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Rost K, Ziegenhain U, Fegert JM, Buchheim A, Köhler-Dauner F. Maternal insecure attachment representation as a long-term risk factor for disrupted mother-child-interaction and child mental health. BMC Psychol 2024; 12:385. [PMID: 38982522 PMCID: PMC11234699 DOI: 10.1186/s40359-024-01874-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 06/26/2024] [Indexed: 07/11/2024] Open
Abstract
Maternal childhood maltreatment (CM) represents an important factor in the transmission of trauma that may lead to impaired child mental health. Apart from childhood maltreatment insecure attachment has been identified as a risk factor for insensitive caregiving behavior, which may affect child's mental health. The aim of this study is to identify the working mechanisms in the relationship between maternal CM and child mental health, considering maternal attachment representation, mother-child-interaction und maternal helplessness and fear. N = 103 mother-child-dyads from a longitudinal cohort study were examined at four different measuring points. Data was assessed using self and external report questionnaires as well as the AMBIANCE scales during the Strange Situation Procedure and the Adult Attachment Projective Picture System (AAP). Maternal CM experience did not predict an insecure attachment representation (OR = 2.46 [0.98, 6.53], p = .060). Maternal insecure attachment was associated with higher AMBIANCE scores (F(8, 94) = 11.46, p < .001), which indicates more disrupted communication between mother and child. AMBIANCE scores in turn predicted higher self-perceived helplessness (F(9, 93) = 8.62, p < .001) and fear (F(9, 93) = 7.40, p < .001) in mothers. Helplessness and fear both were associated with higher SDQ-scores, indicating more mental health problems in children (F(10, 92) = 3.98, p < .001; F(10, 92) = 3.87, p < .001). The results of this study highlight how even insecure attachment in a low-risk sample has a long-term impact on parenting behavior and child mental health, therefore underlining the need of early intervention programs in affected and at-risk families.
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Affiliation(s)
- Katharina Rost
- Department of Child and Adolescent Psychiatry/Psychotherapy, University Hospital of Ulm, Ulm, Germany.
| | - Ute Ziegenhain
- Department of Child and Adolescent Psychiatry/Psychotherapy, University Hospital of Ulm, Ulm, Germany
| | - Jörg M Fegert
- Department of Child and Adolescent Psychiatry/Psychotherapy, University Hospital of Ulm, Ulm, Germany
- German Center for Mental Health (DZPG), partner site Ulm, Ulm, Germany
| | - Anna Buchheim
- Institute of Psychology, University of Innsbruck, Innsbruck, Austria
| | - Franziska Köhler-Dauner
- Department of Child and Adolescent Psychiatry/Psychotherapy, University Hospital of Ulm, Ulm, Germany.
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Rost K, Gossmann E, Fegert JM, Ziegenhain U, Köhler-Dauner F. Long-term consequences of childhood emotional abuse in mothers on parental load and child mental health. Acta Psychol (Amst) 2024; 244:104169. [PMID: 38341882 DOI: 10.1016/j.actpsy.2024.104169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 01/29/2024] [Accepted: 01/29/2024] [Indexed: 02/13/2024] Open
Abstract
BACKGROUND Childhood emotional maltreatment can be associated with long-term consequences on mental health. In addition, transgenerational transmission of adverse childhood experiences to the next generation can occur and thus have an impact on the mental health of one's own children. OBJECTIVE The purpose of this study was to examine the role of stress on the association between childhood emotional maltreatment and parental load what is referred to in this study as limitations in parental functioning that affect the resources available to parents to cope with the demands of raising, caring for, and providing for their child. Furthermore the effect of parental load on the mental health of one's own children will be examined. PARTICIPANTS AND SETTING N = 237 mother-child dyads (age mother M = 33.76, SD = 4.07 years; age child M = 11.91 months, SD = 0.89 months) from a longitudinal cohort study were examined at two different measuring points. METHODS Emotional abuse, perceived stress, parental load and child mental health were assessed using self and external report questionnaires. RESULTS The calculation of a mediation showed that the association of emotional abuse and parental load was completely mediated by perceived stress (indirect effect ab = 0.44, 95 %-CI[0.17, 0.78]). In addition, effects of parental load on the child's mental health (β = 0.13, 95%CI [0.07;0.20]), mainly hyperactivity (β = 0.06, 95%CI [0.03;0.11]) and prosocial behavior (β = -0.04, 95%CI [-0.07; -0.01]), were evident. CONCLUSIONS The results of this study provide evidence that the mental health of children can be influenced in the long term by increased parental load.
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Affiliation(s)
- Katharina Rost
- Department of Child and Adolescent Psychiatry/Psychotherapy, Ulm University, Ulm, Germany.
| | - Emily Gossmann
- Department of Child and Adolescent Psychiatry/Psychotherapy, Ulm University, Ulm, Germany
| | - Jörg M Fegert
- Department of Child and Adolescent Psychiatry/Psychotherapy, Ulm University, Ulm, Germany
| | - Ute Ziegenhain
- Department of Child and Adolescent Psychiatry/Psychotherapy, Ulm University, Ulm, Germany
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Köhler-Dauner F, Dalhof Gulde M, Hart L, Ziegenhain U, Fegert JM. The negative association of the SARS-CoV-2 pandemic with the health of mother and child considering maternal childhood maltreatment. BMC Psychol 2023; 11:292. [PMID: 37759267 PMCID: PMC10523770 DOI: 10.1186/s40359-023-01327-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Social distancing strategies during the SARS-CoV-2 pandemic have left families facing a variety of different constraints. Especially in this stressful time, children need a stable parental home to prevent developmental consequences. Additional risk factors such as maternal childhood maltreatment (CM) may affect mother's psychosomatic health and children's physical well-being in this period. OBJECTIVE It was aimed to analyze the associations between maternal CM, mother's mental health, and children's physical complaints during the SARS-CoV-2-pandemic. METHOD Mothers of a well-documented birth cohort from a longitudinal study were included in this study. Psychosomatic health was assessed with the PHQ-D and children's physical health with the GBB-KJ during the pandemic. N = 159 mothers completed the online survey. To describe the maternal CM, data from a longitudinal survey were used. RESULTS The calculation of three mediation analyses demonstrate that maternal depression symptoms (c-path: β = 0.10, p = .02; c'-path: β = 0.07, p = .13), somatic symptoms (c-path: β = 0.10, p = .02; c'-path: β = 0.07, p = .13) and psychosomatic symptoms (c-path: β = 0.10, p = .02; c'-path: β = 0.06, p = .19) fully mediate the relationship between CM and children's physical health complaints. CONCLUSIONS Maternal CM experiences seem to be one relevant risk factor during the pandemic and seem to influence the way in which parents deal with stressful situations and increase the risk for depressive symptoms. The present results highlight the importance to provide individually adjusted assistance to help the families to get through the pandemic.
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Affiliation(s)
- Franziska Köhler-Dauner
- Department of Child and Adolescent Psychiatry/Psychotherapy, University Hospital of Ulm, Steinhövelstraße 5, 89075, Ulm, Germany.
| | - Manuela Dalhof Gulde
- Department of Child and Adolescent Psychiatry/Psychotherapy, University Hospital of Ulm, Steinhövelstraße 5, 89075, Ulm, Germany
| | - Lara Hart
- Department of Child and Adolescent Psychiatry/Psychotherapy, University Hospital of Ulm, Steinhövelstraße 5, 89075, Ulm, Germany
| | - Ute Ziegenhain
- Department of Child and Adolescent Psychiatry/Psychotherapy, University Hospital of Ulm, Steinhövelstraße 5, 89075, Ulm, Germany
| | - Jörg M Fegert
- Department of Child and Adolescent Psychiatry/Psychotherapy, University Hospital of Ulm, Steinhövelstraße 5, 89075, Ulm, Germany
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Zwönitzer A, Rost K, Fegert JM, Ziegenhain U, Köhler-Dauner F. Emotional problems in young children during the SARS-CoV-2-pandemic and child attachment. Front Pediatr 2023; 11:1191032. [PMID: 37534198 PMCID: PMC10392938 DOI: 10.3389/fped.2023.1191032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/20/2023] [Indexed: 08/04/2023] Open
Abstract
Background Restrictions imposed by national governments during SARS-CoV-2-pandemic have impacted the mental health of children around the world. Studies have already proven the importance of secure attachment acting as a protective factor in child development. Therefore, children with secure attachment have a higher chance of developing and using appropriate coping mechanisms. Objective The goal of this study was to explore the possible connection between the pandemic, as well as child attachment, and young children's emotional health. The general hypothesis assumes a lower rate of emotional problems among children with secure attachment and a higher rate of emotional problems among children with insecure-disorganized attachment, as well as an increase of these problems during the pandemic. Method The analysis included N = 129 mothers (M = 39.98 years) and their children (M = 5.19 years). Via an online survey, which was held at different time points during the pandemic, information on the children's emotional problems was retrieved. The survey used the Strengths and Difficulties Questionnaire (SDQ). Data regarding the quality of attachment was collected via the Strange Situations Test (SST). At this point the participating children were approximately 12 months old. Results The calculation of a mixed ANCOVA showed, that attachment quality had a significant influence on children's emotional problems [F(2, 121) = 4.01, p = .021]. The interaction effect between time and child attachment reached significance [F(3.45, 208.42) = 3.58, p = .011]. The calculation of an additional mixed ANCOVA showed, that the reported emotional problems of girls were higher than those of boys F(1, 118) = 4.56, p = .035). Conclusions Our study shows that there is an association between attachment security and emotional problems and the impact of the SARS-CoV-2 pandemic on the mental health of preschool children in Germany. The emotional problems of all children increased, especially the disorganized attached children had been reported as emotionally stressed in the first lockdown. The results indicate the need for preventive services (for children and parents) to promote and maintain stress coping skills in order to maintain children's mental health in times of crisis.
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Yates J, Mantler T. The Resilience of Caregivers and Children in the Context of COVID-19: A Systematic Review. JOURNAL OF CHILD & ADOLESCENT TRAUMA 2023; 16:1-20. [PMID: 36778656 PMCID: PMC9902831 DOI: 10.1007/s40653-022-00514-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/21/2022] [Indexed: 06/18/2023]
Abstract
The COVID-19 pandemic has necessitated caregivers and school-aged children to adapt to ongoing changes and uncertainty. Understanding why some caregivers and school-aged children area able to adapt and others are not could be attributed to resilience. The relationships between caregiver or child resilience and socioeconomic status (SES) in the context of COVID-19 remain largely un-explored. Therefore, the purpose of this qualitative systematic review was to explore (1) what is currently known about the relationship between caregiver and child resilience in the context of COVID-19; and (2) the role of SES on caregiver or child resilience throughout the COVID-19 pandemic. Four databases (i.e., MEDLINE, Scopus, PsycINFO, and CINAHL) were systematically searched, title/abstract and full-text screening were conducted, and 17 articles met the inclusion criteria (i.e., discussed resilience of caregivers/children during COVID-19, mean age of children between 7-10, primary research/grey literature, English), including 15 peer-reviewed and two grey literature sources. Thematic analysis revealed five themes: (1) the mitigating effects of child resilience; (2) overcoming the psychological toll of the pandemic; (3) the unknown relationship: caregiver and child resilience; (4) family functioning during COVID-19; and (5) the perfect storm for socioeconomic impacts. Results from this review provide the first synthesis of the impact of the COVID-19 pandemic on the resilience of caregivers and school-aged children. Future research should conduct longitudinal data collection to understand the possible long-term impacts of the pandemic on these populations' resilience. Understanding these impacts will be integral to assisting families in bouncing back from the long-lasting adverse circumstances caused by the COVID-19 pandemic.
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Affiliation(s)
- Julia Yates
- Health and Rehabilitation Sciences Program, Faculty of Health Sciences, The University of Western Ontario, London, ON Canada
| | - Tara Mantler
- School of Health Studies, Faculty of Health Sciences, The University of Western Ontario, London, ON Canada
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Clemens V, Köhler-Dauner F, Keller F, Ziegenhain U, Fegert JM. Adverse childhood experiences are associated with a higher risk for increased depressive symptoms during Covid-19 pandemic - a cross-sectional study in Germany. BMC Psychiatry 2022; 22:540. [PMID: 35948968 PMCID: PMC9365680 DOI: 10.1186/s12888-022-04177-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 06/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Covid-19 pandemic has been profoundly affecting people around the world. While contact restrictions, school closures and economic shutdown were effective to reduce infection rates, these measures go along with high stress for many individuals. Persons who have experienced adverse childhood experiences (ACEs) have an increased risk for mental health problems already under normal conditions. As ACEs can be associated with a higher vulnerability to stress we aimed to assess the role of ACEs on depressive symptoms during the Covid-19 pandemic. METHODS In a cross-sectional online survey, 1399 participants above the age of 18 years were included during the first lockdown in Germany. Via two-way repeated measures ANOVA, differences in depressive symptoms before (retrospectively assessed) and during the pandemic were analyzed. Linear regression analyses were performed in order to identify predictors for increase of depressive symptoms. RESULTS Compared to prior to the Covid-19 pandemic, depressive symptoms increased among all participants. Participants with ACEs and income loss reported about a stronger increase of depressive symptoms. Other predictors for increased depressive symptoms were young age and a lack of social support. CONCLUSIONS Based on these results, ACEs are a significant predictor for an increase in depressive symptoms during the pandemic, indicating that personss with ACEs may be a risk group for mental health problems during the current and potential later pandemics. These findings underline the relevance of support for persons who have experienced ACEs and may help to provide more targeted support in possible scenarios due to the current or possible other pandemics. Besides, economic stability seems to be of prior importance for mental health.
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Affiliation(s)
- Vera Clemens
- Hospital of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstraße 5, 89075, Ulm, Germany.
| | - Franziska Köhler-Dauner
- grid.6582.90000 0004 1936 9748Hospital of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstraße 5, 89075 Ulm, Germany
| | - Ferdinand Keller
- grid.6582.90000 0004 1936 9748Hospital of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstraße 5, 89075 Ulm, Germany
| | - Ute Ziegenhain
- grid.6582.90000 0004 1936 9748Hospital of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstraße 5, 89075 Ulm, Germany
| | - Jörg M. Fegert
- grid.6582.90000 0004 1936 9748Hospital of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstraße 5, 89075 Ulm, Germany
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Klein S, Fegert JM, Geprägs A, Brähler E, Clemens V. The Impact of the COVID-19 Pandemic on Health, Quality of Life and Intrafamilial Relations – A Population-Based Survey in Germany. Front Psychol 2022; 13:844057. [PMID: 35360600 PMCID: PMC8963202 DOI: 10.3389/fpsyg.2022.844057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/16/2022] [Indexed: 12/28/2022] Open
Abstract
The occurrence of the novel severe acute respiratory syndrome coronavirus-2 (COVID-19) at the end of 2019 comes along with many challenges. Besides worry for one’s own health and the well-being of the family, all measures applied to limit the spread of the coronavirus affected daily life. School closures, economic shutdown and contact restrictions have led to high levels of stress. The impact on health and families has been widely discussed. However, population-based data are scarce. Here, we have assessed health, quality of life and intrafamilial relations depending on the COVID-19 pandemic. Using a three-step random-route approach, a population-based sample of 2,515 persons (52.6% female, average age of 50.3 years) was recruited during the second COVID-19 wave in Germany in winter 2020/21. While the majority of participants reported no change in their health status and the relationship with their partner and children, more than half of participants reported a decreased quality of life since the beginning of the pandemic. Female gender, age above 60 years, a low household income, not living with a partner and the experience of childhood adversity were associated with a higher risk for a worsening of health, quality of life and intrafamilial relations. These had already been well-established risk factors ahead of the pandemic. In order to avoid further increase of inequality in our society and more devastating impact of the pandemic on health and intrafamilial relations, low-level support and intervention programs are urgently needed.
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Affiliation(s)
- Stephanie Klein
- Hospital of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Ulm, Germany
| | - Jörg M. Fegert
- Hospital of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Ulm, Germany
| | - Alina Geprägs
- Hospital of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Ulm, Germany
| | - Elmar Brähler
- Department for Psychosomatic Medicine and Psychotherapy, University Medical Center of Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Vera Clemens
- Hospital of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Ulm, Germany
- *Correspondence: Vera Clemens,
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Seeger FR, Neukel C, Williams K, Wenigmann M, Fleck L, Georg AK, Bermpohl F, Taubner S, Kaess M, Herpertz SC. Parental Mental Illness, Borderline Personality Disorder, and Parenting Behavior: The Moderating Role of Social Support. Curr Psychiatry Rep 2022; 24:591-601. [PMID: 36282473 PMCID: PMC9592879 DOI: 10.1007/s11920-022-01367-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2022] [Indexed: 01/29/2023]
Abstract
PURPOSE OF REVIEW Parental mental disorders, particularly borderline personality disorder (BPD), impair parenting behavior. Consequently, the children exhibit an elevated risk for psychopathology across their lifespan. Social support for parents is thought to moderate the relationship between parental mental illness and parenting behavior. It may dampen negative effects and serve as starting point for preventive interventions. This paper provides a literature overview regarding the impact of social support on the sequelae of parental mental illness and BPD for parenting behavior. RECENT FINDINGS Current literature highlights the increased burden of families with a mentally ill parent and associated changes in parenting behavior like increased hostility and affective dysregulation, especially in the context of parental BPD. Literature further demonstrates the powerful impact of social support in buffering such negative outcomes. The effect of social support seems to be moderated itself by further factors like socioeconomic status, gender, or characteristics of the social network. Social support facilitates positive parenting in mentally ill parents and may be particularly important in parents with BPD. However, social support is embedded within a framework of influencing factors, which need consideration when interpreting scientific results.
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Affiliation(s)
- Fabian R Seeger
- Department of General Psychiatry, Centre for Psychosocial Medicine, University of Heidelberg, Voßstraße 4, D - 69115, Heidelberg, Germany
| | - Corinne Neukel
- Department of General Psychiatry, Centre for Psychosocial Medicine, University of Heidelberg, Voßstraße 4, D - 69115, Heidelberg, Germany
| | - Katharina Williams
- Department of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, University of Heidelberg, Heidelberg, Germany
| | - Marc Wenigmann
- Department of General Psychiatry, Centre for Psychosocial Medicine, University of Heidelberg, Voßstraße 4, D - 69115, Heidelberg, Germany
| | - Leonie Fleck
- Department of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, University of Heidelberg, Heidelberg, Germany
| | - Anna K Georg
- Department of Psychosocial Prevention, Centre for Psychosocial Medicine, University of Heidelberg, Heidelberg, Germany
| | - Felix Bermpohl
- Department of Psychiatry and Psychotherapy, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Svenja Taubner
- Department of Psychosocial Prevention, Centre for Psychosocial Medicine, University of Heidelberg, Heidelberg, Germany
| | - Michael Kaess
- Department of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, University of Heidelberg, Heidelberg, Germany
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Sabine C Herpertz
- Department of General Psychiatry, Centre for Psychosocial Medicine, University of Heidelberg, Voßstraße 4, D - 69115, Heidelberg, Germany.
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Clemens V, Köhler-Dauner F, Ziegenhain U, Fegert JM. Predictors of Parental Coping During the Covid-19 Pandemic: A Survey in Germany. Front Psychol 2021; 12:715327. [PMID: 34566797 PMCID: PMC8460925 DOI: 10.3389/fpsyg.2021.715327] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/10/2021] [Indexed: 12/27/2022] Open
Abstract
The Covid-19 pandemic has been profoundly affecting nearly everybody, but families with minors have been hit particularly. Closure of schools and kindergartens, home schooling, and working from home have led to a profound upheaval in family life. Parental adverse childhood experiences (ACEs) are an important determinant for parenting behavior. Importantly, ACEs can increase the vulnerability to stress and impair coping strategies. The current pandemic leads to increased parental stress, a risk factor for harsh parenting behavior, Therefore, we aimed to assess the role of ACEs and sociodemographic factors associated to parental coping during the current pandemic. In a cross-sectional online survey, 687 parents of minors in Germany were included. Demographic and psychosocial factors associated to parental coping during the first lockdown due to the Covid-19 pandemic were assessed. Results show that younger age of the respective child, income loss, dissatisfaction with the sharing of childcare duties, and ACEs were significantly associated with an increase of potential harmful parenting behavior during the Covid-19 pandemic. An increase of dissatisfaction with the sharing of childcare duties during the pandemic was predicted by working from home and taking care of the children mainly by oneself, while sharing childcare duties with the partner equally resulted even in an increase of satisfaction with sharing of childcare duties during the pandemic. These findings demonstrate that a history of childhood adversity in a parent is a risk factor for harmful parenting during the pandemic. Parental satisfaction with sharing of caregiving is an important factor for parental coping during the pandemic. Sharing of caregiving between partners should be encouraged.
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Affiliation(s)
- Vera Clemens
- Hospital of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Ulm, Germany
| | | | - Ute Ziegenhain
- Hospital of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Ulm, Germany
| | - Jörg M Fegert
- Hospital of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Ulm, Germany
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