Pandemic life in families with health anxiety symptoms, parental perspectives

The study was nested in the OCC which is an ongoing population-based prospective birth cohort study on maternal and child health. Between January 1^st, 2010, and December 31^st, 2012, every newly pregnant woman (n = 6,707) in the municipality of Odense, Denmark, was invited to participate in the cohort study (14). Two previously described consecutive cross-sectional studies were performed during the covid-19 pandemic in Denmark (15, 16). In the first study, a questionnaire addressing child HA symptoms, covid-19 exposure, and parental HA symptoms was sent out to 7–9-year-old children and their parents from the OCC via email. Recruitment for the current study was part of the study design of the second study (16).

The study sample was recruited from the group of parents who had provided consent for participation in this qualitative interview in study two (16). The inclusion criteria were: high child HA symptom score and high parental HA symptom score in both questionnaires. Child HA symptoms were assessed with the Childhood Illness Attitude scales (CIAS), which is a self-report measure for 8–15-year-old children (18). High score child HA symptoms were defined as children with a fear factor CIAS score > 90th percentile in the study sample of the 2020 study (15). The cut-off was a pragmatic choice based on previous studies of HA in children, as no cut-off score for clinically significant HA has been defined (15). Parental HA symptoms had been assessed by the Whiteley Index 6 (WI-6), a widely used self-report measure exploring respondents’ fear of being ill and whether they attribute current bodily sensations to physical diseases (19). High score maternal and/or paternal HA symptoms were defined as WI-6 scores > 75th percentile in the study of the 2020 study (15). The exclusion criteria were: participants who could not speak and/or understand the Danish language. The pre-planned sampling strategy aimed for variation regarding child sex, parental sex, parental marital status, parental education, and covid-19 vaccination status. Aliases were used for all participant names to ensure anonymity.

In-depth individual semi-structured interviews were conducted by the first author (IKD) throughout May and June 2022. The interview setting was decided by the participants (the research unit of Child and Adolescent Psychiatry Odense or online). The interview guide was prepared in advance, and research questions were discussed and agreed upon by the entire research team. Furthermore, after the first interview, IKD and DH discussed the interview guide and made minor adjustments. The research questions focused on various aspects of the pandemic’s impact on the family life, the parent’s experience of their child’s worries, including HA-related symptoms, and how the parents dealt with their child’s concerns. All interviews were audio recorded, and field notes were taken after each interview. The interview guide with selected sub-questions is attached in Appendix 1.

The research group consisted of one female medical tudent (IKD) and three senior researchers (DH, NB, CUR), all of whom were consultants in child and adolescent psychiatry. DH and CUR had experience with qualitative research and IPA. DH supervised IKD on interview technique. The interviews were transcribed verbatim by IKD in the original language (Danish) using a transcription guide. Quotes were translated for publication. The coding of the interviews was assisted by NVivo 12 software (20) and performed according to IPA principles (21). An IPA-based structured, stepwise approach to analysis provided the analytical framework. Initial steps involved individual interviews, beginning with thoroughly reading each individual interview while noting initial thoughts and ideas in NVivo “annotations”. Initial themes were coded using the “nodes” function in NVivo. In the next step, connections between themes were explored, and themes were clustered into main and subordinate themes. Selected interviews were independently coded by two researchers (DH and IKD), and similarities and differences in coding were discussed, with main themes agreed upon by consensus decision. Finally, a cross-case analysis was performed. The emerging themes were discussed in plenary within the entire research group, and main themes were decided by consensus decision (17).

This study was conducted in accordance with the second Helsinki Declaration and approved by The Regional Committees on Health Research Ethics for Southern Denmark (J. no. S-20090130).

Furthermore, it was approved by the Danish Data Protection Agency (J. no. 22/21442). Participating parents received written and oral information and provided written consent before the interviews.

The sample consisted of all eligible families who agreed to participate. However, the predefined aims for variation were widely met (Table 1). The recruitment flowchart is displayed in Figure 1. The average interview duration was 45 minutes (ranging from 16 to 82 minutes).

FIGURE 1.

Three main themes were identified, reflecting parental experiences during pandemic life in families with HA symptoms. These themes covered the parental experiences of how the pandemic and its consequences influenced family life, including their child’s anxious thoughts, and how these were expressed as well as perpetuated or relieved within the context of the pandemic. The first theme, Anxious children in a pandemic world, describes how child factors, including pre-pandemic anxiety, may have influenced children’s understanding and reaction to the pandemic. The second theme, Parental influences on child anxiety, portrays parental reflections on how they might influence child worries. The last theme, Living with pandemic guidelines and restrictions, describes how the guidelines and restrictions introduced by Danish authorities were experienced as anxiety-aggravating by some parents and children, while for others, they were anxiety-alleviating. Main themes and sub-themes are illustrated in Figure 2.

FIGURE 2.

Parents described how their child’s pre-pandemic temperament, anxiety, and personal illness beliefs and thoughts affected child behaviours and well-being during the pandemic.

The interview addressed if and how the parents felt that their own worries and anxious thoughts about health, illness, and the pandemic might influence or exacerbate their child’s anxiety. In general, participating parents felt that they did not influence pandemic or health-related anxiety in their children. Still, they were aware of possible influences of their own thoughts and behaviours on their children.

Anny described how, during the pandemic, she was mindful of possible parental influences on their children’s pandemic experiences. She particularly recalled how her own worries about the pandemic was exacerbated, for example when she watched television news.

Anny described a conscious effort throughout the pandemic to keep herself calm and avoid parental “panic”, as she was aware of the risk of transferring panic to her children. Thus, Anny felt that she could avoid influencing or exacerbating anxious thoughts in her children by remaining calm.

Leo described his son to be an anxious child pre-pandemic. During the pandemic, Leo’s son was less troubled by anxiety and enjoyed lockdown life. Leo did not have any examples of how his own pandemic-related fears were transferred from him to his son. However, he explained how, pre-pandemic, his son would be affected by parental worries:

Thus, the father described an awareness that his child was suggestible and would be influenced by parental worries easily. However, he did not describe any similar experiences during the pandemic.

While some of the parents were aware of their children’s suggestibility in relation to anxious thoughts, they generally did not feel that their own pandemic worries influenced possible child HA symptoms. Participating parents felt that they were able to keep their personal anxious thoughts and beliefs in relation to the pandemic hidden from their children and thus not influence pandemic or health-related anxiety in their child.

The participating parents described different perspectives on the interventions, guidelines, and information provided by the Danish government during the pandemic. These were perceived as helpful and anxiety relieving for both themselves and for their children by some parents, while others perceived interventions such as lockdowns and vaccination recommendations and the tone and manor of information delivery, as both stress and anxiety-inducing in child and family.

This study is the first to qualitatively explore the pandemic experience in families where children and one of their parents have reported HA symptoms during the pandemic.

Several measures were taken to increase the validity of the findings of the study. The study was conducted according to the consolidated criteria for reporting qualitative research statement (COREQ), and the criteria were widely met (Appendix 2) (40). Two researchers read and coded the transcribed interviews independently. The analysis was conducted cyclically with several rounds with coding and discussion, and themes were discussed within the entire research group.

Some limitations should be noted. The study focused on parents with high HA symptoms and their perspectives on how various aspects of the pandemic might have influenced their child’s illness-related worries. We know from previous studies that parents' own levels of anxiety also influence how they interpret and report on their child's anxiety (32, 41). Thus, it could have been interesting to also include the perspectives of parents with a normal level of HA for comparison, as well as the perspectives of the children themselves. However, this would have meant a considerably broader focus for the current study. Furthermore, we found it specifically important to understand the views of parents in families who might be more vulnerable due to HA under the pandemic and therefore potentially in need of support. However, these quite strict inclusion criteria meant that the number of eligible families for the study was limited, and the sample size was further reduced by the number of participants who agreed to participate. Fortunately, the included sample still widely met the predefined aims regarding the variation of sample characteristics, but the participants were mainly mothers, as only one father agreed to participate. Finally, the transcribed interviews were not returned to the participants for feedback.

Increased knowledge of parental experiences of pandemic life in families with HA symptoms may inform clinicians on how to best support these families in managing illness-related fears, including HA symptoms in the children. Furthermore, it is relevant for the health policymakers to understand how anxious families may react to pandemic information, guidelines, and restrictions. Politicians should be aware that governmental information and rhetoric could imply blame and be experienced as fearmongering. The results of the current study can inform the development of appropriate information materials for families, health professionals, and government for future use during if another pandemic arises.