1. Introduction
The media (Internet, TV, radio) contained information about the actual situation and spread of the coronavirus disease (COVID-19) [
1,
2,
3]. It was feared that simply providing updates by the government about the epidemiological situation during the COVID-19 pandemic in the media might not be enough to draw public attention to the threat [
4]. It was shown that during the COVID-19 pandemic, anxiety and depression were common problems in the general population [
5,
6], as well as in people suffering from COVID-19 [
7], and mental health problems worsened during isolation [
8]. As is known, anxiety and depression can occur as isolated disorders or coexist [
9]. Various posts in social media reflected the interest and emotions evoked by the COVID-19 pandemic [
10]. Spontaneous searching for information on the COVID-19 pandemic resulted in an increase in the amount of time spent browsing the Internet, watching TV, listening to the radio, and looking at newspapers, and was associated with unpleasant mental experiences [
11].
Much has been written in the literature about the impact of the COVID-19 pandemic on the general population, while little attention has been paid to the difficulties faced by children with neurological disorders and their caregivers. Compared to the general population, this group had to struggle to secure the necessary medical care and therapy because, due to the clinical characteristics of these disorders, disabled children required continuous rehabilitative treatment. It was often very difficult because during the intensification of the pandemic many rehabilitation centers were closed, which deprived children with disabilities from access to rehabilitation services. For children with neurological disorders, this led to negative consequences such as increased muscle tone/spasticity, pain, poorly fitting orthotics, and delay in getting therapeutic equipment. In addition, caregivers were impacted as they had to perform more of the therapeutic exercises with their children at home [
12].
The interruption of rehabilitation services due to a COVID-19 pandemic-related lockdown can significantly impact the functional abilities of patients with chronic neurological diseases [
13]. In children, the most common neurodevelopmental disorders are cerebral palsy, myelomeningocele, hydrocephalus, spinal muscle atrophy, congenital polyneuropathy, muscle dystrophy, and autism spectrum disorders [
14,
15]. The COVID-19 pandemic caused prolonged home isolation and forced caregivers of children with neurodevelopmental disorders to change their daily strategies to prevent their children from getting worse. It was necessary to introduce regular online consultations, conduct online therapy, educate the child in the field of COVID-19 and preventive behaviors, create a structured daily schedule and a reinforcement system, and select activities appropriate for the child [
15]. Caregivers of children with special needs assessed performing independent therapeutic tasks at home during the COVID-19 pandemic as difficult [
16]. A number of similar demands related to the care of autistic children during the COVID-19 pandemic increased the risk of mental health problems for caregivers [
17]. Solutions were sought for this difficult situation related to the pandemic. For example, given the difficulties of COVID-19, a novel, virtual, multidisciplinary, short intervention program for families with children with neurodevelopmental disorders was developed and rapidly implemented at the Hospital for Sick Children (SickKids) in Toronto, Ontario, Canada [
18].
The COVID-19 pandemic also posed new organizational challenges to the Polish healthcare system [
19]. Changes were gradually introduced in the healthcare units, which had to reconcile the satisfaction of the health needs of patients and the needs of medical workers related to ensuring safety [
20]. At the turn of March and April 2020, due to the occurrence of COVID-19 in Poland, the first restrictions on the provision of various rehabilitation services were introduced [
21]. This resulted in the termination of the work of the units in which the tests were carried out for less than two months. This also applied to centers operating in our region. In April 2020, the Clinical Regional Rehabilitation and Education Center in Rzeszow served as an isolation facility [
22]. As a result, caregivers faced a serious problem because their children were deprived of access to neurorehabilitation. After resuming work, caregivers strived to ensure that their children could benefit from rehabilitation services. Surprisingly, they expressed no significant concerns about the pandemic.
In many of them, an increase in the intensity of symptoms such as anxiety, depression, or a sense of helplessness was observed. Results of similar research show that perceived treatment control over the illness and its course is related to mild to severe symptoms of anxiety and depression among parents of children with neurological disorders [
23]. It has also been shown that emotion- and avoidance-oriented coping styles and socioeconomic status are crucial factors in the adjustment process of parents of children with neurodevelopmental conditions. By contrast, parenting stress and child difficulties were the most significant predictors of negative psychological outcomes in such parents [
24].
As is known, parents’ attitudes and psychological adjustment during their child’s implementation of the neurorehabilitation program are key aspects for the child’s adherence to care and the impact of the disease. Therefore, it can be expected that the conditions caused by the COVID-19 pandemic will contribute to the occurrence of negative psychological consequences in them, which may disrupt the course of pediatric neurorehabilitation.
The aim of this study was to determine which of the selected data presented in the media showing the intensity of the COVID-19 pandemic differentiated the level of anxiety and depression in caregivers of children using neurorehabilitation services. Another research aim was identification of predictors that might help professionals to develop screening procedures to identify parents (caregivers) at high risk for anxiety or depression. Knowing these predictors would enable them to conduct early interventions to reduce uncertainty and maladaptive coping strategies that may influence neurorehabilitation processes.
4. Discussion
Among caregivers of children benefiting from neurorehabilitation services during the COVID-19 pandemic, the incidence of borderline state and clear symptoms of anxiety (HADS) was 35.68% and the incidence of borderline state and clear symptoms of depression (HADS) was 13.44%. Other researchers showed that among parents of children with neurological disorders, the incidence of similar anxiety states (HADS) was 41.0%, and similar depressive states (HADS) was 39.5% [
22]. In another study conducted among caregivers of children with special needs in India, from 29 April 2020 to 22 May 2020, during the COVID-19 pandemic, the prevalence of symptoms of depression, anxiety, and stress was 62.5%, 20.5%, and 36.4%, respectively (Depression Anxiety Stress-21 Scale) [
15]. On the basis of research conducted in Italy among parents of children with neuropsychiatric diagnosis, an increase in stress levels (Parenting Stress Index—Short Form) was found during the COVID-19 pandemic compared to the pre-pandemic period [
31,
32].
In Italy, there was also a rehabilitation lockdown during the COVID-19 pandemic. Research conducted in the period from 26 March 2020 to 11 May 2020 showed that caregivers of children with disabilities reported anxiety and depression symptoms and concerns about their child’s development during the rehabilitation lockdown, but the main concerns were also related to the risk of COVID-19 contagion [
33]. Meanwhile, Chinese researchers found that the alarming data provided by the government on the epidemiological situation during the COVID-19 pandemic were not interpreted by the general population as a state of emergency [
4]. This is a similar tendency as in our study, where selected epidemic data presented in the media—daily number of infections, total number of infections, daily number of deaths, total number of deaths, total number of recoveries, number of hospitalizations, and daily number of people quarantined—did not differentiate levels of anxiety and depression.
It has been shown that female gender, admission to an inpatient ward, and indifference or lack of religious commitment are statistically significant and independent predictors of the level of anxiety. They account for 7.56% of the variability in the level of anxiety in the adopted multivariate linear regression model. Female caregivers had a higher level of anxiety than male caregivers. A decreased level of anxiety was present in caregivers whose children were admitted to the inpatient ward compared to those whose children were admitted to the outpatient clinic. An increased level of anxiety was reported by caregivers showing indifference or lack of religious commitment compared to those showing strong religious commitment. In this study, female caregivers predominated. The statistical tests used in our study abolish the effect of inequality in the numbers of subgroups. Therefore, it cannot be said that female sex is a predictor of the level of anxiety, because more women participated in the study. It was noted that a female predominance has also been observed in other studies on the prevalence of anxiety and depression during the COVID-19 pandemic in the general population [
5]. In our rehabilitation center, the closeness of the staff is most prevalent in the inpatient ward. Caregivers of children requiring neurorehabilitation admitted to this unit had the lowest level of anxiety. In the opinion of caregivers of patients with neuromuscular diseases, the constant support of the center and the proximity of the center staff was a positive aspect of the healthcare services provided in the rehabilitation center during the COVID-19 pandemic [
12]. In another study conducted among parents of children with neurological diseases, other predictors were found to differentiate the level of anxiety (HADS): perceived treatment control over the illness, perceived understanding the illness, and perceived personal control over the illness (Brief Illness Perception Questionnaire) [
23].
It has been shown that statistically significant and independent predictors of the level of depression are the caregiver’s secondary education, the caregiver’s primary education, and the child’s ailments that occurred suddenly as the reason for admission to the hospital. These predictors account for 10.29% of the variability in the level of depression in the surveyed caregivers in the multivariate linear regression model. Caregivers with primary education and caregivers with secondary education had higher levels of depression compared to caregivers with higher education. Caregivers of children with sudden health decline being the reason for admission to the hospital were characterized by higher level of depression compared to caregivers of children with chronic ailments. Difficulties in access to medical care caused by the COVID-19 pandemic affected the caregivers of patients with spinal muscular atrophy. During the COVID-19 pandemic, caregivers were required to make decisions about the treatment and urgent interventions included, while taking the risks associated with the severity of symptoms and the threat of the coronavirus pandemic into consideration. It was a new challenge, unknown prior to the pandemic [
34]. In another study conducted among parents of children with neurological diseases, other statistically significant predictors differentiating the level of depression (HADS) were found: perceived treatment control over the illness, perceived understanding of the illness, and perceived timeline of the illness (Brief Illness Perception Questionnaire) [
23].
Anxiety and depression (marked disorders) coexisted in 4.19%. It was found that there is a statistically significant relationship between the level of anxiety and depression: the higher the level of anxiety, the higher the level of depression; and the higher the level of depression, the higher the level of anxiety. It was found that statistically significant predictors reducing the probability of co-occurrence of anxiety and depression are secondary and higher education, and admission to the inpatient department of the center. Other researchers showed that severe depression in parents of children with neurodevelopmental disorders in May 2020 had a synergistic effect on severe parental stress and severe depressive state in May 2021 [
35].
Our study showed that caregivers of children undergoing neurorehabilitation treatments showed high motivation to continue them. It is likely that this motivation, caused by concern for their children’s health, resulted in less severe symptoms of anxiety and depression during the peak period of the COVID-19 pandemic. This seems to be one of the most important findings from our research.
5. Conclusions
None of the selected data presented in the media showing the severity of the COVID-19 pandemic differentiated the level of anxiety and depression among caregivers of children using neurorehabilitation services.
It has been shown that significant predictors increasing the level of anxiety of caregivers of children using neurorehabilitation services during the COVID-19 pandemic are female compared to male gender, and indifference or opposition to religious commitment compared to strong religious commitment.
It was also shown that a significant predictor increasing the level of anxiety of caregivers of children using neurorehabilitation services during the COVID-19 pandemic was the child’s admission to an inpatient ward compared to the child’s admission to an outpatient clinic.
It has been shown that significant predictors increasing the level of depression in caregivers of children using neurorehabilitation services during the COVID-19 pandemic are secondary and primary education of the caregiver compared to higher education, and ailments of the child that occurred suddenly as the reason for hospitalization compared to chronic ailments.
Additionally, it has been shown that significant predictors reducing the co-occurrence of anxiety and depression in caregivers of children using neurorehabilitation services during the COVID-19 pandemic are secondary and higher education of the caregiver compared to primary education, and admission of a child to an inpatient ward compared to an outpatient department.
- a.
Defining the direction of future research
Exploring more of the factors that shape anxiety and depression levels in caregivers of children, targeting their children, spouses, work environment, and more.
- b.
Limitations
Not taking into account more factors shaping the level of anxiety and depression in caregivers of children, targeting their children, spouses, work environment, and others.