/08870446.2014.1001390

Discussion:

1)    When speaking about the results related to aim 1, the manuscript focuses on how young adults have more care responsibilities than children. However, because this study did not compare young adults to children, the results cannot speak directly to this comparison. I think that a discussion of the potential differences between young adults caring for a parent vs. non-parent family member would be more relevant here.

RESPONSE: We discuss the differences between young adults caring for a parent vs. non-parent family member in the introduction to justify our predictions regarding the differences in caregiving responsibilities. In particular, we provide an explanation as to why young adult carers in a parental illness context are more likely to have higher levels of caregiving responsibilities compared to young adult carers in an ill non-parent family member context. And then again, we discuss these differences with respect to our results in the Discussion section. We have referred to findings showing that young adult carers are likely to take on more care responsibilities, particularly if caring for a parent, than their child/adolescent siblings because this may in part account for the differences in caregiving responsibilities between the two groups, and between the total sample of young adult carers and non-carers.

2)    This sentence is long and confusing. Please revise: “Spending more time at home working or undertaking distance learning where the living space is perceived as insufficient, is also likely to result in less opportunities for the young adult to escape caregiving tasks and hence, the associations between these factors and higher caregiving responsibilities.”

RESPONSE: Sentence revised as follows: “Spending more time at home working or undertaking distance learning where the living space is perceived as insufficient, is also likely to result in less opportunities for the young adult to escape caregiving tasks. This may account for the associations between both insufficient home space and working and learning from home and higher caregiving responsibilities.”

3)    I wonder if insufficient home space and time spent distance working and learning are both related to the severity of illness/disability of the ill family member. If a family member requires more assistance and funds to manage the illness, this could lead to both insufficient home space (due to income problems and potentially due to equipment related to illness) and need for the carer to be closer to the family member to take care of them. Relatedly, please include not measuring severity of illness/disability for the ill family member as a limitation.

RESPONSE: We have noted as a limitation the fact that we did not assess the illness severity of the ill family member, which is likely to be related to young adult carer caregiving responsibilities.

4)    I think there is a paragraph missing in the discussion section in which authors provide insight into potential mechanisms of how/why caregiving responsibilities may affect mental health (supported by relevant literature), and potentially how these mechanisms may affected by the context of the pandemic.

RESPONSE: We have now included a new paragraph discussing potential mechanisms of how/why caregiving responsibilities may affect mental health in the context of the pandemic as follows:

“There are several potential pathways by which caregiving responsibilities may adversely affect the mental health of young adult carers. The wide range of potentially demanding caregiving tasks that young adult carers undertake can impose restrictions on the amount of time and type of activities they engage in within education, employment, social and recreational settings (Pakenham et al., 2006). Restricted engagement in activities in these areas can reduce skill development and increase isolation which, in turn, is associated with vulnerability to mental health problems. Caregiving pressures can conflict with the demands of establishing a career and elicit decision-making conflicts regarding future life planning relative to their ongoing caregiving predicament (Chevrier et al., 2022; van der Werf et al., 2022). Young adult carers may worry about the ill family member and feel guilty when they pursue their own interests (Pakenham et al., 2006). The redistribution of caregiving tasks in the family can strain family relations and reduce the amount of family support Pakenham & Cox, 2012). These challenges and stressors can interfere with the timely and smooth accomplishment of emerging adulthood milestones (e.g., autonomy, identity formation, career development, and intimate relationships) and lead to mental health problems. As mentioned in the introduction, the healthcare system disruptions and social isolation caused by the COVID-19 pandemic, intensify caregiving responsibilities (Blake‐Holmes & McGowan, 2022). In addition, COVID-19 related stressors and anxiety, are likely to exacerbate the abovementioned mental health challenges.”

5)    Please provide more detailed description of the “whole family” approach, as well as citations about the efficacy of this approach.

RESPONSE: The whole family approach is not a specific intervention but rather a broad approach or orientation to the co-ordination and provision of welfare and healthcare services across sectors which can also guide government policy around social and healthcare issues. Hence, there is no efficacy research that we are aware of. However, in the practice implications paragraph we have clarified the whole family approach in the manuscript to better convey it as a broad approach or orientation to service provision that offers coordinated assessments and services to support the person with care needs and their family as well as the young carer. In addition to providing a clearer description of the whole family approach we also cite authoritative references recommending this approach be used to inform the provision of services for young carers across many countries including Canada, USA, UK, and Europe.

6)    Please address the limitation of not being powered to look at differences in mental health outcomes between carers for ill parents (n = 45) and carers for ill non-parents (n = 16). Relatedly, I would not include large sample size in the list of strengths, especially due to lower numbers for Aim 3.

RESPONSE: We have deleted relatively large sample size as a study strength. We also examined differences in mental health outcomes between PI vs. OIFM and non-carers. For aim 3, irrespective of health status, we tested the hypothesis that higher caregiving responsibilities will predict worse mental health outcomes. As reported above, we have conducted the analyses in Mplus using the complete baseline sample (N=1,048) and the Full Information Maximum Likelihood estimator to address missing data. Furthermore, the results of a posteriori power analyses for aim 3 revealed that we achieved high power for each of the four tested mental health outcomes (range 0.96-0.99).

7)    Please address the limitation that while these measures were technically longitudinal, authors could not test for bidirectional effects because the study design only measured mental health factors at one time point after other measures. Some of the mental health factors may also affect a carers’ perception of their caregiving responsibilities. 

RESPONSE: We have noted this limitation as follows: “Seventh, due to the assessment of mental health outcomes at one timepoint the causal relations between caregiving responsibilities and mental health outcomes remain ambiguous.”

8)    It is not clear to me what this means in the list of strengths: “the contextualizing of young adult carer mental health in the COVID-19 pandemic.”

RESPONSE: We have clarified this strength as follows: “the investigation of young adult carer mental health relative to a range of COVID-19 pandemic factors.”

9)    Please number strengths for readability.

RESPONSE: Amended.

Author Response File: Author Response.docx

Reviewer 3 Report

Based on emerging adults sample this paper aims to increase our understanding of caregiving responsibilities and their mental health effects on young adult carers during the COVID-19. I congratulate the authors for the great work done on this manuscript. However, I have some minors concerns on the manuscript:

 ---Specific comments---

-      Manuscript title is too long so, I recommend authors to try to shorten the title in some way.

-        Abstract section should include more specific sample information at the three study time points (e.g., n, Mean, SD, % women and % men…). Authors could review this aspect in the section.

-        Overall, authors do sparce mention to emerging adulthood stage. Although it is not a central point in the manuscript, I consider important to include literature review focused on explain this developmental stage in the introduction section. Helpful references could be:

Arnett, J. J. (2014). Emerging adulthood: The winding road from the late teens through the twenties (2nd ed.). New York, NY: Oxford University Press

-        For the questionnaire measures that were used, please follow the same order presenting the information. Add a item example for each scale or subscale used (item example for depression or anxiety are missing in the present manuscript way) and indicate whether response scores were summed or averaged to create their composite scores for data analysis.

-        I believe that it would add value to the manuscript and that it would be very interesting to include a cultural lens in the discussion to interpret the results found. In this sense, emerging adulthood is a stage with specific sociocultural influences. These influences are different in northern Europe or the United States and in southern Europe. Specifically, in southern Europe countries as Italy, family acquires a special role and family system it is characterized by strong family ties. Helpful references could be:

García-Mendoza, M. C., Parra, A., Sánchez-Queija, I., Oliveira, J. E., & Coimbra, S. (2022). Gender differences in perceived family involvement and perceived family control during emerging adulthood: A cross-country comparison in Southern Europe. Journal of Child and Family Studies, 31(4), 1007-1018. http://dx.doi.org/10.1007/s10826-021-02122-y

Crocetti, E., & Meeus, W. (2014). “Family comes first!” Relationships with family and friends in Italian emerging adults. Journal of Adolescence, 37(8), 1463–1473. https://doi.org/10.1016/j. adolescence.2014.02.012.

Parra, Á., Sánchez-Queija, I., García-Mendoza, M. D. C., Coimbra, S., Egídio Oliveira, J., & Díez, M. (2019). Perceived parenting styles and adjustment during emerging adulthood: A cross-national perspective. International journal of environmental research and public health, 16(15), 2757. http://dx.doi.org/10.3390/ijerph16152757

-        Because of the interesting results of the study, I recommend describing the contributions of the study more clarify and extensity.

-        At the end of the manuscript, the practical applications/implications of the study should be explained in details.

-        Please, revise the entire manuscript according to 7th Edition APA style. 

Author Response

Reviewer 3

Based on emerging adults sample this paper aims to increase our understanding of caregiving responsibilities and their mental health effects on young adult carers during the COVID-19. I congratulate the authors for the great work done on this manuscript. However, I have some minors concerns on the manuscript:

 ---Specific comments---

-      Manuscript title is too long so, I recommend authors to try to shorten the title in some way.

RESPONSE: We have shorted the manuscript title in line with edits suggested by Reviewer 2, as follows: “Caregiving Responsibilities and Mental Health Outcomes in Young Adult Carers during the COVID-19 Pandemic: A longitudinal study”.

-        Abstract section should include more specific sample information at the three study time points (e.g., n, Mean, SD, % women and % men…). Authors could review this aspect in the section.

RESPONSE: Amended.

-        Overall, authors do sparce mention to emerging adulthood stage. Although it is not a central point in the manuscript, I consider important to include literature review focused on explain this developmental stage in the introduction section. Helpful references could be:

Arnett, J. J. (2014). Emerging adulthood: The winding road from the late teens through the twenties (2nd ed.). New York, NY: Oxford University Press

RESPONSE: As suggested, we have added a paragraph in the introduction as follows: “According to Arnett (2014), emerging adulthood has five defining features: identity exploration (search for meaning in ideologies, work, and relationships), instability (frequent changes in residences, jobs, and relationships), opportunities (increased options regarding career and life directions), self-focus (reduced obligations to family members and increased freedom to focus on self), and feeling in-between (the transitioning from adolescence to full adulthood). How these features intersect and fluctuate in prominence varies across time within and between young adults (Syed, 2015).  In addition, sociodemographic factors such as culture and socioeconomic status can influence how individuals manage these aspects of emerging adulthood and master associated challenges such as autonomy, identity formation, career progression, and intimate relationships. The workload, time, and interpersonal demands related to elevated caregiving during emerging adulthood can interfere with the smooth and timely navigation through this developmental period. Indeed, transactions with one’s living context, such as the presence of a seriously ill family member, can have a marked influence on one of the key tasks in emerging adulthood, identity formation (Sestino & Sica, 2014).”

References

Arnett, J. J. (2014). Emerging adulthood: The winding road from the late teens through the twenties (2nd ed.). New York, NY: Oxford University Press

Syed, M. (2015). Emerging Adulthood: Developmental Stage, Theory, or Nonsense? In J. J. Arnett (Ed.) (2015). The Oxford Handbook of Emerging Adulthood (pp. 11-25). New York: Oxford University Press.

Sestito, LA, & Sica, LS. (2014) Identity formation of Italian emerging adults living with parents: A narrative study. Journal of Adolescence, 37, 1435-1447. http://dx.doi.org/10.1016/j.adolescence.2014.02.013

-        For the questionnaire measures that were used, please follow the same order presenting the information. Add a item example for each scale or subscale used (item example for depression or anxiety are missing in the present manuscript way) and indicate whether response scores were summed or averaged to create their composite scores for data analysis.

RESPONSE: Amended.

-        I believe that it would add value to the manuscript and that it would be very interesting to include a cultural lens in the discussion to interpret the results found. In this sense, emerging adulthood is a stage with specific sociocultural influences. These influences are different in northern Europe or the United States and in southern Europe. Specifically, in southern Europe countries as Italy, family acquires a special role and family system it is characterized by strong family ties. Helpful references could be:

García-Mendoza, M. C., Parra, A., Sánchez-Queija, I., Oliveira, J. E., & Coimbra, S. (2022). Gender differences in perceived family involvement and perceived family control during emerging adulthood: A cross-country comparison in Southern Europe. Journal of Child and Family Studies, 31(4), 1007-1018. http://dx.doi.org/10.1007/s10826-021-02122-y

Crocetti, E., & Meeus, W. (2014). “Family comes first!” Relationships with family and friends in Italian emerging adults. Journal of Adolescence, 37(8), 1463–1473. https://doi.org/10.1016/j. adolescence.2014.02.012.

Parra, Á., Sánchez-Queija, I., García-Mendoza, M. D. C., Coimbra, S., Egídio Oliveira, J., & Díez, M. (2019). Perceived parenting styles and adjustment during emerging adulthood: A cross-national perspective. International journal of environmental research and public health, 16(15), 2757. http://dx.doi.org/10.3390/ijerph16152757

RESPONSE: As suggested, we have added a paragraph which briefly discusses relevant cultural issues as follows: “In taking a cultural lens to the results of this study, it is important to note how youth and family culture in Italy may shape the experience of caregiving during emerging adulthood. For example, Italian youth tend to prolong academic study, delay entry into the labour market, live at home for a protracted period, and move out of their family homes predominantly for marriage and parenthood (Bacci, 2008). Family ties also tend to be very strong in Italy and other Mediterranean countries (Crocetti & Meeus, 2014; García-Mendoza et al., 2022). It is possible that these youth and family cultural factors may intensify the caregiving experience of young adults who care for a seriously ill family member. To the extent that these Italian youth and family cultural factors are not prominent in other cultures, findings from the present study may not generalize to some countries. However, as noted above, the pattern of findings from this study related to youth caregiving responsibilities and mental health outcomes are consistent with the results of similar studies conducted across many different countries.”

-        Because of the interesting results of the study, I recommend describing the contributions of the study more clarify and extensity.

RESPONSE: Thank you for acknowledging that the study findings are interesting. In the Discussion section we have presented study findings in the context of the relevant broader literature and indicated where our results have added to our knowledge of the associations between young adult carer caregiving responsibilities and mental health in the context of a pandemic. We have been cautious not to overstate or interpret findings beyond the limitations of our data and study design. 

-        At the end of the manuscript, the practical applications/implications of the study should be explained in details.

RESPONSE: We have devoted an entire paragraph to a relatively extensive discussion of the practical implications of study findings. The original practical implications paragraph has in fact been extended in the revised manuscript due to a request from Reviewer 2 to expand on the whole family approach to service provision. We believe this revised paragraph is sufficiently thorough in discussing the practice implications of study findings given the study design.

-        Please, revise the entire manuscript according to 7th Edition APA style. 

RESPONSE: We have followed the references format of the instructions for authors of the International Journal of Environmental Research and Public Health which does not require APA style.

Author Response File: Author Response.docx

Reviewer 4 Report

The manuscript is very detailed and provides an extensive dive into the psychological impact of caregiving during the pandemic. It is well written and extensive. Your previous work is also quite similar, with the present manuscript adding the longitudinal perspective, which can be considered an evolution of the previously published manuscript. However I have noticed that the number of participants declined dramatically reaching less than a third of the original number, any particular reason why this decline in participants ? maybe this decline in participants should be detailed. 

Author Response

Reviewer 4

The manuscript is very detailed and provides an extensive dive into the psychological impact of caregiving during the pandemic. It is well written and extensive. Your previous work is also quite similar, with the present manuscript adding the longitudinal perspective, which can be considered an evolution of the previously published manuscript. However I have noticed that the number of participants declined dramatically reaching less than a third of the original number, any particular reason why this decline in participants ? maybe this decline in participants should be detailed. 

RESPONSE: As indicated in the “Participants and Recruitment Procedure” subsection of the method section, in the first cross-sectional study we obtain a sample of 1,823 young adults aged 18–29 years. Of these, only 1,048 consented to take part in the longitudinal project and thereby provide their email addresses to be re-contacted and constituted the total young adult sample for the longitudinal study. So the decline is from 1,048 not 1,823. Some attrition in longitudinal studies is to be expected.

Author Response File: Author Response.docx