In normal times, many parents fulfill multiple roles at work as an employee and at home as a spouse and parent. When too many demands result from these multiple roles, expectations of each cannot be met and parents experience role overload [1
]. Role overload has been associated with increased stress and negative outcomes at work as well as in the family [1
]. Parents of children with chronic conditions are under particular stress as their parental role is often more demanding. Many studies have reported increased parenting stress among parents of children with chronic disorders [2
Due to the unprecedented context of the 2020 pandemic caused by the SARS-CoV-2 pandemic, also called the COVID-19 pandemic, many parents have experienced increased role overload and stress as family life has been upended. In March 2020, several US states implemented orders to stay at home, except for essential work or shopping for essential needs. Most workplaces, schools and non-essential retail or services were closed, including temporarily halting non-emergency doctor visits [4
]. Furthermore, people were asked to socially distance (keeping a distance of at least 6 ft between others) and quarantine at home when showing COVID-19 symptoms. The economic fall out of the stay at home orders was large, with 43% of Americans in April 2020 reporting to have lost a job or taken a pay cut [5
]. One report found about half of all people in the US worked from home early in the pandemic [6
]. Furthermore, according to the National Center for Education Statistics, school closures affected 55.1 million students across the US in April 2020 [7
], with most schools switching to online learning. Stay at home orders and extra protection of the elderly has also isolated families from much of their support system and childcare options, with daycare centers, sitters and grandparents generally unavailable to help parents. In addition, parents of children with chronic conditions may have an additional loss of support and services from the medical community because of the closures of health care facilities and the move to virtual clinical encounters.
In a call to action for mental health science, 24 world experts indicated that an “immediate priority is collecting high-quality data on the mental health effects of the COVID-19 pandemic across the whole population and vulnerable groups.” [8
]. Data have been published showing global rates of psychological distress that are worrisomely high, with some studies finding a doubling of clinical anxiety and depression among adults [9
]. Parents particularly are negatively affected, with one study reporting that almost one out of three parents reported a worsening of their mental health during the pandemic [10
]. It seems reasonable that parents of children with chronic diseases are hardest hit by the many stressors created due to the pandemic, such as loss of childcare, loss of services through school and loss of access to medical care. This is the first study to describe and compare the level of stress and mental health of parents of either healthy children or children with chronic conditions, during the 2020 pandemic.
The mental health effects of the 2020 SARS-CoV-2 pandemic are yet to be fully understood. In this nationally representative study, we found that levels of stress among parents were moderate to high but additionally so for parents of children with either physical or mental health chronic conditions. Stressors due to community restrictions during the pandemic were high: the vast majority of families practiced social distancing, over half of parents lost their job or had reduced income, 42% transitioned to working from home and three out of four children were schooled at home/online. In the meanwhile, traditional support systems for childcare dwindled, with 1% of parents having access to sitters or daycare and 15% able to rely on grandparents (compared to 38% in a 2018 AARP survey [20
]). The reduction in childcare by grandparents is likely not only an effect of social distancing but also to protect the elderly from SARS-CoV-2 infection and COVID-19. In a study conducted in June (two months after our study) 24% of parents reported losing care during the pandemic [10
], supporting our findings. Many of these stressors add to the already moderately high stress levels in Americans, which in 2019 were reported on a scale of 1–10 with an average of 4.9 in the past month [21
]. The stress level in our sample was 6.7 in the past 7 days. In a non-peer reviewed study, by the American Psychological Association, similar stress levels were found among parents during the 2020 pandemic, while adults without children were significantly less stressed (average stress level 6.7 vs. 5.5 in the past month) [22
]. Thus, during the 2020 pandemic, parents report a high level of stress.
Rates of clinical anxiety (44.6%) and depression (42.2%; based on norm scores) were high among parents, and substantially above rates from previous studies. For example, based on the same PROMIS norm scores, the rates of depression (10%) and anxiety (17%) in adults with a musculoskeletal condition were much lower than the rates found in the current sample [23
]. Furthermore, a meta-analysis of studies in conflict areas, a high-stress environment, found 22% of adults to be clinically depressed or anxious [24
]. Even during the COVID-19 outbreak in China, rates of depression (20.1%) and anxiety (35.1%) were lower in adults compared to our sample of parents [25
]. Although no statistical test can be performed to find if these differences before and during the pandemic are statistically significant, they seem to be clinically significant. These data suggest that anxiety and depression rates for parents during the SARS-CoV-2 pandemic were twice as high as in these comparable studies. Clearly, our results support that during the SARS-CoV-2 pandemic, mental health of parents was suboptimal.
Not surprisingly, stress levels, anxiety and depression were significantly higher in parents who take care of children with chronic conditions (physical or mental) compared to parents of healthy children. Not only is the care of a child with a chronic condition stressful in itself, the effects of the pandemic restrictions also reduced social support for childcare, increased financial concern due to loss of income and introduced the new worry about COVID-19 health effects. This is simultaneous with reduced access to medical care and increased stress when receiving care because of infection concerns. A recent study found that the pandemic resulted in delays in medical care for 39% of children [10
]. The impact of these stressors is greater for those caring for a child with a chronic condition. Our data suggest that parents of children with chronic conditions are a group that needs additional support and intervention while SARS-CoV-2 and related community restrictions continue as a threat.
This study has many strengths: it is the first to describe parenting stress during times of the SARS-CoV-2 pandemic and is based on a representative sample of the USA. We examined specifically the effects on parents of children with a variety of chronic conditions, including common mental and physical health disorders. The main limitation of our study is the cross-sectional design, capturing only one time point during the 2020 pandemic. Longitudinal data are needed. In addition, the study is descriptive and includes no direct comparisons with pre-pandemic levels. Third, all data are collected by self-report. Childhood chronic conditions included in the study varied widely from ADHD to cancer. We chose this to provide a general overview of the level of stress during the pandemic of parents who have a child with a chronic disorder. However, future studies are needed to examine levels of parenting stress during the 2020 pandemic by disorder as the impact may vary for each. Lastly, the sample was recruited through a commercially available recruitment service. These parents volunteer to be contacted for survey research and this may introduce bias in our sampling. However, we and others have previously used the same sampling methods for nationally representative samples [26
In sum, the 2020 SARS-CoV-2 pandemic has introduced unprecedented levels of stress for parents, especially those of children with chronic conditions. More data are needed to look at the impact on children, but it is not difficult to imagine it being substantial, as parental mental health significantly impacts the child’s experience. These findings emphasize the need to support parents while pandemic community restrictions continue to significantly interfere with daily life, and find ways to help families deal with the aftermath of this collective experience. Mental health effects of this pandemic for children and parents are expected to continue for months or years. Studies like this one offer a description of the problem; health care preparation needs to follow to identify targeted interventions tailored to the specific challenges of the pandemic experience. Innovation will be needed to do that on a large scale to meet this increased demand in mental health care.