Family Resilience, Media Exposure, and Children's Mental Health in China During COVID-19
Abstract
This study aims to describe children's mental health conditions in the time of COVID-19 and its associations with the risk factor (media exposure) and the protective factor (family resilience) during COVID-19. The study took place from February 13th to February 29th, 2020, at the peak of the outbreak all across China. In total 441 children (M = 11.83 years old, SD = 0.79) from Jiangxi province, China, filled out online surveys. The results showed that children's rates of depression were relatively high and post-traumatic stress disorder (PTSD) rates were low. Based on the results of multiple linear regression analyses, family resilience was negatively associated with children's mental health issues including depression, anxiety, PTSD, and poor sleep quality counting the effects of children's age, gender, and media exposure. Children's media exposure to COVID-related news reports did not significantly contribute to the total variance of children's mental health symptoms. The findings guide the development of prevention and interventions to mobilize families’ strengths and resilience for reducing children's maladjustment during the occurrence of pandemics.
The COVID-19 pandemic has significantly affected the psychological well-being of the general populations around the world including children in an unforeseeable way (Duan et al., 2020; Singh et al., 2020). Because children infected with COVID-19 were found to show milder clinical symptoms and lower rates of infection and mortality than adults. Mental health professionals paid less attention to children's mental health problems at the early stage of the COVID-19 outbreak (Imran et al., 2020). More literature on children's psychological adaptation during the COVID-19 pandemic is emerging. However, most articles are literature reviews of empirical studies on children experiencing local disasters such as tsunami or pandemics such as H1N1 (Imran et al., 2020; Loades et al., 2020). Among few empirical studies that investigated children's mental health conditions during COVID-19, children showed a higher level of depression, anxiety, irritability, lack of attention, and persistent inquiry than prior to the pandemic (Drouin et al., 2020; Duan et al., 2020; Jiao et al., 2020; Viner et al., 2020). Those adverse outcomes may be related to the interruption of routines and education, lack of in-person interaction with peers and teachers, limited physical exercise and personal space, and longer screen time due to school closure and home confinement (Brooks et al., 2020).
Adaptation to a pandemic is a dynamic process and involves multiple levels of interactions between individuals within a changing context such as family (Masten & Narayan, 2012). However, when designing psychosocial prevention and intervention during or after natural disasters, war, pandemics, and terrorism, which are collective trauma, intervention at the family level is often ignored (Masten & Obradovic, 2008). Developing such a family-based intervention requires a better understanding of the protective factors and risk factors for children's mental health conditions during the pandemic. Furthermore, children's adjustment and its salience factors are always shaped by the cultural contexts in which families are embedded (Masten & Monn, 2015). In this study, we aimed to describe the rates of children's mental health issues during the COVID-19 outbreak in China and examine how two of the salient risk and protective factors (i.e., children's media exposure to COVID-19 related news and family resilience) (Masten & Narayan, 2012) are associated with children's symptoms of anxiety, depression, post-traumatic stress disorder (PTSD), and sleep quality. Given children across the world experience quarantine due to the spread of COVID-19 and other infectious diseases, this study sheds light to the pressing need of conducting family studies and implementing evidence-based programs that mobilize families’ strengths and resilience to meet children's mental health needs during and post-pandemic (Singh et al., 2020).
COVID-19: A Multisystem Disaster
Disaster is defined as a severe ecological and psychosocial interruption that largely goes beyond the coping capacity of the community (World Health Organization, 1992). Masten and Motti-Stefanidi (2020) considered the Covid-19 pandemic as a multisystem disaster. It does not only cause risks of infections and death at the individual level but also disrupt the functions of all social systems important to human life and well-being. Those social systems include economies, education, health care, family life, transportation, manufacturing, government, and recreation services.
Furthermore, compared to many major disasters (e.g., hurricane) that are local and short-term with ripple effects over time, pandemics such as Covid-19 are disasters that can persist over months and even years (Walsh, 2020). The responses to other disasters often encourage convergence and gathering in shelters. However, responses to pandemics include isolation, separation, and quarantine (Sprang & Silman, 2013). During the COVID-19 pandemic, a large population throughout the world experience ongoing home confinement, quarantine, and isolation. While quarantine is deemed necessary to eliminate the spread, it inhibits the function of societal structures and infrastructures by increasing social isolation and challenging individuals and families to adjust their rituals, norms, communication, and values to adapt to the outbreak (Fiese & Spagnola, 2007). As a result, individuals are experiencing intense fear of being infected, loneliness, panic, anxiety, and depression while families are undergoing a tremendous sense of loss (Walsh, 2020; Xiang et al., 2020). Families who lost their loved ones because of COVID-19 are dealing with the loss of tragic deaths (Walsh, 2020). Families who do not reside in the epicenter of the outbreak lose senses of normalcy, connection with others and security (Walsh, 2020).
Bronfenbrenner's bioecological theory provides a useful conceptual framework to understand children's mental health conditions during COVID-19. Bronfenbrenner (1979) stated that human development is nested within five systems of interaction and the former system is embedded in the latter system: microsystem, mesosystem, exosystem, macrosystem, and chronosystem. In Bronfenbrenner's model, the individual child interacts with his or her microsystems, which include family, peers, and schools. Facing a pandemic such as COVID-19, family is the primary microsystem children interact in their immediate environments on a regular basis due to limited contact with peers and school closure. Families typically live together, quarantine together, worship together, and cope together (Masten & Obradovic, 2008). Physically they can infect each other if one individual is diagnosed. Psychologically they can acquire each other's fear and anxiety. Parents play a key role in this proximal process reflected by their own behaviors and interaction with children. Beyond the microsystem, children are also influenced indirectly by the connections of family members, teachers, and others to additional systems, known as mesosystems. During the pandemic, parents may navigate resources from school and intermediate environment to support children's at-home learning and mental health conditions.
On a larger scale, child development is affected by the operations of exosystems such as community, media, and national policy. The last two systems are the macrosystem (e.g., cultural and economic conditions of the society) and the chronosystem (i.e., the nested relationships are located in time). To summarize, children's mental health conditions are embedded within the interactions across multiple levels of systems. This study investigated children's mental health condition and its associations with two of the salient factors-family resilience (exists in both the microsystems and mesosystems) and media exposure to COVID-19 related news reports situated at the exosystem within the Chinese cultural context (the macrosystem).
Children’s Mental Health Conditions during COVID-19
Previous studies on children who experienced disasters suggested that children might undergo a greater level of stress than adults due to their physical, emotional, cognitive development and coping abilities (Shaw et al., 2012). The prevalence of depression, anxiety, and poor sleep quality among adults was elevated during the outbreak of COVID-19 (Gao et al., 2020; Huang & Zhao, 2020). Moreover, in a study conducted in the United States, 49.6% of the 260 parents reported moderate or severe anxiety symptoms while 62.7% of them stated their child experiencing anxiety symptoms (Drouin et al., 2020). A preliminary study found that 320 children aged 6 to 18 years in Shannxi Province of China in early February 2020 demonstrated a higher level of inattention and persistent inquiry than children aged from 3 to 6 years (Jiao et al., 2020). Based on parents’ reports, children felt uncertain and isolated during the quarantine due to the disruption in their education and daily routine, lack of socialization opportunities, and limited physical activities (Jiao et al., 2020). Another study indicated that 22.28% of a sample comprised of 3613 Chinese children and adolescents met the diagnosis for clinical depression during COVID-19 according to children's self-report, which were much higher than the generally estimated 13.2% among Chinese children (Duan et al., 2020; Stewart & Sun, 2007).
Although the influence of a pandemic including quarantine on children's adaptation is usually short-term, some children may develop PTSD following a pandemic, which may persist for months to years (Murray, 2010). A study on the influence of influenza A (H1N1) pandemic found children who were isolated or quarantined showed a higher likelihood (30%) to meet the criteria for PTSD than those who were not isolated or quarantined (Sprang & Silman, 2013). School-aged children can understand an infectious pandemic at a higher level than children at a younger age (Murray, 2010). However, they are still vulnerable to stress reactions and experience adjustment issues such as social withdrawal, fluctuations in mood, fear of death, decreased interests in daily activities, sleep difficulties, and nightmares (Murray, 2010).
Children's Mental Health and Family Resilience
Grounded in family systems theory, family resilience is defined as the ability of a family system to adapt and prosper from adversity with a personal and relational transformation throughout the adaptive process (Walsh, 2003, 2016). Family resilience recognizes the interdependent nature of family relationships that enables a family system to collectively organize resources and strengths that promote family well-being as well as individual resilience. Walsh (2007, 2016) identified three key processes for promoting family resilience to cope with trauma: family belief systems, organization patterns, and communication processes. Based on Walsh's work, resilient families are capable of making meaning of crisis situations and maintaining a hopeful outlook. Family resilience can be promoted through family connectedness, flexibility in the family's organization, shared leadership, and mutual support when facing life challenges. In addition, family resilience can be reflected by the family communication processes that foster open emotional expression and empathy and build a collaborative problem-solving team to stay proactive when action needs to be taken.
The concept of family resilience for investigating children's mental health problems is particularly important within the context of COVID-19 because it captures both the microsystem (i.e., family strengths) and the mesosystem (family searching for community resources). Family factors are strong predictors of the child's response to catastrophic events (Masten & Obradovic, 2008; Shaw et al., 2012). For school-aged children including adolescents who need support from communities, school systems, and peers, their resources are constrained because of home confinement. They must largely rely on their family to provide support and navigate resources during home confinement. Parents manage their children's exposure to COVID-related information and help children regulate their stress-related reaction. How the family adapts its belief systems, organization, ways of communication, and problem-solving to deal with the pandemic certainly has important implications for children's psychological adjustment. Family resilience is a prominent factor across the microsystem and mesosystem that may be negatively related to children's mental health problems during COVID-19.
To our knowledge, the relationship between family resilience and children's mental health conditions during outbreaks of pandemics has not yet been explored, particularly in a collectivist culture (Main et al., 2011). Because family resilience is shaped by the cultural contexts in which families are embedded (Masten & Monn, 2015), it is important to understand how family resilience is defined and related to children's mental health problems in different cultures (the macrosystem). Most of the studies on family resilience were conducted in western countries and several studies were completed in collectivist culture such as Singapore, India, South Africa, and China but only qualitative methods were used (Chang et al., 2015; Faqurudheen et al., 2014; Li et al., 2018; Theron & Theron, 2013). The qualitative studies suggest that individuals in Asian countries that emphasize family-oriented cultural values cope collectively-people coped as an integrated family unit rather than isolated individuals in the coping process (Chang et al., 2015; Chang & Sivam, 2004). One study investigated family resilience among 30 nurses in Singapore who worked with severe acute respiratory syndrome (SARS) patients through ethnographic interviews (Chang et al., 2015). When asked how to cope with stress, the common themes participants identified include “involving the family as a unit, being united, shared family belief systems, hope and positive outlook, interaction and information sharing within the family, engage practical attitudes and strategies in dealing with stressful situations during the SARS outbreak” (Chang et al., 2015, p. 1596). It is important to investigate the relationship between family resilience and Chinese children's psychological functioning during COVID-19 outbreak using a quantitative method. It may provide empirical evidence for considering family resilience as a protective factor for children's adjustment during the pandemic and contribute to the development of family-based prevention and interventions in a collectivist culture.
There are three ways for children to be exposed to trauma, including a direct experience of its impact, an observation of trauma and harm indirectly and visually via media exposure, and a direct contact with trauma survivors and others who are directly affected by trauma (Shaw et al., 2012). Previous studies pointed out that indirect exposure to mass trauma through media increased psychological problems such as PTSD because overloaded information triggered fears (Choi et al., 2017; Neria & Sullivan, 2011). Empirical studies suggested a positive association between mental health symptoms of adults and their media exposure during the outbreak of COVID-19 (Gao et al., 2020). However, few empirical studies have investigated the relationship between children's mental health condition and media exposure to COVID-19 related news reports during a pandemic. During a pandemic, children's exposure to media such as television, Internet, and social network sites is inevitable because of home confinement and online learning even though parents may try to limit such exposure (Murray, 2010). Children's exposure to trauma may be related to their media exposure that includes massive negative news (Schuster et al., 2001). Inaccurate information and false reports about COVID-19 appeared on Internet and media and made it difficult for the public to identify truthful information and caused more fears among the general populations (Gao et al., 2020). For children who live far from the epicenters, they may experience the distant stressor, “a traumatic stimulus experienced from a remote and physical safe distance away from the impact zone” (Shaw et al., 2012, p. 8). For example, one-third of children in a national survey who watched television coverage of the 9/11 attacks reported stress symptoms and 47% were worried about their own safety (Schuster et al., 2001). Because media is one important factor located in the exosystems of children's adaptation which also affects the microsystem (e.g., parents’ monitoring of children's media use), it is important to understand how children's media exposure to COVID-19 news reports is connected to their mental health issues to design prevention and interventions.
The Current Study
The first goal of the current study is to describe the mental health condition of school-aged children (early adolescents) including their depression, anxiety, PTSD, and sleep quality. The second goal of the present study is to examine how family resilience and children's media exposure to COVID-19 related news reports are associated with children's mental health condition during the outbreak of COVID-19 in China. Given the results of some preliminary studies on children's mental health symptoms during the COVID-19 pandemic, we hypothesized that children would show a high level of depression, anxiety, and PTSD symptoms and demonstrate poor sleep quality. Regarding the second goal, we hypothesized that children's depression, anxiety, PTSD, and poor sleep quality are negatively related to family resilience and positively related to media exposure based on the existing literature. Because of the cross-sectional nature, no longitudinal associations or causal relationship among those variables were tested.
Methods
Procedures and Participants
This study was approved by the Ethics Committee of the School of Psychology in the Nanjing Normal University at Nanjing, China. Two elementary schools in Nanjing, Jiangsu province of China were selected for the current study. With permission from the school, the study was introduced to children and their parents of the schools through an online survey platform. Parents were informed about the nature, benefits, and risks of the study and their written consents were obtained for the children's participation in the study before children began filling out the survey. Data collection took place from February 13th to February 29th, 2020, at the peak of the outbreak all across China, during which all children and their parents were staying at home responding to the unprecedented quarantine order. It was also during China's Spring Festival holiday when people usually travel around the country to visit families. Children were instructed to fill out the questionnaires alone, which took about 15 min to complete, through the same online survey platform. After completing the questionnaires, children were offered three one-hour online psychoeducation services at their convenience. A total of 441 children (242 boys and 199 girls) completed the survey and all of them lived in Jiangsu province, China. The age of the sample ranged from 11 to 14 years old with an average age of 11.83 years old (SD = 0.79).
Measures
Demographic questionnaire
We used a self-designed questionnaire to measure the demographic information of children during this disaster. The questionnaire included three variables: gender, age, and media exposure to COVID-related news reports. The media exposure measure included four self-designed questions: (1) How much do you care about the COVID-related media reports? This question was rated on a five-point Likert scale from 1 (do not care) to 5 (care very much); (2) How much time do you spend on reading and watching COVID-related news reports every day? This question was also rated on a five-point Likert scale from 1 (less than 1 h) to 5 (more than 5 h); (3) What do you think of the number of media reports of the outbreak? This question was also rated on a five-point Likert scale from 1 (very insufficient) to 5 (too much); (4) How many media reports about the outbreak have you received on the latest day? These questions were rated by children on a five-point Likert scale from 1 (very insufficient) to 5 (too much). For all questions, a higher score indicates a higher degree of exposure to the disaster.
Anxiety
Anxiety was measured by the Self-Rating Anxiety Scale (Zung, 1971). The scale was tested to have good reliability and validity in the Chinese population (Liu & Peng, 1995). Although this scale was used mostly among adults, several studies supported its validity and reliability among children and adolescents between 11 years to 18 years in China and Italy (Masi et al., 2002; Xu et al., 2011). There are 20 items in this scale, and they are scored on a four-point Likert scale with 1 representing “no or little time” and 4 representing “most or all time”. Example items include “I am troubled with headaches, neck pain and backache.” This scale demonstrated good internal consistency reliability with Cronbach's α at 0.73 in this study.
PTSD
PTSD was assessed using the Child PTSD Symptom Scale (Foa et al., 2001) designed to assess the occurrence and frequency of PTSD symptoms in relation to the most distressing event experienced by an individual. It is a 17-item self-report scale rated on four-point Likert scales ranging from 0 (not at all/only once) to 3 (almost always or more times a week). There are four subscales named invasive symptoms, avoidant symptoms, negative cognitive and emotional disorders symptoms, and hypervigilant symptoms. An overall severity score is generated by summing the scores for the four symptom types. A higher score indicates more severe levels of PTSD. An example item includes “I had a flashback about sad thoughts or images of the trauma.” According to the diagnostic criteria of PTSD in Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (American Psychiatric Association, 2013), individuals were categorized as having a “high risk of PTSD” if they met the following four criteria at the same time: (1) at least 1 of the 5 items for assessing invasive symptoms scored equal to or more than 2 points; (2) at least 1 of the 2 items for assessing avoidant symptoms scored equal to or more than 2 points; (3) at least 2 out of 7 items for assessing negative cognitive and emotional disorders symptoms scored equal to or more than 2 points; and (4) at least 2 out of 6 items for assessing hypervigilant symptoms scored equal to or more than 2 points. The scale was tested to have good reliability and validity in the Chinese population (Ying et al., 2013). In this study, this scale demonstrated good internal consistency reliability with Cronbach's α at 0.91.
Depression
Depression was assessed using the Center for Epidemiologic Studies Depression Scale for Children, developed by Radloff (1977), and revised by Wang (1993). The scale is used for epidemiological investigation of depression among the general population, focusing on the measurement of emotional components of depression. It is widely used in the measurement of depression among children and adolescents in China, with good reliability and validity (Fan et al., 2018; Wang et al., 1999). There are 20 questions in this scale and participants were asked to rate the frequency of their symptoms in the latest week from “0” (never) to “3” (always). Higher scores indicate a more serious degree of depression. Example items include “I had trouble keeping my mind on what I was doing.” The cut-off score for the presence of depression is 16 (Radloff, 1977). The scale was tested to have good reliability and validity in the Chinese population (Wang, 1993). The Cronbach's score coefficient of the scale was 0.83 in the current study.
Sleep quality
Sleep quality was measured using “subjective sleep quality” from the Pittsburgh Sleep Quality Index (PSQI), compiled by Buysse et al. (1989) and revised by Liu et al. (1996). The exact item is “During the past month, how would you rate your sleep quality overall?” and with a four-point Likert scale from “very good” to “very bad.” The PSQI scale is tested to have good reliability and validity in the Chinese population and has adequate psychometric properties to assess sleep quality among adolescents (de la Vega et al., 2015; Liu et al., 1996).
Family resilience
Family resilience was measured by the shortened Chinese version of the Family Resilience Assessment Scale, compiled by Sixbey (2005), and revised by Li et al. (2016). This Chinese version of the scale was tested to have good reliability and validity in the Chinese population (Li et al., 2016). The psychometrics of the Chinese version of this scale including concurrent validity, internal reliability, and test-retest reliability have been established based on a study of 1478 Chinese children and adolescents in a recent study (Yue et al., under review). The scale has 40 items, including four dimensions named family communication and problem-solving, maintaining a positive outlook, family connectedness, and utilizing social and community resources, respectively. The scale is scored on a four-point Likert scale, with 1 representing “strongly disagree” and 4 representing “strongly agree.” Higher scores represented higher levels of family resilience. An example item for family communication and problem-solving include “My family and I would try new ways to solve problems.” A sample item for positive outlook is “We hold a positive attitude towards problem and its resolution.” A sample statement for family connectedness is “Our family structure is flexible to deal with the unexpected.” An example item for social and community resources includes “We can trust and rely on people in the community.” In this study, the internal consistency reliability of the scale was 0.98.
Statistical Analyses
To achieve the first research aim, descriptive statistics were computed for the participants’ demographic characteristics including gender, and for their mental health symptoms. T-tests and analysis of variance with Tukey post-hoc tests were conducted to identify differences in children's depression, anxiety, PTSD, and sleep quality by demographic variables. To achieve the second research aim, correlations were computed to determine the associations between children's media exposure, family resilience, and their mental health problems including depression, anxiety, PTSD, and sleep quality. Then multiple linear regression analyses were conducted for children's anxiety, depression, PTSD, and sleep quality. Children's demographic variables including children's age and gender, the four media exposure items, and the total score of family resilience were included in each regression model predicting children's mental health adjustment. Assumptions of normality and homogeneity of variance were met. Multicollinearity was assessed by computing variance inflation factors (VIF), which were acceptable at less than 10 (Cohen et al., 2003). Data were analyzed using SPSS v22.0. No missing data existed in this study.
Results
The descriptive statistics of the key variables were presented in Table 1. To examine the first aim, the prevalence of children's depression was 19.1% (n = 84) according to the cut-offs and classification of scoring established for the depression self-rating scale (Radloff, 1977). According to the diagnostic criteria for PTSD (American Psychiatric Association, 2013; Foa et al., 2001), the prevalence of PTSD was 2.04% (n = 9). There was no significant difference between boys and girls and among different ages in anxiety, depression, PTSD, and sleep quality. Children on average spent 1.77 h daily watching COVID-19 related media reports (SD = 0.82, median = 2 h, range 1–5 h).
| M | SD | Median | Range | Skew | Kurtosis | |
|---|---|---|---|---|---|---|
| Age | 11.83 | 0.79 | 12 | 11–14 | 0.57 | −0.48 |
| Care about media exposure | 4.30 | 0.94 | 5 | 1–5 | −1.26 | 0.75 |
| Time exposed to media | 1.77 | 0.82 | 2 | 1–5 | 1.13 | 1.49 |
| Perception of the number of media reports | 2.92 | 0.57 | 3 | 1–5 | −0.16 | 5.70 |
| The number of media reports received | 2.98 | 0.66 | 3 | 1–5 | 0.26 | 3.84 |
| Family resilience | 142.41 | 17.83 | 149 | 80–160 | −0.75 | −0.40 |
| Anxiety | 36.55 | 7.42 | 36 | 25–62 | 0.64 | 0.11 |
| Depression | 10.17 | 7.30 | 9 | 0–35 | 1.08 | 0.73 |
| PTSD | 7.63 | 7.96 | 5 | 0–37 | 1.30 | 1.21 |
| Sleep quality | 0.41 | 0.59 | 0 | 0–2 | 1.15 | 0.31 |
Abbreviations: PTSD, post-traumatic stress disorder; SD, standard deviation
To test part of the second aim, the correlations among key variables were conducted and shown in Table 2. The results indicated that four items of children's media exposure were significantly and positively correlated with each other (p < 0.05) except no significant correlation between children's time exposed to COVID-related news reports and their perception of the number of news reports. Family resilience was significantly and positively correlated with care about COVID-related news exposure (p < 0.01). Anxiety, depression, PTSD, and sleep quality were significantly and positively related to each other (p < 0.001), and all significantly and negatively related to family resilience (p < 0.001).
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |
|---|---|---|---|---|---|---|---|---|---|
| 1 Age | – | ||||||||
| 2 Care about COVID-related news reports | −0.01 | – | |||||||
| 3 Time exposed to COVID-related news reports | 0.05 | 0.29*** | – | ||||||
| 4 Perception of the number of COVID-related news reports | −0.01 | 0.11* | 0.07 | – | |||||
| 5 The number of COVID-related news reports received | −0.002 | 0.16** | 0.10* | 0.51*** | – | ||||
| 6 Family resilience | 0.04 | 0.14** | 0.06 | 0.02 | 0.01 | – | |||
| 7 Anxiety | 0.02 | −0.06 | −0.05 | 0.07 | 0.06 | −0.33*** | – | ||
| 8 Depression | 0.002 | −0.08 | −0.02 | −0.01 | 0.01 | −0.46*** | 0.71*** | – | |
| 9 PTSD | −0.02 | 0.05 | 0.03 | 0.02 | 0.02 | −0.40*** | 0.45*** | 0.68*** | – |
| 10 Sleep quality | 0.07 | 0.001 | 0.09 | −0.08 | 0.01 | −0.25*** | 0.26*** | 0.23*** | 0.34*** |
Abbreviation: PTSD, post-traumatic stress disorder
Note: ***p < 0.001, ** p < 0.01, * p < 0.05.
In support of the second research aim, four multiple linear regression analyses were computed with each of children's mental health symptoms as dependent variables and children's age, gender, family resilience, and their media exposure to COVID-related news reports as independent variables (see Table 3). For children's anxiety, depression, PTSD, and sleep quality, the adjusted R2 of each regression models were .10, .20, .16, and .07. Family resilience was significant in all four models and was negatively associated with children's anxiety, depression, PTSD, and sleep quality. For children's PTSD, Children's care about COVID-related news reports was significant in the model and it was positively related to children's PTSD. For children's sleep quality, their perception of the number of COVID-related news reports was negatively related to their sleep quality in the model.
| Variable | Predictor | B | β | t |
|---|---|---|---|---|
| Anxiety | Gender | −0.14 | −0.01 | −0.21 |
| Age | 0.32 | 0.03 | 0.75 | |
| Care about media exposure | −0.12 | −0.02 | −0.31 | |
| Time exposed to media | −0.33 | −0.04 | −0.76 | |
| Perception of the number of media reports | 0.71 | 0.06 | 1.04 | |
| The number of media reports received | 0.48 | 0.04 | 0.81 | |
| Family resilience | −0.14 | −0.34 | −7.21*** | |
| Depression | Gender | 0.19 | 0.01 | 0.30 |
| Age | 0.17 | 0.02 | 0.43 | |
| Care about media exposure | −0.13 | −0.02 | −0.36 | |
| Time exposed to media | 0.11 | 0.01 | 0.28 | |
| Perception of the number of media reports | −0.05 | −0.004 | −0.08 | |
| The number of media reports received | 0.16 | 0.01 | 0.28 | |
| Family resilience | −0.19 | −0.46 | −10.71*** | |
| PTSD | Gender | 0.42 | 0.03 | 0.60 |
| Age | −0.003 | <0.001 | −0.01 | |
| Care about media exposure | 0.87 | 0.10 | 2.20* | |
| Time exposed to media | 0.22 | 0.02 | 0.49 | |
| Perception of the number of media reports | 0.17 | 0.01 | 0.24 | |
| The number of media reports received | −0.05 | −0.004 | −0.09 | |
| Family resilience | −0.19 | −0.42 | −9.39*** | |
| Sleep quality | Gender | 0.02 | 0.02 | 0.35 |
| Age | 0.06 | 0.08 | 1.62 | |
| Care about media exposure | 0.01 | 0.01 | 0.29 | |
| Time exposed to media | 0.07 | 0.10 | 1.98 | |
| Perception of the number of media reports | −0.12 | −0.11 | −2.15* | |
| The number of media reports received | 0.05 | 0.06 | 1.05 | |
| Family resilience | −0.01 | −0.26 | −5.60*** |
Abbreviation: PTSD, post-traumatic stress disorder
Note: B = unstandardized beta; β = standardized regression weight. ***p < 0.001, ** p < 0.01, * p < 0.05.
Discussion
Due to limited empirical studies on examining children's mental health and its associations with media exposure and family resilience during a pandemic, we believe that our study makes a unique contribution to the design of prevention and intervention programs that target children's healthy adjustment and strengths during and after a pandemic. Children's depression rate (19.1%) in the current study is higher than the generally estimated 13.2% among Chinese children (Stewart & Sun, 2007) despite low PTSD rates. COVID-19 may particularly challenge children's beliefs that they are always safe and protected by their parents and community in a way that they need to reassess their beliefs and cognitively assimilate and generate meanings about how the world works and why the disease happens. In addition to cognitive adjustment, developmentally it is difficult for children to cope with isolation, separation from school and peers, and identify and regulate difficult emotions (Jiao et al., 2020). It may increase children's depression during the occurrence of COVID-19. Because participants filled out the surveys in early February was the period when COVID-19 was approaching its peak in China and they did not reside in the epicenters, it is reasonable that their PTSD rates were not high. The descriptive results showed that children's rate of depression was lower than that in a recent study (22.28%; Duan et al., 2020) which was conducted at a similar time with the 99.25% of the sample lived in the non-epicenter areas.
Different from our hypothesis, most of the children's media items did not significantly contribute to the total variance of children's depression, anxiety, PTSD, and sleep quality. The children in this sample on average watched 1.77 h of COVID-19 related news (SD = 0.82) daily. Perhaps because they were not highly exposed to media, their anxiety and depression were not significantly affected by their media exposure. Although this finding needs to be replicated, this result may be generalized to parents not located in the epicenter who might keep their children's media exposure limited. However, there were some exceptions. Children's subjective view of the number of the COVID-19 news was negatively associated with good sleep quality. Perhaps children who viewed the number of COVID-19 related news reports as too much might be affected by the news report and thus have poor sleep quality.
Few empirical studies have investigated family resilience and family/relational systems within the context of an outbreak of disease. The current study showed that family resilience was negatively associated with children's mental health issues including depression, anxiety, PTSD, and poor sleep quality counting the effects of children's age, gender, and media exposure. Consistent with the findings in the western countries where family resilience is negatively associated with children's psychosocial problems (Lester et al., 2013), the current study indicates that family resilience can potentially serve as a protective factor for reducing children's mental health problems during a pandemic such as COVID-19. Although these findings need to be replicated in future research, it is possible that family resilience in the micro and mesosystem is more important to buffer the impact of COVID-19 on the mental health symptoms of children residing in non-epicenter areas than children's media exposure to COVID-19 news which is situated in the exosystem when children's media consumption is not high. Because children are confined at home and the family is their microsystem, their families may discover untapped resources (e.g., childcare, educational, and financial resources), the networks and communities around the family in the mesosystem to help all individuals within the family unit to navigate the challenges brought by the outbreak. A study investigating the relationship between resilience and family resilience among 104 Chinese patients with Inflammatory Bowel Disease in China suggested that perception of change as beneficial and growth-producing and proactive orientation in managing stressful situations predicted individual resilience (Li et al., 2017). Because individuals’ resilience is embedded in interdependent family and social systems, family resilience may strengthen children's individual resilience that buffers the negative effects of traumatic exposure of COVID-19 on their mental health problems.
Theoretical and Clinical Implications
The current study suggests that family resilience may be an important concept to understand children's coping and recovery process in China from a family system's perspective. The findings provide preliminary evidence for the benefits of developing family-based interventions that promote family resilience for children's healthy development during and after a pandemic such as COVID-19. Family-based interventions promoting family resilience may be particularly beneficial for reducing children's mental health issues in a collectivist culture. During COVID-19, the Chinese government announced a series of national and provincial policies to implement emergency psychological crisis interventions for the COVID-19 outbreak (National Health Commission of China, 2020). However, most of them were individual-focused treatments (Zhou et al., 2020). Although family is considered the major social support in a collectivist culture, one of the reasons for the lack of family-based interventions is the traditional Chinese belief, “don't wash your dirty linen in public” (Deng et al., 2013). It leads to some Chinese families’ reluctance to seek family-based interventions. Compared to psychopathology, studies showed that Asian populations respond favorably to topics that are strength-based, including psychological well-being, happiness, resilience, and post-traumatic growth (e.g., Morelli et al., 2000). Therefore, family-based prevention and interventions that foster family resilience may engage Chinese families to utilize their strengths and resources to cope with the pandemic. Family educators and mental health professionals may want to invite children's primary caregivers to attend family interventions with the children. They can implement behavioral interventions to facilitate families’ open communication and problem-solving skills, conduct cognitive interventions to enhance families’ optimism by reframing the challenge as an opportunity to unite the whole family and accept what is beyond their control, establish stability by navigating structural reorganization in the families.
Limitations and Future Directions
This study makes a unique contribution to the field by exploring children's mental health issues during the outbreak of COVID-19 and its potential predicting factors, but it is not without limitations. First, the recruitment method for this sample may have affected its representativeness of the general population (e.g., reporting only on children who were enrolled in two elementary schools). Second, few demographic information about the family was collected which limited the understanding of the children's family background's associations with children's adjustment, media use and family resilience during COVID-19.
Future research on children's mental health adjustments during pandemics such as COVID-19 would help mental health clinicians and families better understand the risk and protective factors and how to provide effective treatment to prevent and intervene children's mental health problems. Longitudinal studies during and after a pandemic would allow researchers to test causal and bi-directional relationships between children's media exposure, mental health problems, and family resilience. Future research can include both parents’ reports as well as children's reports to obtain family-level data, such as family structure, family income, parents’ marital status, and parents’ employment status, which can provide a more thorough view of children's mental health issues and family relationships within the family socioeconomic contexts. For example, changes in family structure and living arrangements and parents’ employment status due to COVID-19 may enrich or limit families’ resources to cope with challenges, which will ultimately affect parental support for children's healthy adjustment. Moreover, future studies should seek to better understand children's adaptive behaviors and individual resilience beyond mental health problems. In addition, the impact of different types of media sources (television, Instagram, Twitter, and Facebook) on children's mental health condition can be studied. Finally, this study should be replicated in individualist culture to test cultural differences.
Conclusion
This study contributes to the knowledge of children's mental health condition during a pandemic and how two important factors – media exposure to COVID-related news reports and family resilience – are related to children's adjustment using a relatively large sample. The results support the potential benefits of improving family resilience for reducing children's mental health problems due to COVID-19 and yield crucial implications for the design of family-based preventions and interventions.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.
ORCID iDs
Xiaohui Sophie Li https://orcid.org/0000-0002-4851-4786
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