key: cord-0759212-fji3nwaz
authors: Yanaz, Muruvvet; Yilmaz Yegit, Cansu; Ergenekon, Almala Pinar; Toksoy Aksoy, Ayse; Bilicen, Gulcin; Gokdemir, Yasemin; Erdem Eralp, Ela; Rodopman Arman, Ayse; Karakoc, Fazilet; Karadag, Bulent
title: The Effect of COVID‐19 on Anxiety Levels of Children with CF and Healthy Peers
date: 2021-10-01
journal: Pediatr Int
DOI: 10.1111/ped.15009
sha: ce7c8907ad3926cc2791be7b488495b4a510174c
doc_id: 759212
cord_uid: fji3nwaz

BACKGROUND: Cystic fibrosis (CF) is a chronic disease causing recurrent respiratory tract infections. Viral respiratory tract infections are more severe in CF. The first case of COVID‐19 was seen in our country on March 11, 2020 and nationwide school closure and lockdown were implemented. School closure and home confinement might have adverse effects on children’s physical and mental health. In this study, we aimed to compare the effect of COVID‐19 pandemic on psychological reactions of CF patients and healthy controls. METHODS: This is a controlled cross‐sectional study including 7‐18 year‐old children with CF. The survey included questions regarding family environment and peer relations, self care and psychological reactions to COVID‐19 pandemic. The questionnaire was applied to children via telephone call under parental supervision. RESULTS: We evaluated 132 CF patients and 135 their healthy peers. Mean age was 11.5±2.9 years in CF group and 11.8±3.2 years in control group (p=0.98). There were 55 girls (41.7%) in CF group and 81 girls (60%) in control group (p=0.027). The socioeconomic status of families was similar. CF patients were found to be less anxious for family members having the risk of COVID‐19, less upset for school closure, less anxious about the COVID‐19 pandemic (p<0.001, 0.02, 0.01 respectively). CONCLUSION: CF patients seem to show more resilience in coping with the pandemic. Appropriate psychological support should be provided to them and resilience strategies in coping with the pandemic should be nurtured.

Cystic fibrosis (CF) is a chronic, life-shortening disease causing recurrent respiratory tract infections and loss of lung functions [1] . Previous meta-analyses and systematic reviews have shown that adults and children with chronic diseases have higher risk of depression and anxiety compared to community [2, 3] . A number of studies reported increased anxiety and depression in CF pateints compared to healthy controls [4] [5] [6] . Facing a chronic disease such as CF on a daily basis cause significant emotional burden which can be attributed to large number of treatments, hospitalizations, multiple diagnostic procedures, chronic respiratory symptoms, a lower body mass index [6] . During COVID-19 pandemic people are likely to experience fear of falling sick, dying or feelings of helplessness and a number of studies revealed a wide range of psychosocial impacts on people [4] . In a study by Wang et al, included 1210 Accepted Article respondents, psychological impact of the outbreak was present in 53.8%. Moderate to severe depression, anxiety symptoms and stress levels were present in 16.5%, 28.8% and 8.1% of the participants respectively [10] . Another cross-sectional study in 7143 college students demonstrated that 21.3% had mild and 3.6% had moderateto-severe anxiety symptoms where economic effects on daily life and delays in academic activities were positively associated with anxiety symptoms [11] .

Although children seem to be less vulnerable than adults to COVID-19, initial reports from China indicate that children and adolescents also have been impacted In this study, our aim was to evaluate the effect of COVID-19 pandemic on family environment and relations, self-care practises and peer relations, psychological reactions including anxiety and coping of CF patients and compare with healthy controls.

This is a case-control, cross-sectional, single center study including 7-18 year-old CF children who have been followed up in Cystic Fibrosis Center of our hospital and their healthy peers. All 7-18 year-old CF patients undergoing regular follow-up at our CF center were considered for participation. Children on psychiatric treatment for clinical anxiety and/or depression, children with mental problems and children who had been caught COVID-19 or had a family member with COVID-19 were excluded from the study. As a result 27 of 159 CF patients were excluded from the study and 83% participated. We recruited a control group consisting of 135 participants who were contacted from close associations of patients' group like neighbours, children's classmates and friends.

In CF patients, data regarding presence of pancreatic insufficiency, colonisation of Pseudomonas aeruginosa and level of forced expiratory volume in 1 second (FEV 1 ) were collected from patients' medical records. Lung disease was categorised as mild, moderate and severe according to their baseline FEV 1 measurements (FEV 1 Accepted Article 70-89% mild lung disease, FEV 1 40 to 69% moderate lung disease, FEV 1 < 40% severe lung disease) [19] .

The data was collected between 30th April, 2020 and 15 th of May, at which time COVID-19 started to peak in our country, schools were closed and education was online. We conducted phone survey by asking questions directly to the children under parental supervision. Informed consent was obtained from all parents following their agreement to participate the phone survey and the study was approved by the medical ethics committee of our university.

Separate behavioral questionnaires for two different age groups 

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Data were analyzed by using the SPSS Statistical Package for Windows version 23.0. Numerical variables were expressed as mean±standart deviation or median.

Caterogical variables were compared using the Chi-square test and expressed as numbers and percentages. A p value of less than 0.05 was considered statistically significant.

This study included 132 CF patients and 135 healthy peers. The mean age was 11.53±2.86 and 11.76±3.15 years respectively, in CF group and control group (p=0.98).

There were 55 girls (41.7%) in CF group and 81 girls (60%) in control group (p=0.027).

Of the 132 CF patients, 95 (72%) had pancreatic insuffiency, 41 (31.1%) were colonised with Pseudomonas aeruginosa, 59 (44.7%) had normal FEV 1 value, 40 (30.3%) had mild, 23 (17.4%) had moderate and 5 (3.8%) of them had severe lung disease. There was no statistically significant difference in terms of severity of the disease and anxiety levels of CF patients (p >0.05). Comparison of psychosocial and psychological findings between CF patients and control group was presented in Table- 1. CF patients were found to be less anxious for family members having the risk of COVID-19, less upset for the school closure, less anxious about the COVID-19 pandemic (p<0.001, 0.02, 0.01 respectively). Control group was more overthinking about the pandemic, and feeling sad, lonely or reluctant to have playful time (p=0.03 and 0.02, respectively). Control group also tried to have new hobbies more compared to CF group (p= 0.01).

In CF group 71 (53.8%) of patients were children and 61 (46.2%) were adolescents.

Children were feeling more upset for the school closure (p=0.01) and more anxiety about the COVID-19 pandemic (p=0.008), had more appetite changes (p=0.03), Accepted Article expressed more reluctance of doing homework for online education (p=0.03), engaging activities to decrease their anxiety (p=0.01) and tried to find new hobbies during lockdown (p=0.005) more than adolescents. Although it is not statistically significant, children stated that they needed psychological help more than adolescents (p=0.059). Adolescents communicated with their friends via social media more than children (p=0.005). Comparison of psychological and psychosocial findings in CF group as children and adolescent was presented in Table- 2.

In control group, 79 (58.5%) of them were children and 56 (41.5%) of them were adolescents. Although adolescents communicated with their friends from social media more than children (p=0.003), children felt happier for communicating online with their friends (p=0.02). Also children engaged new activities more than adolescents (p=0.008). Comparison of psychosocial and psychological findings in control group as children and adolescent was presented in Table- 3.

In our country examinations for high school and university admission are big stressors for adolescents. Twenty-four (39.4%) of CF and 17 (30.4%) of control group had admission examinations for high school or university. We also asked these adolescents if the pandemic, school closure and online education increased their anxiety. Although it was not statistically significant (p=0.21), exam anxiety was higher in control group compared to CF patients (46.4% vs 24.6%). In this study we evaluated the psychological reactions, family and peer relations, self-care practises and coping methods of CF patients during pandemic and compared with healthy controls. Symptoms of anxiety were unexpectedly higher in controls compared to CF patients. Almost 50% of the children in control group and 33% of the CF patients were feeling anxious about the COVID-19 pandemic. Although no significant difference was found between CF and control groups regarding family environment and relations or self care and peer relations, it is important to emphasize that almost half of the children were having appetite changes in both groups and incidence of sleeping problem were 10% in CF patients and 15% in control group. In our country, during disease outbreak, right after the school closure and home confinement, home schooling plan has been implemented.

In addition to academic learning, age appropriate and attractive videos may motivate children to have a healthy lifestyle at home by increasing physical activities, having a balanced diet, regular sleep pattern, and good personal hygiene.

Whereas CF patients had a lower tendency to need psychological help compared to control group, children in CF group had more anxiety symptoms compared to adolescents and required more psychological help than adolescents in both groups.

During pandemic children are constantly exposed to pandemic-related news, so having direct conversations with children about these issues could alleviate their anxiety. Home confinement, with the right parenting approaches could be a good opportunity to enhance family interactions and improve their self-sufficiency skills of children [25] .

Resilience is the ability of properly adapt and react positively to adversity, trauma, Several studies reported increased anxiety and depression in CF pateints compared to healthy controls and routine screening is strogly recommended, [4] [5] [6] . In a recent unpublished study, before pandemic, we revealed that moderate to severe depression

This article is protected by copyright. All rights reserved and moderate anxiety was present in 25.5% and 17.6% of 50 adolescent CF patients respectively in our center.

Current study revealed that CF patients had lower anxiety symptoms and they were more resilient in coping during pandemic than their healthy peers.

In conclusion, although acute events such as pandemics may not seem to increase baseline anxiety and not associated with an important physcological impact in CF patients compared to heathy population, lack of psychological support in routine care may lead to higher levels of anxiety and depression in long term. 

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Cystic fibrosis pulmonary guidelines: treatment of pulmonary exacerbations

Depressive symptoms in children and adolescents with chronic physical illness: an updated meta-analysis

Depression, chronic diseases, and decrements in health: results from the World Health Surveys

Psychiatric morbidity and quality of life in children and adolescents with cystic fibrosis

Anxiety and depression in adolescents with CF and their caregivers

The prevalence of anxiety and depression in Italian patients with cystic fibrosis and their caregivers

There is no source of financial grant and other funding.

The authors declare no conflict of interests.

Mürüvvet Yanaz performed the questionnaires, collected the data, performed the statistical analysis and wrote the manuscript. Cansu Yilmaz Yegit performed the questionnaires, collected the data, performed the statistical analysis. Almala Pinar Ergenekon performed the statistical analysis and wrote the manuscript. Ayse Toksoy Aksoy contributed to the conception of the study and tables in the manuscript, and collected the data. Gulcin Bilicen performed the questionnaires and collected the data. Yasemin Gökdemir performed study design, conceptualization and statistical analysis, wrote the manuscript and supervised the whole study process. Ela Erdem Eralp performed study design, conceptualization and statistical analysis, wrote the manuscript and supervised the whole study process. Ayşe Rodopman Arman performed study design, conceptualization and and supervised the statistical analysis

This article is protected by copyright. All rights reserved and the manuscript. Fazilet Karakoc wrote the manuscript and supervised the whole study process. Bulent Karadag performed study design, conceptualization and statistical analysis, wrote the manuscript and supervised the whole study process.All authors read and approved the final manuscript.

This article is protected by copyright. All rights reserved (n,%) Feeling sad, lonely or reluctant to have playful time (n,%)