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Comment & Response
November 16, 2020

Factors Affecting Children's Mental Health During the Coronavirus Disease 2019 Epidemic—Reply

Author Affiliations
  • 1Department of Maternal and Child Health and Ministry of Education Key Lab of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
  • 2Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
JAMA Pediatr. 2021;175(3):320. doi:10.1001/jamapediatrics.2020.4936

In Reply We agree with Liang and Zeng, and we do not dispute that their extensive discussion of our findings would be helpful to the JAMA Pediatrics readership. However, we were not allowed for a more in-depth discussion in the Research Letter.1 Liang and Zeng raised great points, which we could respond to herein.

We agree with their argument that parents’ mental health plays an essential role in children’s mental health. Additional information regarding parents’ anxiety symptoms, measured by the Self-Rating Anxiety Scale, was collected in this questionnaire. The association of children’s and parents’ mental health was examined and reported in the Zhu et al article.2 A total of 1264 child-parent pairs were used for analysis, and we found that children with parents who had anxiety symptoms had a greater risk of anxiety symptoms than those whose parents did not have anxiety symptoms (odds ratio, 2.96; 95% CI, 1.28-6.88). Students with a closer parent-child relationship had a decreased risk of reported anxiety symptoms (odds ratio, 0.50; 95% CI, 0.33-0.76).2

Liang and Zeng suggest that diagnoses of depression and anxiety are more common with increased age, and behavior problems are more prevalent among children aged 6 to 11 years. In China, children aged 6 years enter elementary school. The children in the spring semester of grades 2 through 6 tend to have the age range of 7 to 11 years, approximately. We analyzed the association between the grade, instead of age, with the depressive/anxiety symptoms in the Research Letter.1 The odds of depressive symptoms increased with the grade, while there was no trend in the anxiety symptoms. Taking the depressive symptoms as the continuous variable, we performed the additional regression analysis to confirm this observation.1

In addition, in our project, we evaluated the behavioral problems using the Strengths and Difficulties Questionnaire and found that the prevalence of behavioral problems in children varied from 4.7% to 10.3%. When compared with a previous study,3 the behavioral problems in children confined to home for approximately 1 month were not obviously increased. This might be explained by the hypothesis that the risk factors play a prolonged and cumulative role in affecting children's behavior problems.4 Moreover, the resiliency factors (ie, close parent-child relationships) may protect the children from the short-term exposure to disaster.

Lastly, we agree with Liang and Zeng that the income level and other risk factors may lead to children’s mental health problems. When we designed the questionnaire during the quarantine, the primary focus of the questionnaire was to understand the prevalence of anxiety and depressive symptoms among students during the outbreak of coronavirus disease 2019. Thus, we did not collect other risk factors such as income, which is one of the limitations of our study. However, the adverse childhood experiences (ie, parental substance misuse, lack of love/support, and poverty), one of the characteristics of which is chronicity, may cumulatively result in toxic stress and be associated with a greater risk of psychological health problems.5,6 We are planning to follow up this cohort for future study, where we will then have opportunity to collect additional risk factors of interest.

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Article Information

Corresponding Author: Ranran Song, PhD, MS, Department of Maternal and Child Health and MOE Key Lab of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, No. 13 Hangkong Road, Wuhan, Hubei, China (songranran@hust.edu.cn).

Published Online: November 16, 2020. doi:10.1001/jamapediatrics.2020.4936

Conflict of Interest Disclosures: None reported.

Xie  X, Xue  Q, Zhou  Y,  et al.  Mental health status among children in home confinement during the coronavirus disease 2019 outbreak in Hubei Province, China.   JAMA Pediatr. 2020;174(9)898-900. doi:10.1001/jamapediatrics.2020.1619PubMedGoogle Scholar
Zhu  K, Zhou  Y, Xie  X,  et al  Anxiety symptom and its associates among primary school students in Hubei province during 2019 novel coronavirus diseases epidemic.   Chin J of Public Health. 2020:1-4. doi:10.11847/zgggws1129050Google Scholar
Du  Y, Kou  J, Coghill  D.  The validity, reliability and normative scores of the parent, teacher and self report versions of the Strengths and Difficulties Questionnaire in China.   Child Adolesc Psychiatry Ment Health. 2008;2(1):8. doi:10.1186/1753-2000-2-8PubMedGoogle ScholarCrossref
Appleyard  K, Egeland  B, van Dulmen  MH, Sroufe  LA.  When more is not better: the role of cumulative risk in child behavior outcomes.   J Child Psychol Psychiatry. 2005;46(3):235-245. doi:10.1111/j.1469-7610.2004.00351.xPubMedGoogle ScholarCrossref
Jirapramukpitak  T, Harpham  T, Prince  M.  Family violence and its ‘adversity package’: a community survey of family violence and adverse mental outcomes among young people.   Soc Psychiatry Psychiatr Epidemiol. 2011;46(9):825-831. doi:10.1007/s00127-010-0252-9PubMedGoogle ScholarCrossref
Briere  J, Jordan  CE.  Childhood maltreatment, intervening variables, and adult psychological difficulties in women: an overview.   Trauma Violence Abuse. 2009;10(4):375-388. doi:10.1177/1524838009339757PubMedGoogle ScholarCrossref