Experiences of parents of children with psychiatric disorder from Covid-19 pandemic and its related quarantine: A qualitative study.

Introduction: Owing to the considerable mortality caused by Covid-19, different countries have made some decisions for dealing with this virus, one of which was quarantine. It was shown that a range of behavioral and emotional changes may exacerbate in children while staying more at home, and parents may then experience these positive or negative behavioral changes. The present study was conducted to examine the experiences of families with children with psychiatric disorders in a psychiatric outpatient clinic in Iran. Method: The phenomenological method, which is a qualitative approach, was used in this study. The population was the parents of children with psychiatric disorders referred to the pediatric psychiatric clinic of Imam Hossein Hospital. Sampling was purposeful, which continued until data saturation. Finally, the number of included participants reached 14. As well, the Colaizzi method was used for data analysis.
Results: The results of this study included 12 secondary codes and 10 tertiary codes, which were divided into three main thematic groups as follows: effective factors for improving behavior, effective factors for worsening behavior, and affective factors on creating a new behavior during quarantine.
Conclusion: In conclusion, quarantine, social restrictions, closure of schools, and online classes can affect the mental health status of children and adolescents in different ways, especially in children with a history of psychiatric disorders.

INTRODUCTION

Coronaviruses are a large family of viruses. A large number of such viruses are known to cause some respiratory infections ranging from a common cold to severe diseases such as Middle East Respiratory Syndrome and severe acute respiratory syndrome (SARS). The recently discovered Coronavirus is the cause of the Covid‐19 disease. In this regard, this new‐emerging virus and its disease were unknown before the recent epidemic in Wuhan, China, in December 2019. Since then, we are experiencing coronavirus variants worldwide.

This virus, similar to most viruses in its family, is highly contagious so it rapidly spread all over the world until the World Health Organization declared it a pandemic. Thus, the Covid‐19 pandemic is the largest outbreak of atypical pneumonia since the time of the SARS outbreak in 2003. The total number of patients and death cases of SARS were passed during the first few weeks of the Covid‐19 outbreak. The virus is also easily mutating the time and making new variants. Some of them are more transmissible and dangerous than others. Accordingly, due to the considerable complications and deaths resulting from Covid‐19, the governments in different countries made some decisions for dealing with this virus, one of which was social/physical distancing. Social distancing means that people keep a secure space from each other, in both indoor and outdoor places. Mandatory face mask use for all people outside the home environment was another policy executed in some countries. These strategies had an impact on slowing down the speed of Covid‐19 transmission. However, the terms “social/physical distancing,” “lockdown,” and “mandatory face mask” evoke different feelings, such as fear, anger, curiosity, confusion, and reactions, which are often associated with insufficient information about the origin and meaning of these strategies. ,  Isolation means isolating and confining the individuals diagnosed with an infectious disease and it is used for preventing the transmission of disease to others. Recently, quarantine is becoming a dominant part of the public health response to new infectious diseases.

It was shown that during previous epidemics, the number of people who were psychologically affected tends to exceed the number of people affected physically by the infection. Some past tragedies have indicated that mental health problems can become chronic and can have a higher frequency than the epidemic itself. Moreover, the psychosocial and economic impacts caused by that can be incalculable. Previous studies identified some factors as the predictors of the psychological effects of quarantine on individuals. For instance, an online cross‐sectional survey among 15−65 years old Bangladeshi people demonstrated that mental health problems during Covid‐19 were associated with female sex, being unemployed, obesity, living alone, and being a student.  In another study of seven middle‐income countries in Asia, some risk factors and protective ones for adverse mental health effects were found. People under 30 years old who were highly educated, unmarried, and who had contact with people with the Covid‐19 disease were at a greater risk for adverse mental health sequels. The protective factors were male gender, staying with children, being employed, believing in doctors, and spending less time to get information about health issues. Moreover, it was shown that those with a previous history of psychiatric disorders experienced more anxiety and anger bypassing 4−6 months from their release from quarantine.  Managing psychiatric patients during the Covid‐19 pandemic and responding to their needs poses some challenges. There are some differences between mental health needs in people with and without psychiatric problems during the pandemic. In a case−control study by Hao and colleagues, people with pre‐existing psychiatric problems were more likely to present higher levels of depression, anxiety, PTSD, and insomnia scores during the Covid‐19 pandemic.  Due to the restriction factors of quarantine, including school closures and reduced leisure activities, children and adolescents may experience some behavioral and emotional changes while staying more at home and parents may then experience these positive or negative behavioral changes.  In a recent study, Wang and colleagues compared the severity of psychological impacts of Covid‐19 between Iran and China. They found that Iranians had higher levels of psychiatric problems as compared to Chinese, which was mainly due to lower access to healthcare services and strategies used by the government. This study was conducted on the general population and the participants were adults.  Another study demonstrated that children experienced psychological trauma in Bangladesh due to abrupt changes like quarantine, remote education, and social distancing.  Since no study has been conducted on children and adolescents with psychiatric disorders in Iran to investigate psychological changes, the present study aimed to examine the experiences of the families with children with psychiatric disorders, who are considered to be at great risk for psychological impacts of Covid‐19 and its related quarantine.

METHOD

The method used in this study was phenomenology. The population was the parents of children with psychiatric disorders referred to the child and adolescent psychiatric outpatient clinic of Imam Hossein Hospital in Tehran in May−August, 2020. Sampling was conducted using a purposeful sampling method, and the parents of the children who experienced the Covid‐19 quarantine and were interested in interviews and recalling their daily life experiences were selected to be enrolled in this research. Sampling continued until data saturation and since the sample should be the source of information, so the individuals in the pediatric psychiatric clinic were selected and interviewed. By conducting the interviews, observations, and taking notes, data saturation was achieved and when the sample size reached 14 participants, there was no need to collect more data. In this study, some deep unstructured interviews were used for data collection. After selecting the participants based on the inclusion criteria, the necessary explanations were given to them. The time and place of the interviews were also set based on the participant's opinions after taking their consent. Before beginning the interview, the participants' consent was received and they were assured of the confidentiality of their information and voice records. Each interview lasted for a minimum of 20−30 min and a maximum of 45 min. Of note, the interviews were recorded on the cellphone application. During these interviews, nonverbal gestures, such as crying, tone of voice, and observations about the communication in the atmosphere were recorded and then noted in the absence of the participants after the interview. Notably, these interviews were conducted in May−August, 2020. The participants of this study were the parents of 14 children with psychiatric disorders, the demographic information of whom and diagnosis of their disease are presented in Table 1. The interviews were started by asking the general question, “Describe your quarantine experience with your child,” and the next questions were asked based on the conditions of the interview and the answers of the participants. If there was any ambiguity in their response, more questions were asked in the same area. All interviews were done by one of the psychiatric residents of Imam Hossein Hospital.

Table 1

Codes extracted from the clinical interviews with the parents.

Final codes	Tertiary codes	Secondary codes
Factors affecting the behavior improvement	Not going to school
	Spending more time with family members	Relaxation because of children's being at home
		More presence of parents at home
	Reduced stressors because of reduced social relationships
Factors affecting the worsening of behavior	Quarantine conditions	Quarantine limitations
		Prolonged quarantine
	Discontinued medical treatment	No need because of schools closure
		Non‐access to the medical system
	Bad news
	Fear from Corona	Infection of family members
		Fear of corona
Factors affecting the creation of new behavior	Increased addictive behavior to electronic devices	Dependence on TV, mobile, and computer games
	More family conflicts	More conflicts with siblings
		More conflicts with parents
	Changes in previous daily habits	Lack of discipline
		Changes in good daily habits
		Doubt in medical treatment

In this study, Colaizzi's analysis method was used as a guide for fundamental activities. Based on the first step of Colaizzi's method, the participants' recorded words were repeatedly listened to up to the end of each interview, notes were taken, and then their words were written on paper. Thereafter, the written interview was read several times to understand the feelings and experiences of each participant. Based on the second step of Colaizzi's, a line was drawn under the significant information after reading all the descriptions of the participants to understand their feelings and in this way, the important sentences were identified. In the third step, which was extracting the concepts of the formula, it was attempted to extract a concept from each phrase, indicating the meaning and basic part of the individual's thoughts after identifying the important phrases in each interview. However, it was attempted to evaluate the relevance of the compiled meaning to main sentences after obtaining these concepts, to ensure the correctness of the relationship. Subsequently, the fourth step was organizing the developed concepts into thematic categories and the results were then mixed, to obtain a comprehensive description of the studied phenomenon at the fifth step was to create more general categories. The sixth step was developing a comprehensive description of the studied phenomena as clearly as possible. As well, the seventh step was validation by referring to each sample along with asking about the findings.  In this study, the two criteria of reliability and credibility were used to reinforce the study. To make the findings credible, the extracted codes were referred to the participants and the findings were then validated by obtaining the participants' approval. In addition, the researcher referred the extracted findings and codes to an expert in qualitative studies, to confirm the validity of the findings of the research. Besides, the researcher explained the research process in detail for the reliability of the findings and also explained how the results will be reached so that other researchers could understand the procedures.

RESULTS

The demographic information and type of the children's disease are presented in Table 1. After writing and then reading the interviews based on the first step of Colaizzi, some significant sentences were identified in the second step. For instance, participant no. 2 who was one of the parents of a 13‐year‐old girl with obsessive‐compulsive disorder (OCD) and tic disorder, stated: “Her bath is prolonged because her psychotherapy sessions had interruptions at this time.” Participant no. 6, who was one of the parents of a 9‐year‐old boy with attention deficit hyperactivity disorder (ADHD) and learning disorder, stated:” He wakes up in the middle of the night and checks if we're okay.”

Afterward, the most significant phrases were extracted from the subjects' statements. This step resulted in obtaining 12 secondary codes and 10 tertiary codes. Tertiary codes 1−3 indicated the factors affecting “a behavior improvement,” codes 4−6 indicated the factors affecting the” worsening of a behavior,” and codes 7−10 indicated the factors affecting “a new behavior” during the Covid‐19 quarantine. These three thematic categories are as follows (also shown in Figure 1):

Figure 1

Graphical figure of the study results

Factors affecting the worsening of a behavior:

exacerbation of some underlying diseases, such as OCD, ADHD, and some anxiety disorders because of quarantine conditions;

fear of the coronavirus and repeated bad news in the media;

discontinuation of their medical and psychological treatments.

Factors affecting behavior improvement:

the improved symptoms of some psychiatric disorders, such as school phobia and social phobia due to school closures;

longer stay at home with family members;

the reduced stressors following the limitation of social relationships.

Factors affecting the creation of a new behavior:

more family conflicts;

the increased addiction to social media and the Internet;

changes in previous daily habits.

DISCUSSION

This was a qualitative study that examined the experiences of parents of children with psychiatric disorders during the Covid‐19 pandemic and related quarantine. Three significant factors were extracted after collecting and analyzing data, which include the following.

Factors affecting the worsening of behavior

Exacerbation of underlying diseases

The parents of children with OCD complained of an increased amount of time spent taking a shower and care of personal hygiene by their children during the day. Social distancing, as well as hand and respiratory hygiene, have been recommended by the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) as the major strategies used to prevent contamination. All media sources also are emphasizing the importance of hygienic measures. While it seems unchallenging to follow, what about those who already suffered from uncertainty about hygiene and the compulsive need to stay clean, such as patients with OCD. In a systematic review, the impact of the Covid‐19 pandemic on obsessive‐compulsive symptoms was evaluated. The findings showed that these symptoms worsened during the pandemic, especially in patients with previously diagnosed OCD, which is similar to our findings.

Another study has been done in the child and adolescent psychiatry department of the Istanbul Medical Faculty on subjects aged 6−18 years who had an OCD diagnosis. Their results were in line with ours. Children with OCD, especially contamination type, were clinically worsened during the pandemic.  Based on the experiences reported by the parents included in this study, it seems that there are some factors related to the current pandemic, which play essential roles in worsening the symptoms of children with OCD. Correspondingly, these factors are the followings: the discontinuation of medical treatment and cognitive‐behavioral psychotherapy because of the closure of some healthcare systems or fear of going to medical centers due to the risk of being infected by the coronavirus, the increased demand for hand washing, frequent emphasis on the minimum time required for it, and step‐by‐step instructions for a proper hand‐washing that can be added to the patient's ritualistic pattern, and the need to disinfect hands after touching the suspected surfaces.

A study by Banerjee considered the negative effects of the Covid‐19 pandemic on the symptoms of patients with both OCD and hoarding disorders. In this regard, it was stated that there have been worldwide reports of the exacerbation of symptoms, increased tension, and concern about this illness during the pandemic. Unfortunately, these aftereffects may last for months after the end of the pandemic.

Fear of the coronavirus

Fear of Covid‐19 disease was another psychological complication reported by the parents in this study, which brings negative effects on the mental health status of children and adolescents. On the other hand worsens their underlying diseases. The predictors of this fear have been discussed in Mertens and colleagues' study. One predictor mentioned in their study was psychological vulnerability, which includes intolerance of being uncertain and illness anxiety. We noticed the same in our study. For instance, one parent reported that her 4‐year‐old son woke up in the middle of the night to ensure that his parents are healthy. Fear is defined as an unpleasant feeling evoked by a threatening stimulus. It should be noted that the feeling of fear during the outbreak and epidemic of diseases is more evoked in people. Such fears lead to suicide attempts in some people believing that they were infected with Covid‐19 during the Covid‐19 pandemic, while their autopsy after death not showed such a thing. Numerous studies were previously conducted on the fear of developing the Covid‐19 disease, which showed the significance of evaluating this issue and led to the formation of different psychometric scales for evaluating this fear. On the other hand, the infection of family members with Covid‐19 disease and the fear of losing their children resulted in some negative psychological effects, such as increased anxiety, irritability, and worsening of their underlying disease. The constant bad news on media and social networks about the number of patients infected with Covid‐19 and the number of deaths were also found to be effective in intensifying the fear of being infected and worsening the underlying disease.

Discontinuation of medical and psychological treatments

Another problem reported by some parents participating in this study was doubt about continuing medical treatment because of the limited access to the healthcare systems, which could naturally lead to the worsening of their underlying disease. For example, some parents of children with ADHD doubted if it was necessary to continue taking their medications during school closures. Besides, some others had problems with the time of taking sedative drugs due to changes in the children's sleep−wake cycle. In addition, the quarantine conditions and restrictions on leaving home have sometimes led to the formation of aggression and oppositional behaviors in children with ADHD, which could affect the pattern of parent−child interactions. However, this problem has decreased over time because of using online treatment systems. Similar patterns of behavior and worsening ADHD symptoms were found in Shah and colleagues' online survey.  Additionally, in a review article, it was demonstrated that the Covid‐19 lockdown and homeschooling led to worsening ADHD symptoms in a majority of children with ADHD.  These findings highlight the importance of having more healthcare plans for ADHD children during the same situations.

Factors affecting behavior improvement

The improved symptoms of some psychiatric disorders such as school phobia and social phobia due to school closures

Some parents whose children were suffering from separation anxiety disorder and fear of school stated that anxiety about attending school and participating in exams reduced to the point that some parents agreed to continue online education in the future.

Longer stay at home with family members

Another positive effect of quarantine reported by some parents was a more relaxed home atmosphere due to less time spent out of the house, especially for teenagers. Similarly, in Evans et al.'s qualitative study, Australian parents of children aged 0−18 years were asked to answer an open‐ended question about how Covid‐19 had influenced their family. Some families reported positive benefits during the Covid‐19 pandemic due to more time spent with family members and the formation of new hobbies.

The reduced stressors following the limitation of social relationships

It seems that parents had less concern for their children socializing with friends and strangers outside the house and have less control over them leading to less conflict in their family.

On the other hand, the more time spent together at home increased the positive parent−child interactions in some cases. Although the limitation in having social relationships has had major negative psychological effects, it has led to reduced stressors and as a result, an improvement was observed in some children, especially those suffering from social anxiety. Of note, because this study was conducted in the early months after the onset of the pandemic, maybe these effects change following the prolongation of this crisis.

Factors affecting the creation of a new behavior

More family conflicts

Some parents reported an increase in the conflicts between siblings and parents during the quarantine. All family members are involved in the stress of pandemics and quarantine during this period. Moreover, family members spend more time with each other because of school closures and telecommuting of some parents. Some of the parents enrolled in this study mentioned that their children had less opportunity to have a conflict with each other before quarantine because of spending more hours of the day at school or the playground. Previously, it was indicated that the increased conflict between children is related to higher stress levels at home, which consequently causes more conflicts between parents and children. A study by Griffith suggested some significant factors associated with the current pandemic and parental burnout. In this regard, the unemployment of some parents, financial problems, low levels of social and emotional support received from friends and family, and fewer recreational activities have all been found to be associated with an increased risk for parental burnout. The researchers found that parents with higher scores on measures of parental burnout are more engaged with child abuse and neglect. Due to the important association between child abuse, neglect, and the mental health of children, it is essential to recognize parental burnout as a possible incident during periods of disaster. A study by Fegert et al. showed that during quarantine, parents were experiencing increased pressures from some factors, such as working from home, keeping their jobs running, as well as taking care of schooling children at home at the same time. On the other hand, disruption of family connections and support, fear of losing family members, and decreased freedom and privacy during quarantine had led to increased domestic violence and child abuse, which had significantly affected children's mental health status.  In addition, Huang et al. proved a doubling of the incidence of abusive head trauma, which is a severe form of child abuse, associated with a high mortality rate during the “Great Recession”. The present study also demonstrated that marital and parent−child conflicts have increased during Covid‐19 quarantine, which could have consequently intensified domestic violence. For example, one of the parents stated that his child considered taking his medicine if their parents let him leave the house, so for this reason, the conflict in their family increased. Moreover, another parent stated that the economic hardship and worrying about grandparents who were infected by Covid‐19 caused a lack of ability in managing their stress and increased child and physical abuse in their homes. One study that analyzed the text and chat inquiries of youth from The Child help National Child Abuse Hotline (which covers the United States and Canada) revealed increased tensions due to close contact and increased rate of child abuse during the lockdown of Covid‐19, which led to an understanding of the importance of hotlines.

Increased addiction to social media and the Internet

Based on the reports of the participants in this study, children's dependency on the Internet and cell phones has increased during the current quarantine, which can be put in the category of new habits. Today, the Internet is an essential part of our life. Internet addiction refers to psychological dependency on the use of the Internet, which can result in different psychiatric problems, such as anxiety, depression, and social communication disorders for victims.

The increased Internet dependency during quarantine can be justified in terms of the reduced social communication, emphasis on social distance, spending more time on the Internet because of school closures and online classes, and easy access to the Internet. In a study conducted by Yuchen Li on 1442 students at a university in China, the increased Internet dependency during quarantine was found to be related to the increased risk of the acute stress response (ASR), particularly among women.  Another study from Indonesia assessed the prevalence of Internet addiction among adolescents during Covid‐19 and revealed an acceleration in Internet addiction.

Change in previous daily habits

Social distancing, school closures, quarantine, and telecommuting caused deep changes in the usual family plans. For some people, it was difficult to be adapted to a new daily routine. Quarantine and spending all day at home, nonexposure to sufficient natural light, disturbed circadian rhythm, fear of developing Covid‐19 in family members, having stress about economic issues, and increased time using cell phones and the Internet were found as the factors affecting sleep‐related disorders during quarantine, which also affects children. According to the parents enrolled in this study, their children often slept later than usual at night and woke up late in the morning, so they disrupted the family's daily plans and mealtimes, and sometimes they prevented them from attending online classes because of the temporary closure of schools. In a study conducted by Casagrande in Italy, more than half of the participants had complained of sleep‐related problems during quarantine. It was also shown that young people and women are more likely to suffer from sleep disorders under this condition.  Since it has been proved that sleep disorders have some significant effects on the immune system and the risk of infectious diseases, so paying enough attention to this issue during the quarantine is of great importance.

Recommendations and future directions

Based on our study, many parents refused to go to medical centers during the Covid‐19 pandemic; thus, it is recommended that medical staff provide online services as much as possible. The efficacy of telepsychiatry in children is another issue that should be paid attention to. We would like to emphasize that this study was conducted in the early months after the beginning of the pandemic, so online psychotherapy and telepsychiatry were not yet common in Iran. But after a few months, these interventions began to increase.

Children and adolescents with OCD during the quarantine require special attention from the treatment team. It is suggested to continue treatment through online psychotherapy sessions and consult with psychiatrists about their medications.

The most evidence‐based treatment is cognitive behavioral therapy, especially Internet‐based CBT (I‐CBT), which could replace face‐to‐face sessions to prevent the spread of infection during the pandemic. I‐CBT may help the patients to maintain adaptive coping behaviors and alleviate anxiety. However, it has its limitations. Making assessments of details, such as body language, gestures, and posture may be difficult. On the other hand, the costs of Internet‐based programs should be considered in areas with limitations in the availability of these facilities.

Besides the threats of the recent pandemic and quarantine to mental health, some benefits have also been raised. Since family members spent more time with each other and external stressors are reduced, relaxation has been established more in some families. In addition, the children and adolescents who had difficulty with going to school, whether because of anxiety disorders, such as social anxiety disorder and separation anxiety or because of stressors in school, experienced a pleasant quarantine due to online classes. Thus, it is recommended to conduct some studies on different dimensions of the effects of holding some classes online for such individuals under normal conditions.

Because of the increased dependency on Internet use during quarantine and its adverse effects on the mental and physical health statuses of children and adolescents, it is suggested to plan educational programs for children and their parents for using the Internet in different ways (social media, online games, etc.) and to inform them about both advantages and disadvantages of this technology. Parental control is another important issue for children using the Internet.

LIMITATIONS

The limitations of this study were the followings:

The unwillingness of parents to cooperate in conducting the interviews is due to its time‐consuming nature.

Lack of information and experience sharing among some parents because of breaking the quarantine rules and having no idea about this subject.

Selection of all participants from a specific clinic, so it is suggested to conduct similar studies in other pediatric psychiatric centers.

CONCLUSION

In conclusion, quarantine, social restrictions, closure of schools, and online classes can affect the mental health status of children and adolescents in different ways, especially in children with a history of psychiatric disorders. Thus, strategies for reducing the negative effects and increasing the positive ones seem essential for the rest of the Covid‐19 pandemic and possible future scenarios. More studies are needed to assess the psychological effects of Covid‐19 and quarantine on children and adolescents worldwide.

AUTHOR CONTRIBUTIONS

Nastaran Samani: Conceptualization; data curation; investigation; writing—original draft; writing—review and editing. Rozita Davari Ashtiani: Conceptualization; investigation; project administration; resources; supervision; writing—review and editing. Ali Kheradmand: Conceptualization; formal analysis; supervision; visualization; writing—review and editing. Fariba Arabgol: Supervision; writing—review and editing.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

ETHICS STATEMENT

The project was in accordance with the ethical principles and standards for conducting medical research. All participants provided written informed consent. The study received ethical clearance through the Research Ethics Committees of the Vice‐Chancellor in Research Affairs‐Shahid Beheshti University of Medical Sciences. (Approval ID: IR.SBMU.RETECH.REC.1400.204).

TRANSPARENCY STATEMENT

The lead author (manuscript guarantor) affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.