International Journal of

Environmental Research
and Public Health

Article
Family Function and Child Adjustment Difficulties in the
COVID-19 Pandemic: An International Study
Sarah Foley 1, *, Farzaneh Badinlou 2,3 , Karin C. Brocki 2 , Matilda A. Frick 2 , Luca Ronchi 4 and Claire Hughes 5,†

1 Moray House School of Education and Sport, University of Edinburgh, Edinburgh EH8 8AQ, UK
2 Department of Psychology, Uppsala University, 751 42 Uppsala, Sweden;
farzaneh.badinlou@psyk.uu.se (F.B.); Karin.Brocki@psyk.uu.se (K.C.B.); matilda.frick@psyk.uu.se (M.A.F.)
3 Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet,
117 63 Stockholm, Sweden
4 Department of Brain and Behavioural Sciences, University of Pavia, 27100 Pavia, Italy; luca.ronchi@unipv.it
5 Centre for Family Research, University of Cambridge, Cambridge CB2 3RQ, UK; ch288@cam.ac.uk
* Correspondence: sarah.foley@ed.ac.uk
† i-FAM COVID-19 Consortium.

Abstract: To estimate specific proximal and distal effects of COVID-19-related restrictions on families
on children’s adjustment problems, we conducted a six-site international study. In total, 2516 parents
from Australia, China, Italy, Sweden, the United Kingdom, and the United States of America living
with a young child (Mage = 5.77, SD = 1.10, range = 3 to 8 years, 47.9% female) completed an
online survey between April and July 2020. The survey included the Strengths and Difficulties



Questionnaire and family risk factors (parent distress, parent–child conflict, couple conflict, and


household chaos) as well as a scale to index COVID-19-related family disruption. Our analyses also
Citation: Foley, S.; Badinlou, F.; included public data on the stringency of national restrictions. Across the six sites, parental responses
Brocki, K.C.; Frick, M.A.; Ronchi, L.; indicated elevated levels of hyperactivity, conduct, and emotion problems in children from families
Hughes, C. Family Function and
characterized by heightened levels of parent distress, parent–child conflict, and household chaos. In
Child Adjustment Difficulties in the
contrast, increased peer problems were more strongly related to COVID-19-related social disruption
COVID-19 Pandemic: An
and stringency measures. Mediation models demonstrated that associations between COVID-19
International Study. Int. J. Environ.
social disruption and child difficulties could be explained by parental distress. Taken together, these
Res. Public Health 2021, 18, 11136.
https://doi.org/10.3390/
results suggest that although the experience of the pandemic differed across countries, associations
ijerph182111136 between COVID-19-related family experiences and child adjustment difficulties were similar in their
nature and magnitude across six different contexts. Programs to support family resilience could help
Academic Editor: Paul B. Tchounwou buffer the impact of the pandemic for two generations.

Received: 20 September 2021 Keywords: COVID-19; child adjustment; family; risk; distress; international
Accepted: 20 October 2021
Published: 23 October 2021

Publisher’s Note: MDPI stays neutral 1. Introduction

with regard to jurisdictional claims in
While the COVID-19 pandemic has dramatically restricted everyone’s lives, its impact
published maps and institutional affil-
on young children may be especially important for at least four reasons. First, according to
iations.
developmental systems theory [1], children’s trajectories and developmental outcomes are
the result of dynamic interactions between individual (e.g., genetic, neural, biological, and
cognitive), family, and contextual factors. Crucially, children’s outcomes show heightened
susceptibility to the influence of family processes, especially during sensitive periods of
Copyright: © 2021 by the authors. development. One such period is the preschool to early school-age years, when children
Licensee MDPI, Basel, Switzerland.
make the important transition to school and begin to develop friendships [2]. Second,
This article is an open access article
compared with older school-aged children and adolescents, young children spend much of
distributed under the terms and
their time near parents and so may be indirectly affected by the impact of the pandemic via
conditions of the Creative Commons
parental wellbeing and availability (e.g., [3]). Third, young children lack the experience
Attribution (CC BY) license (https://
and skills needed to maintain social relationships via virtual platforms, so their social
creativecommons.org/licenses/by/
4.0/).
interactions depend upon face-to-face contact and outdoor play [4]. Fourth, difficulties in

Int. J. Environ. Res. Public Health 2021, 18, 11136. https://doi.org/10.3390/ijerph182111136 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021, 18, 11136 2 of 14

understanding health risks may amplify the stress associated with changes and restrictions,
for example, “stay-at-home” rules and mass school closures.

1.1. Cascading Effects of COVID-19 Experiences on Child Adjustment

During times of stress and crisis, children are likely to require closer contact with
caregivers [1,5]. Evidence to support this view comes from reports of increased child
clinginess, distractibility, and irritability during the pandemic [6,7]. Compounding these
child demands, the pandemic has also generated widespread financial strain, family
conflict, and concern for loved ones [8], while mass school closures have obliged many
working parents to deliver home-schooling, further escalating parent stress [9]. Parental
distress in response to these multiple stressors may have cascading effects on child mental
health [10], as illustrated by worrying evidence of a significant increase in child abuse dur-
ing the pandemic [11]. In presenting this conceptual framework, Prime and colleagues [10]
draw on evidence illustrating both direct and indirect adverse effects of natural disas-
ters/economic crashes on parent wellbeing, with negative consequences for children.
To date, research on the impact of the pandemic on young children has typically relied
on data from single-site samples, raising questions regarding the generalizability of the
study findings. This is significant as developmental systems theory (e.g., [12]) emphasizes
the importance of interactions between familial and societal factors (i.e., micro and macro
levels of influence) that vary across time and place. Contrasts in both levels of virus
transmission and political motivations have led to significant between-country variation in
responses to the COVID-19 pandemic (c.f. [13]) such that families have had markedly dif-
ferent pandemic experiences. This between-country variation accentuates within-country
socioeconomic and racial inequalities. Focusing on between-country differences, the cur-
rent study adopted an international design combining data from six different countries to
estimate specific effects of COVID-19-related experiences on child adjustment difficulties.
Informed by Prime’s theoretical framework [10], we also sought to test whether the effect
of COVID-19 disruption on child adjustment difficulties was mediated by parental distress.
To this end, given the hypothesized importance of parental wellbeing, a preliminary goal
of the current study was to test whether our measure of parent distress was invariant
across site.

1.2. Cross-Cultural Differences in Child Adjustment during the Pandemic

A survey of almost 18,000 caregivers in 46 countries showed that markers of child
distress (e.g., sleep disturbances and aggression) were positively related to the length of
school closures [14]. Whilst this suggests a pervasive adverse effect of COVID-19 restric-
tions on children’s psychosocial adjustment, meaningful cross-cultural research hinges
upon establishing the equivalence of measures. This entails testing whether instruments
assessing child adjustment difficulties show “measurement invariance” across groups [15].
Adopting this approach, the current international consortium brought together researchers
with a common interest in family influences on children’s adjustment across six countries
with diverse COVID-19 experiences: Australia, China, Italy, Sweden, the United Kingdom,
and the United States of America.
In Spring 2020, these six countries were at different points of virus transmission.
Notably, infections in China preceded cases in the other sites. These six sites also adopted
distinct policies to limit the spread of the virus. Indeed, Sweden was widely considered
an outlier on the global stage with their relatively liberal level of pandemic restrictions
and, crucially for young children and their parents, lack of national school closures. After
demonstrating across-site measurement invariance for parental SDQ ratings [16], we
showed that during the pandemic, Swedish parents reported the lowest levels of child peer
problems and the highest level of child prosocial behaviors, whilst British parents reported
the highest levels of child emotional and hyperactivity problems. These descriptive data
are important, but research is needed to understand the mechanisms underpinning these
adverse effects [17]. The overarching aim of the current study was to test whether similar
Int. J. Environ. Res. Public Health 2021, 18, 11136 3 of 14

or distinct family and COVID-19 experiences are associated with individual differences in
children’s adjustment difficulties across these six different countries.

1.3. Domain-Specific Influences on Child Adjustment

Given that the COVID-19 pandemic has had multiple impacts on family life, an obvi-
ous question is whether different risk factors show distinct patterns of association with child
outcomes. As noted above, the developmental systems framework [1] posits three levels
of influence on developmental outcomes: individual, family context, and society/culture.
Empirical evidence also highlights the domain-specific nature of influences within any one
of these levels. For example, in a longitudinal and detailed observational study, Hughes
and Devine [18] found that while some family measures (e.g., home learning environment
and frequency and complexity of family talk) have a relatively global influence, other
measures (e.g., negative control and parental scaffolding) show specific associations with
distinct aspects of children’s development.
Three pandemic studies indicate that child adjustment problems are associated with
poorer parent mental health, household chaos, and family conflict. However, these family
risk factors have yet to be considered in tandem or across different contexts. As a result,
little is known about either their relative salience and independence or about the general-
izability of pathways. Addressing these gaps, the current international study examined
the unique impact of parent mental health, household chaos, and family conflict on both
child internalizing and externalizing problems in the early stages of the pandemic. Find-
ings from two studies suggest a differentiated pattern of associations between family risk
factors and child outcomes in the context of COVID-19. First, consistent with robust evi-
dence for a negative impact of parental depression on children’s behavioral and emotional
problems [19,20], Romero et al. [21] surveyed parents of 1049 Spanish 3- to 12-year-olds
and found that parents’ self-reported distress showed moderate links with ratings of child
externalizing problems but was unrelated to ratings of children’s prosociality. Second, in
an American study of 303 parents of 6-year-olds, Waller et al. [22] reported that reduced
parental warmth and increased harsh discipline during the pandemic were each associated
with elevated levels of callous unemotional traits, but only harsh parenting was associated
with elevated levels of conduct problems. These findings are consistent with theoretical
accounts attesting to the negative impact of “coercive cycles” of conflictual parent–child
interactions (rather than simply the absence of warmth) on children’s conduct problems
(e.g., [23]). By contrast, less differentiated findings have emerged from a socially diverse
American sample of preschoolers [24]. Specifically, increased levels of household chaos and
parenting stress appear associated with elevated depressive symptoms and externalizing
problems [24]. These domain-general findings are consistent with longitudinal work with
511 families establishing the negative impact of household instability and disorganization
on a variety of outcomes across China, Colombia, Jordan, Kenya, the Philippines, and
Thailand [25].
Within the growing body of family studies of child adjustment in the context of
the pandemic, the potential role of couple relationship quality has as yet received very
little attention. This is surprising as parallels between economic adversities and the
pandemic indicate that both can affect child wellbeing via couples’ dyadic processes,
such as increasing hostility or withdrawing support [26]. Associations between conflict
and child negative outcomes may be direct, for example, via social learning mechanisms,
triggering child distress or undermining feelings of security [27], or indirect via impacting
the quality of parent–child relationship [28]. Thus, in addition to considering parent–child
conflict, our study sought to test whether couple relationship conflict also had a deleterious
effect on children’s adjustment and, crucially, whether patterns of association between
family risk factors and children’s psychosocial problems were similar across six different
pandemic contexts.
Int. J. Environ. Res. Public Health 2021, 18, 11136 4 of 14

1.4. The Current Study

Our multisite design served two purposes: (i) to test whether the family processes
implicated in the impact of the pandemic on children’s psychosocial functioning are similar
across the six sites and (ii) to disentangle the impact of proximal (i.e., family disruption)
versus distal (i.e., stringency of government restrictions) COVID-19-related experiences on
children’s adjustment difficulties. Alongside these cross-cultural comparisons, our study
addressed two further questions. First, do family risk factors and COVID-19-related expe-
riences show specific influences on child adjustment difficulties? Here, we hypothesized
independent contributions from each risk factor to child difficulties but anticipated that
more proximal COVID-19-related disruption would exert a stronger influence than distal
factors (i.e., government stringency). We adopted an exploratory approach when consider-
ing whether the magnitude of associations would differ by child outcome. Second, does
parental distress mediate the association between COVID-19 social disruption and child
adjustment difficulties? Here, we hypothesized that COVID-19-related social disruption
would indirectly impact child adjustment difficulties via elevated levels of parental distress.

2. Methods
2.1. Participants and Procedure
Between 1 April and 7 July 2020, we recruited 2516 parents with one or more children
aged 3 to 8 years old (Mage = 5.77, SD = 1.10) to participate in an online survey (via
Qualtrics) of family wellbeing and child adjustment in the COVID-19 pandemic. To be
eligible to participate, parents had to be aged 18 or above, report no major psychiatric
problems or learning difficulties, and have one or more child aged 4–6. Parents were asked
to choose one child in the relevant age group when completing the survey. Following
ethical review in each site (and translation from English), the survey was advertised widely
via social media and university/school mailing lists in Australia, China, Italy, Sweden, the
United Kingdom (UK), and the United States of America (USA).
In total, 6.4% of respondents were in Australia (n = 161), 13.4% were in China (n = 336),
9.7% were in Italy (n = 244), 31.6% were in Sweden (n = 795), 28.1% were in the UK
(n = 706), and 10.9% were in the USA (n = 274). As described in Table 1, respondents were
typically female (81.5% female and 8% male, with 10.5% preferring not to say), aged 21 to
65 years old (Mage = 37.34, SD = 5.39 years), and highly educated (63.1% undergraduate or
higher degree or equivalent vocational qualification). Only 50% reported their ethnicity,
of which 50% identified as white, 29% as Asian, and 21% as having mixed or multiple
ethnicities. Between-site contrasts for each of these demographic characteristics were weak
(see Table 1); however, these subsamples are not considered to be representative of all
parents and children in each site, in particular those from low socioeconomic backgrounds.

Table 1. Family demographics by site.

Between-Site
Australia China Italy Sweden UK USA
Overall Differences
n = 161 n = 336 n = 244 n = 795 n = 706 n = 274
Effect Size
Parent
Age M (SD) 37.15 (5.93) 38.89 (5.55) 34.98 (5.75) 39.32 (4.78) 36.63 (4.85) 37.43 (6.92) 37.70 (6.48) η2 = 0.04
Education % a
63.1% 73.9% 19% 59.4% 69.8% 67.4% 83.2% Cramer’s V = 0.11
degree
Child
Age
5.77 (1.10) 6.09 (1.08) 5.34 (0.99) 5.83 (1.13) 5.65 (1.11) 6.06 (1.05) 5.68 (1.08) η2 = 0.05
M (SD)
Gender
47.9% 50.3% 48.2% 51.2% 47.9% 46% 47.8% Cramer’s V = 0.04
% female
Family
No. of children
2.02 (1.01) 2.09 (0.78) 1.70 (1.73) 1.72 (0.74) 2.22 (0.84) 2.04 (0.85) 2.00 (0.81) η2 = 0.04
M (SD)
Note. degree = undergraduate degree or higher and/or equivalent vocational qualification. a = 75% missing.
Int. J. Environ. Res. Public Health 2021, 18, 11136 5 of 14

2.2. Measures
Child Adjustment
Participants completed the parents’ version of the Strengths and Difficulties Question-
naire (SDQ), which is used globally to screen for children’s social, emotional, and behavioral
problems [29]. The SDQ consists of 25 statements, each rated on a three-point scale (not
true, somewhat true, and certainly true), with five items yielding a prosociality subscale
and 20 items relating to child difficulties, namely hyperactivity and emotional, peer, and
conduct problems [29,30]. Multiple group confirmatory factor analysis confirmed that a
5-factor solution was the best fitting model and showed across-site scalar invariance [16].
For the purposes of this study, we focused on the four child difficulties subscales.

2.3. COVID-19 Experience

Social Disruption. A 5-item composite was created to index whether the COVID-19
pandemic had led to respondents experiencing disruption. The first item asked if the parent
had experienced a change in employment (i.e., unemployment) because of the COVID-19
pandemic (0 = no, 1 = yes). The second item asked if the parent had experienced a drop
in income due to the COVID-19 pandemic (0 = no, 1 = yes). The last three items asked
respondents how much they had experienced financial strain, work/family conflict, and
worry about loved ones as a result of the COVID-19 pandemic, with these three items
rated on a 4-point scale: “not at all”, “very little”, “moderate”, and “very much”. To index
any level of disruption, scores were dichotomized so that respondents who indicated “not
at all” received a 0 and those who responded “very little”, “moderate”, or “very much”
received a 1. Total scores for social disruption ranged from 0 to 5; higher scores denoted
greater disruption.
Stringency. We extracted data from the Oxford COVID-19 Government Response
Tracker (OxCGRT), which collects twice-weekly data on governmental responses to the
COVID-19 pandemic across countries. The composite stringency index combines nine indi-
cators, including government containment and closure policies (e.g., school and workplace
closure) and public health campaign messaging (e.g., targeted versus general public health
information) [13]. For each of the nine indicators, individual ordinal values are given for
the last week, with a half-point subtracted if the score is general rather than targeted. The
scores are then rescaled by their maximum value to create a score ranging from 0 to 100.
We created individual measures of the macro level constraint experienced by a family by
matching the OxCGRT data with the date the respondent completed the questionnaire.

2.4. Family Risk Factors

Parental Distress. To index parents’ current mental health, we included the widely
used General Health Questionnaire-12 (GHQ-12) [31], which has been translated into more
than 38 languages such that each site could adopt a previously validated translation. On
a 4-point scale, respondents were asked whether they experienced/have experienced a
particular symptom or behavior over the past two weeks. The bimodal (0-0-1-1) was used
for scoring system (0 = less than usual, 0 = no more than usual, 1 = rather more than
usual, and 1 = much more than usual). A total sum score was created, with higher scores
indicating greater distress (α = 0.89).
Parent–Child Conflict. Using one item on a 5-point scale developed for the purpose of
this study, respondents indicated whether they had experienced an increase in conflict with
the target child (1 = marked increase, 2 = small increase, 3 = no change, 4 = small decrease,
and 5 = marked decrease). Scores were revered so that a high score reflected more conflict.
Couple Conflict. Parents’ current relationship quality was measured with 10 items
developed for the purpose of this study. Using a 5-point scale (1 = rarely, 2 = sometimes,
3 = in half of our interactions, 4 = often, and 5 = nearly always), respondents indicated
the frequency of behaviors that signal relationship problems (e.g., criticism, controlling,
and verbal/physical abuse). A mean score was created, with a higher score denoting more
conflict between parents (α = 0.95).
Int. J. Environ. Res. Public Health 2021, 18, 11136 6 of 14

Household Chaos. Each of the 15 items in the Confusion, Hubbub, and Order Scale
(CHAOS) [32] had a 4-point scale enabling respondents to indicate how strongly they
agreed with statements about the current level of noise, crowding, and routines in their
home (1 = very much like our home, 2 = often like our home, 3 = a bit like our home, and
4 = not at all like our home). A mean score was created, with higher scores indicating a
more chaotic household (α = 0.75).
Demographics. Parents also provided information on their child’s age and gender as
well as indicators of their socioeconomic status (SES). A SES composite was developed
comprising measures of the parent(s) education, occupation, and housing. Specifically,
using a scale relevant to their own country, respondents reported on their own educational
attainment and, if applicable, the educational attainment of the target child’s other primary
caregiver. These scores were then recoded to reflect the closest equivalent in the British
system (i.e., high school/secondary, post-secondary, undergraduate, or higher degree).
Next, respondents reported on their own occupation, which was coded according to the
UK Standard Occupation Classification system [33]. Occupations were coded as low-level
(e.g., sales and factory work), mid-level (e.g., skilled-trade and services) and high-level
(e.g., managers and professionals). Finally, respondents were asked to report on their
household, specifically the number of bedrooms in their home and whether their home
was “small and cramped”, “small but adequate”, “quite spacious”, or “very spacious”. A
z-score was created for each item. The final aggregate reflected a mean of z-scores from
four to six items, whereby a high score reflected higher SES (α = 0.67).

2.5. Analysis Plan

Analyses were conducted using Mplus Version 8 [34]. Prior to examining the main
research questions, we examined the latent factor structure of ratings of parent dis-
tress (GHQ). We evaluated model fit using three primary criteria: comparative fit index
(CFI) > 0.90, Tucker–Lewis index (TLI) > 0.90, and Root Mean Square Error of Approxima-
tion (RMSEA) < 0.08 [35]. To test measurement invariance across site, we used multigroup
CFA, which involves systematically adding equality constraints to the model and testing
the change in model fit of these nested models [36]. Nested model comparisons were
judged to be invariant if the CFI decreased by ≤0.020 and RMSEA increased by ≤0.003 [37].
From this basis, we then conducted between-site comparisons of our independent variables
of interest and examined correlations between the main measures (Table 2).

Table 2. Robust maximum likelihood estimates for correlations between main study measures.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
1. Hyperactivity -
2. Conduct Problems 0.86 -
3. Emotion Problems 0.54 0.68 -
4. Peer Problems 0.50 0.63 0.51 -
5. Parent Distress 0.37 0.38 0.39 0.21 -
6. Parent–Child Conflict 0.31 0.38 0.25 0.18 0.24 -
7. Parent Conflict 0.07 0.16 0.14 0.09 0.09 0.05 -
8. Household Chaos 0.44 0.49 0.39 0.29 0.30 0.29 0.17 -
9. COVID-19 Disruption 0.18 0.23 0.20 0.22 0.27 0.15 0.11 0.16 -
10. Gov. Stringency 0.03 0.07 0.04 0.22 −0.05 0.01 0.10 −0.08 0.03 -
11. Socioeconomic Status −0.18 −0.16 −0.14 −0.08 −0.09 0.06 −0.10 −0.10 −0.06 0.08 -

Next, we adopted a path modeling approach to examine the associations between

COVID-19-related experiences, family processes, and child adjustment [34]. We used a
maximum likelihood estimator with robust standard errors (MLR) and evaluated model
fit using Brown’s [35] recommended criteria. Model parameters and standard errors were
estimated in Mplus using all available data [38]. To assess whether path estimates were
similar across countries, a multiple group model was fitted [35]. Brown [33] notes multiple-
group solutions can be evaluated when the group sizes vary. To this end, we fitted a
Int. J. Environ. Res. Public Health 2021, 18, 11136 7 of 14

model in which all paths were freely estimated across site and subsequently compared this
model to a model in which all paths were constrained to be equal across site. We assessed
differences in model fit using the Satorra–Bentler χ2 difference test [39]. Finally, we tested
whether parent distress mediated the association between COVID-19 disruption and child
adjustment problems using Mplus’ bootstrapping procedures (5000 bootstrap samples).

3. Results
3.1. Preliminary Analyses: Between-Site Differences in Parents’ COVID-19 Experience
and Distress
As illustrated in Figure 1, there were between-site contrasts in national government
stringency scores (F(5) = 755.84, p < 0.0001, η2 = 0.60) and in the experience of COVID-
19-related social disruption (F(5) = 38.34, p < 0.0001, η2 = 0.07). Due to the frequency of
planned post-hoc contrasts, we applied a more stringent alpha rate (p < 0.003). In terms
of stringency scores, there were significant contrasts between most countries, aside from
between China and Sweden. For COVID-19-related social disruption, families in the USA
experienced a greater level of disruption compared to families in all sites, aside from the
UK, while families in Sweden reported less disruption than all sites, except for Australia.
Families in the UK reported more disruption than those in Italy, Australia, and Sweden.
Prior to comparing between-site differences in parental distress, we tested for cross-
site measurement invariance of the GHQ using multiple-group confirmatory factor analysis.
A partially scalar invariant single-factor model with factor loadings and thresholds free
to vary across sites for only one out of 12 items (item 8 “Been able to face up to your
problems”) showed a good fit to the data (RMSEA = 0.082 [0.076, 0.087], CFI = 0.969,
TLI = 0.967). This suggests that across site, the organization of the construct is similar
(i.e., configural invariance), with each item contributing in a similar way to the construct
(i.e., metric invariance), and the cut-off underling the distribution of scores are consistent
(i.e., scalar invariance). Together, this suggests that the GHQ is appropriate for use across
different contexts during the pandemic.
Using this partially scalar invariant GHQ model, we then tested for mean differences
in the latent factor for parent distress across sites. Parents in the UK reported significantly
more distress than parents in Italy, China, and Sweden, whilst American parents also
reported higher levels of distress than Italian or Swedish parents.

3.2. COVID-19-Related Experience, Family Risk Factors, and Child Adjustment

We regressed the four child difficulties subscales: conduct problems, hyperactivity,
emotion problems, and peer problems onto variables measuring family risk factors (parent
distress, parent–child conflict, couple conflict, and household chaos), COVID-19 experi-
ences (disruption and stringency), and demographics (child age, sex, and SES). The model
showed good fit (RMSEA = 0.062, 90%CI [0.053, 0.071], CFI = 0.974, TLI = 0.923) and
explained a significant proportion of the variance in child hyperactivity (R2 = 0.29), conduct
problems (R2 = 0.36), emotion problems (R2 = 0.24), and peer problems (R2 = 0.16).
 Int. J. Environ. Res. Public Health 2021, 18, 11136 8 of 14
Int. J. Environ. Res. Public Health 2021, 18, x 8 of 15

A. Government Stringency in Response to COVID-19

Mean Stringency of Government

by Country
100
80

Response
60
40
20
0

B. COVID-19-Related Disruption by Country

4
Mean Level of COVID-19

3
Disruption

0
UK Italy China Australia USA Sweden

C. Parent Distress by Country

12
10
Mean GHQ Score

8
6
4
2
0
UK Italy China Australia USA Sweden

Figure 1. Between-site
Figure comparisons
1. Between-site of (A)
comparisons of government stringency
(A) government in COVID-19
stringency response
in COVID-19 between
response between
April and July 2020, (B) COVID-19-related family disruption, and (C) parent distress.
April and July 2020, (B) COVID-19-related family disruption, and (C) parent distress.

Using this partially scalar invariant GHQ model, we then tested for mean differences
in the latent factor for parent distress across sites. Parents in the UK reported significantly
Int. J. Environ. Res. Public Health 2021, 18, 11136 9 of 14

As illustrated in Table 3, increased levels of parent distress, parent–child conflict, and

household chaos were associated with higher levels of problem behaviors. A Wald chi-
square test of model constraints revealed the association between parent distress and child
problems was similar in magnitude between conduct, hyperactivity, and emotion problems
but weakest for peer problems (χ2 (3) = 54.38, p < 0.0001). There was a stronger association
between parent–child conflict and conduct problems than between parent–child conflict
and hyperactivity, emotional, or peer problems (χ2 (3) = 68.81, p < 0.0001). The association
between household chaos and conduct problems was also stronger than the association
between household chaos and emotion or peer problems (χ2 (3) = 35.63, p < 0.0001). There
was a stronger association between couple conflict and emotion and conduct problems than
with hyperactivity (χ2 (3) = 39.28, p < 0.0001). COVID-19-related disruption and stringency
were both associated with greater child difficulties but more strongly associated with peer
problems than with the other three dimensions (χ2 (3) = 12.91, p < 0.0001; χ2 (3) = 23.91,
p < 0.0001). Specifically, we fitted a multiple-group model in which all paths were freely
estimated across site and subsequently compared this model to a model in which all paths
were constrained to be equal across site. Compared to the baseline model, this constrained
model indicated no significant differences in the pathways between sites (∆χ2 = 16.12,
p > 0.05).

Table 3. Robust Maximum Likelihood Estimates for Structural Equation Model.

Hyperactivity Conduct Problems Emotion Problems Peer Problems

Est SE Std Est. Est SE Std Est. Est SE Std Est. Est SE Std Est.
Family
Parent Distress 0.04 0.01 0.18 * 0.03 0.01 0.15 * 0.05 0.01 0.23 * 0.01 0.01 0.04
Processes
Parent-Child Conflict −0.16 0.02 −0.16 * −0.21 0.02 −0.22 * −0.10 0.02 −0.11 * −0.07 0.02 −0.07
Couple Conflict −0.06 0.05 −0.03 0.13 0.05 0.06 * 0.11 0.05 0.06 * −0.04 0.06 0.02
Household Chaos 0.08 0.01 0.30 * 0.09 0.01 0.34 * 0.06 0.01 0.24 * 0.06 0.01 0.22 *
COVID-19 Disruption 0.02 0.02 0.04 0.04 0.02 0.07 * 0.03 0.02 0.05 0.08 0.02 0.14 *
Stringency 0.01 0.00 0.09 * 0.01 0.01 0.12 * 0.01 0.01 0.09 * 0.02 0.01 0.18 *
Background SES −0.18 0.03 −0.13 * −0.13 0.03 −0.09 * −0.11 0.03 −0.08 * −0.07 0.03 −0.05
Child Gender 0.19 0.04 0.11 * 0.14 0.02 0.08 * −0.01 0.04 −0.00 0.19 0.04 0.11 *
Child Age 0.02 0.02 0.02 −0.02 0.03 −0.02 0.06 0.02 0.08 * −0.01 0.02 −0.01
R2 0.29 0.36 0.24 0.16
Note. * p < 0.001.

3.3. COVID-19-Related Disruption and Child Adjustment: The Mediating Role of

Parental Distress
Following this, using bootstrapping procedures [40], we tested whether parental dis-
tress mediated the impact of COVID-19-related social disruption on children’s adjustment
difficulties. The unstandardized estimate of the indirect effect and 95% confidence intervals
with 5000 bootstrap samples was significant for hyperactivity (0.04 [0.03, 0.05], p < 0.001),
conduct problems (0.03 [0.02, 0.041], p < 0.001), and emotion problems (0.04 [0.03, 0.05],
p < 0.001) but not peer problems (0.01 [0.00, 0.02]).

4. Discussion
Despite significant between-site contrasts in mean levels of parental distress and
experiences of COVID-19, two key findings highlighted the similarity of associations
between family risk factors, COVID-19 experiences, and children’s psychosocial adjustment
in the early stages of the COVID-19 pandemic across the six sites. First, children from
families characterized by parental distress, increased levels of parent–child conflict, and
chaos showed elevated levels of hyperactivity, conduct, and emotion problems. In contrast,
increased peer problems were more strongly related to COVID-19-related experiences (both
stringency of national restrictions and family-level social disruption). The magnitude of
these associations was strongest for chaos, while couple conflict was not significantly related
to child adjustment problems. This differentiated pattern of associations supports domain-
specific models of social influences on child development and highlights the potential
Int. J. Environ. Res. Public Health 2021, 18, 11136 10 of 14

multiplicity of mechanisms implicated in young children’s psychosocial adjustment in the

context of the pandemic [41]. Second, our analyses revealed indirect associations between
COVID-19-related social disruption and child adjustment difficulties that were mediated
by parental distress. Below, we discuss possible explanations for these findings considering
our sample limitations.

4.1. Family Dysfunction and COVID-19 Experiences Show Direct Links with Child Difficulties
Over and above effects of child age and family SES, increased levels of problems across
each of the four problem subscales of the Strengths and Difficulties Questionnaire [29,30]
were associated with both micro (parent distress, parent–child conflict, couple conflict, and
household chaos) and macro (national stringency) levels of influence. This multiplicity of
associations is consistent with developmental systems framework’s central premise that
children’s psychosocial development should always be considered in context and that chil-
dren are particularly responsive to principal relationships within their microsystem [1,12].
While family risk factors were weakly associated with peer problems, they explained
around a third of the variance in ratings for hyperactivity, emotion problems, and conduct
problems, strengthening the view that coregulation (reflecting parent–child reciprocity,
responsiveness, and cooperation) provides a key foundation for behavioral adjustment
(e.g., [42]), that is, children’s acquisition of useful skills and habits for regulating their emo-
tions and behavior hinges upon parental warmth and structure, which can be constrained
by mental health problems and household chaos [43].
Our findings also mirror reports of a protective effect of family routines on children’s
internalizing and externalizing symptoms during the pandemic in the USA [24]. As
economic insecurity, irregular employment, and limited access to childcare all predict
household chaos (e.g., [44]), elevated levels of family chaos are likely to persist. Given that
initial levels and increases in the quality of the home environment predict gains in school
readiness [45], a clear practical implication of our results is the need to support parents in
their efforts to provide a stable home environment.
Family risk factors exerted a weaker effect on peer problems, which is unsurprising
given mass school closures. Instead, highlighting the impact of depriving children of
the stimulation and enrichment associated with interactions with other children, peer
problems were more clearly associated with the country-wide severity of containment and
family-level disruption. On this latter point, it follows that in experiencing unemployment,
financial strain, work–family conflict, and worry about loved ones, parents themselves are
(or feel) unable to participate in typical group practices, thus limiting children’s opportuni-
ties to observe and practice their social skills [46]. Importantly, positive peer relationships
are associated with a host of other child outcomes, including the development of chil-
dren’s identity, socio-cognitive skills, and understanding of social norms [47]. As a result,
“catch-up” interventions need to extend beyond the academic domain to include emotional
support and enriched opportunities for peer play. Notably, these suggestions are possible
due to our inclusion of peer problems as a specific outcome of interest, a domain largely
absent from earlier research that demonstrated large-scale economic crashes were linked to
decline in children’s mental health [48].

4.2. COVID-19-Related Disruption, Family Risk Factors, and Child Difficulties: Indirect Effects
The parents who took part in our online survey reported poor mental health during
the early stages of the pandemic, with just over half of parents scoring 3 or more on the
GHQ, a cut-off with high specificity and sensitivity commonly used to indicate the presence
of a clinically relevant symptoms across diverse samples [49]. Our results highlighted
the impact of parental distress as a mediator of the negative impact of the COVID-19
pandemic on child adjustment. This is consistent with a recent American study that
showed experiencing the disease in the family as well as the succeeding economic effects
both impact family wellbeing [8]. Social learning accounts would suggest the onset and
maintenance of child difficulties result from children modeling their parents’ behaviors or
Int. J. Environ. Res. Public Health 2021, 18, 11136 11 of 14

ineffective coping strategies. Alternatively, this indirect effect may be carried by changes
in parent–child talk, such as inappropriate health risk communication, or compromised
parenting practices, such as reduced sensitivity (e.g., [50]). Interestingly, an American
study found parents’ worries about COVID-19 were not associated with harsh discipline
or reduced warmth [22]. However, this null association may reflect the focus on worrying
about contracting and passing on the virus, which may have instead manifested in other
behaviors, such as increased handwashing. Future longitudinal research will help tease
apart these competing explanations as well as test whether changes in parents’ wellbeing
across the pandemic contribute to individual differences in the trajectories of children’s
psychosocial problems. That said, it seems evident that family-based interventions may
prove most effective in mitigating the negative impact of the pandemic on child adjustment.
Furthermore, the advent of innovative work evaluating the success of online family therapy
suggests that these interventions do not have to wait until families can meet their therapist
in person [51].
Our findings draw on data collected from families across six study sites with different
virus infection rates and government approaches, leading to contrasting social, economic,
and cultural effects. Reflecting these contrasts, our findings showed site contrasts in levels
of COVID-19-related social disruption and stringency. Specifically, families in the USA
and UK experienced more disruption than families in all other sites, and Swedish families
experienced the least disruption. Nevertheless, with regard to mechanisms of influence on
child adjustment, the findings from the different sites indicate striking similarities. This
generality of results strengthens the evidence suggesting the cascading impact of economic
pressure on child developmental outcomes via parent wellbeing across a variety of family
structures, ethnic backgrounds, and geographic locations [52].

5. Conclusions
Our study drew on an international sample of 2516 parents and applied tests of mea-
surement invariance to both our outcome and mediating variables to provide meaningful
cross-cultural comparisons. That said, our findings should be interpreted considering a
number of methodological limitations.
First, our convenience sample of parents from middle to high socioeconomic back-
grounds impacts the external validity and generalizability of our findings. The subsamples
were restricted in terms of geographic (e.g., American parents in Pennsylvania and Ohio
and Chinese parents in Beijing) and socioeconomic (e.g., almost 60% of Italian parents in
our study had a tertiary education qualification compared to the national average level
of 20% [53]) position and were ethnically homogenous. Here, it is worth noting that, un-
fortunately, a large proportion of parents in China did not report on their ethnicity, which
further limits our understanding of the representativeness of the Chinese subsample. Fur-
thermore, the necessary reliance on online research designs during the pandemic increases
the likelihood of selection bias and collider bias [54]. For example, participation is likely
associated with increased engagement with social media campaigns, scientific interest, and
higher education levels [54]. As a result, we cannot rule out that our models replicate across
different countries because those who took part were largely similar (i.e., middle to high
socioeconomic backgrounds). However, given we found associations between COVID-19
disruption, family risk factors, and child adjustment within a restricted range of SES, it
is likely our estimates are conservative. Further research is required with more diverse
samples as well as with families living in low or middle income countries to test whether
our results replicate beyond this specific demographic.
Second, the cross-sectional design limits our appreciation of the nature of the me-
diation findings. The findings may not be pandemic specific given we cannot rule out
the impact of pre-existing levels of distress on parents’ current mental health. That said,
our sample did not have a history of psychopathology, and our theoretically informed
analyses focused on disruption to life due to COVID-19-specific changes in association
with current levels of distress [13]. Future longitudinal research is required to rule out
Int. J. Environ. Res. Public Health 2021, 18, 11136 12 of 14

alternative explanations regarding the directionality of our results (i.e., child difficulties
eliciting parental stress).
Third, like other colleagues, we relied upon a single informant to report on both
parents and children, which may inflate associations between constructs. However, as
illustrated in Table 2, we found modest associations between family processes and child
outcomes. Our results are strengthened by including an objective assessment of COVID-
19 experiences. Specifically, a publicly available data set that assessed the stringency of
national restrictions enabled us to test the impact of this distal influence on child adjustment.
As this measure is strongly positively correlated with national rates of infection [55], it also
provides a proxy for national infection rates and a time-specific index of the severity of the
disease’s impact. As we move towards more open science, future collaborative efforts that
pool individual participant data measuring similar constructs will be helpful in developing
an understanding of the varied impact of the pandemic on parent and child adjustment
across diverse contexts.
With these caveats in mind, the findings from this international study provide further
evidence that the disruptive impact of the COVID-19 pandemic is multigenerational,
impacting parents’ wellbeing and children’s social skills and adjustment difficulties. As
a result, family-based interventions may prove most effective in mitigating the negative
impact of the pandemic on child adjustment.

Author Contributions: Conceptualization, C.H. and S.F.; data curation, S.F.; formal analysis, S.F.
and L.R.; funding acquisition, C.H. and S.F.; investigation, S.F., F.B., K.C.B., M.A.F., L.R. and C.H.;
methodology, C.H.; supervision, C.H.; writing—original draft, S.F. and C.H.; writing—review and
editing, F.B., K.C.B., M.A.F. and L.R. All authors have read and agreed to the published version of the
manuscript.
Funding: The first author was funded by an Economic and Social Research Council Post-Doctoral
Fellowship (ES/T008989/1). The Principal Investigator (C.H.) received funding for the UK arm of
the study from Newnham College Cambridge. Data collection in the USA was supported by the
National Science Foundation under grant DUE1534830, the James S. McDonnell Foundation Scholar
Award, and the National Institutes of Health under grant NICHD F32 HD102106-01.
Institutional Review Board Statement: This study was conducted according to the guidelines
of the Declaration of Helsinki, and approved by the Psychology Research Ethics Committee at
the University of Cambridge, Uppsala University, University of Pavia, University of Pittsburgh,
University of Queensland, and Peking University.
Informed Consent Statement: Informed consent was obtained from all participants involved in
the study.
Data Availability Statement: The data presented in this study are available on request from the
corresponding author.
Acknowledgments: We would like to thank the families involved in the study for completing data
collection in extraordinary circumstances. The i-FAM-Covid Consortium consists of Claire Hughes,
Sarah Foley, Elian Fink, Samantha Friedman, Rory T. Devine, Amy Selby, Karin Brocki, Matilda Frick,
Farzaneh Badinlou, Xin Feng, Meingold Chan, Virginia Slaughter, Sally Clark, Yanjie Su, Shan Wan,
Serena Lecce, Luca Ronchi, Chiara Basile, Paola del Sette, Andrew Ribner, Melissa Libertus, Leanne
Elliott, and Alex Silver.
Conflicts of Interest: The authors report no conflict of interest.

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