Psychosocial stress in young families after the pandemic: no time to rest

doi:10.21203/rs.3.rs-4938360/v1

Background

During the pandemic, parenting stress and mental health challenges for both parents and children have increased. However, the lasting repercussions for families remain largely unexplored. Additionally, young families currently face stressors such as economic inflation, the Russia-Ukraine War, and the climate crisis, whose impacts on family well-being are not yet understood.

Methods

We conducted a cross-sectional study involving families (N = 17,333) with children aged 0–9 years to examine parenting stress and mental health issues among both parents and children in light of current societal challenges. Validated questionnaires were used to gather data, and potential factors contributing to parenting stress were investigated.

Results

We found that 53.7% of parents reported feeling stressed or very stressed in their parenting role, with 13.5% experiencing anxiety symptoms and 14.6% showing signs of depression. Additionally, 34.9% of the infants (0–24 months) had crying and/or sleeping difficulties, whereas emotional and behavioral problems were observed in 10.4% of the toddlers (2–4 years) and 8.7% of the pre- and primary schoolers (˃ 4 years). Economic inflation was perceived as stressful or very stressful for 59.3% of parents, with radicalization and social division (49.3%), the Russia–Ukraine War (37.9%), and the climate crisis (31.8%) also cited as sources of stress. For 31.6% of families, the lingering effects of the pandemic continued to be a (major) burden. Across all age groups, children's mental health issues and societal challenges were the primary predictors of parenting stress. Additionally, there was a positive correlation between the duration of external childcare and parenting stress among parents with toddlers and pre- and primary schoolers.

Conclusion

Our study underscores that psychosocial stressors for families with children remain pronounced even postpandemic and, in some cases, have intensified compared with the peak of the pandemic. Moreover, our findings highlight the impact of broader societal trends, such as economic inflation and social division, on family well-being. Addressing these stressors and promoting the mental health of infants while bolstering parental resilience by alleviating parenting stress should be key priorities for healthcare initiatives in the aftermath of COVID-19.

parent mental health

child mental health

infant regulatory problems

emotional problems

conduct problems

parenting stress

societal challenges

crisis

Parenthood usually brings happiness (1) but is challenging at the same time. Parents bear great responsibility for their child. They want to fulfil their children's needs and often put their own on the back burner, which can result in parenting stress. Parenting stress refers to an imbalance between the demands of the parenting role and the available resources (2). High parenting stress can lead to parental dysfunction (3) and can have several causes, such as high parental workload, low social support, the perception of the child as difficult, negative life events or problems with child caretaking. Higher maternal age (> 35) and having more than one child are also associated factors (4). In times of societal crisis, young families seem to react particularly vulnerable, as observed, for example, during the COVID-19 pandemic (5, 6). Increased depression and anxiety rates have been reported in mothers and fathers during the pandemic (7–9), as has increased parenting stress (10–13). Parenting stress is considered a decisive factor in the development of mental health problems in mothers and fathers (14–16), but it is also linked to impaired parent‒child interaction, especially with respect to limited parental emotional availability and a lower quality of caregiving in general (14, 17, 18). Thus, parenting stress and parental mental health problems also affect children immediately and are risk factors for their mental health (19, 20). Compared with prepandemic data, significant increases in psychological problems in school children and adolescents during the COVID-19 pandemic have been reported (12, 21–24). There is also evidence for an increase in crying, sleeping, and feeding problems in infants as well as highly pronounced behavioral and emotional problems in toddlers during the crisis (25).

Moreover, more than a year has passed since the WHO announced the official end of the pandemic in May 2023. However, the long course of the crisis and the accumulation of stress factors such as existential fears and worries, loss and grief, economic disadvantages, and negative personal and social changes in different life areas may still persist. These psychosocial stressors may leave lasting imprints and could result in serious health consequences (26–28). Psychiatric research has consistently demonstrated that population stressors may manifest as clinically significant disorders even years after exposure (29). To date, there are few longitudinal data on the psychosocial situation of families in the postpandemic era. Even with the interim relaxations and the clear fading or complete termination of restriction measures in Germany in the course of 2022, the after-effects are likely to remain noticeable (30), raising the question of whether or how burden parameters are present in the meantime.

In addition to these potential late effects of the pandemic, further crises arose that might again specifically affect families. Recently, the existential threat posed by climate change, along with psychological distress and anxiety about potential future crises, has garnered significant attention in the literature. This research underscores that the perceived threat of climate change, beyond the immediate impact of natural disasters, constitutes a significant risk factor for mental health issues (26). This might be more pronounced in young families since their future is more affected than the lives of the older generation.

While some studies have examined the immediate effects on those directly affected by the Russian–Ukraine War (31), few studies have addressed the mental health consequences of perceived threats in neighboring countries, with greater anxiety in an adolescent population (32).

Economic inflation can have widespread negative effects on both society and individuals (33). The established connection between socioeconomic conditions, stress exposure, and health demonstrates that these factors are closely linked. These socioeconomic stressors influence health through multiple mechanisms, especially via physiological and psychological stress responses (27). It can be assumed that young parents are particularly affected by financial developments, as they are still building their livelihoods in addition to increased daily expenses.

While these challenges might not affect all families equally, a complex crisis constellation has arisen that has the potential to cause or intensify psychosocial stress (34–36). Most etiological risk models for mental disorders suggest that chronic stress, as well as highly salient stressors, which are characteristic of times of crisis, can deteriorate mental health and have both short- and long-term adverse effects (37). Symptoms of, e.g., anxiety and depression might be intensified by the omnipresence of these social crises in society and the media. This could already be observed in the context of climate change as well as political instability and war (38).

Despite existing evidence of significant links between psychosocial challenges and mental health, some aspects, such as the impact of radicalization movements or social division, have not yet been adequately studied. Furthermore, little is known about the influence of the current challenges on parental and child stress parameters, as research is still scarce.

Overall, we are currently experiencing the post-COVID-19 era coupled with other severe global and societal challenges, leading to the following research questions:

To what extent are parenting stress as well as parent and child mental health symptoms in young families pronounced in the postpandemic phase?

Which factors (sociodemographic, social challenges and child mental health) are associated with parenting stress and parents’ mental health symptoms?

Study design

The JuFaBY (JungeFamilien inBayern: Young Families in Bavaria) study investigates psychosocial stress in families with young children (up to primary school age) in Bavaria (southern Germany). In the following, we present the results of a cross-sectional investigation. Data were collected from February 2023 to March 2024. The study protocol was approved by the Ethics Committee of the Technical University of Munich (vote no. 2022 − 483_1-S-KH).

Participants

All participants were recruited and surveyed via the smartphone app “Meine pädiatrische Praxis” (“My pediatrician”) (www.monks-aerzte-im-netz.de), which is a well-established communication tool connecting parents with their pediatrician. For example, it sends out invitations for regular childhood check-ups. In Germany, preventive regular childhood check-ups (“U-Untersuchung”) take place at 3 weeks, 3 months, 6 months, 12 months and then annually until school age. Check-ups are recommended but not mandatory, and approximately 97% of parents make use of this offer (39). To recruit participants for the JuFaBY study, an invitation was sent out via app coupled with the reminder for the next check-up at the respective age. All app users with children whose pediatric practices have not objected to a digital study invitation were invited to participate. Parents whose German language skills were not sufficient to understand the subject information were excluded from the study.

Study invitations, detailed information and informed consent were sent via app. In total, 345 pediatric practices agreed that their patients were invited, and approximately 152,000 invitations to parents were sent. Overall, 17,333 parents completed the study questionnaires.

Measures

All the data were collected via standardized questionnaires via app. The participants were asked questions on their general sociodemographic characteristics, perceived societal stress factors, parenting stress and parent and child mental health outcomes.

Perceived societal stress factors

Parents were asked a self-developed question about their perceived burden related to the following current societal topics ("How stressful are the following societal issues/events for you? "): climate change, Russia-Ukraine War, financial inflation, social division and radicalization, and the COVID-19 pandemic. The perceived burden was rated via 5-point Likert scales for each topic (from 1 = not at all stressful to 5 = very stressful).

Parenting stress

To assess parenting stress, we applied the parent domain of the German adaptation of the ‘Parenting Stress Index (PSI)’ (“Eltern-Belastungs-Inventar” EBI) (40). High scores indicate limited parental resources for upbringing and caring for the child. The parent domain includes the following subscales: ‘health’ (parental health impairment as a cause or a result of parenting stress), ‘isolation’ (lacking integration in social networks), ‘role restriction’ (perceived limitations as a result of being a parent), ‘parental competence’ (parental doubt about their own ability to manage upbringing and care for their child), ‘attachment’ (emotional relation of parent to the child), ‘depression’ (worries and negative thoughts due to the parental role) and ‘spouse-related stress’ (as a result of being a parent). Answers were given on a 5-point Likert scale ranging from 1 = strongly agree to 5 = strongly disagree, resulting in a possible score range of 28–140. The three cut-off categories for each subscale and the whole parent domain were ‘not stressed’ (T value < 60), ‘stressed’ (T value = 60–69), and ‘strongly stressed’ (T value ≥ 70). The internal consistency of the parent domain has been proven to be good (α = 0.93), and the retest reliability after one year has been shown to be r = 0.87. Correlations with stress indicators and related constructs have resulted in the assumption of test validity (41).

Parental mental health

Current parental depression and anxiety symptoms were assessed with the very short screening tool Patient Health Questionnaire 4 (PHQ-4, German Version, (42)). The questionnaire comprises two items each on the occurrence of depression and anxiety symptoms over the last two weeks. The four items are used to record the two diagnostic core criteria of major depression and generalized anxiety disorder. The response options on a 4-point Likert scale range from 0 “not at all” to 3 “almost every day”, resulting in a possible score range of 0–12. A cut-off of ≥ 2 for the depression items indicates depressive symptomatology, and a cut-off of ≥ 3 for the anxiety items refers to generalized anxiety symptomatology. The internal consistency of the PHQ-4 has been proven to be good (α = 0.85) (43). The PHQ-4 showed acceptable reliability, with ω = 0.85. Construct validity was supported by intercorrelations with other self-reported scales and demographic variables (44).

Infants’ crying, sleeping and feeding problems

For infants (0–24 months), the two subscales ‘crying/whining/sleeping’ and ‘feeding’ of the Questionnaire for Crying, Sleeping and Feeding (CSF; (45)) were applied. Parents answered 38 questions about the behavior of their infants. Answers were given on 4-point scales, and mean values were calculated (ranging from 1 to 4). According to validated cut-off values, the dichotomous outcomes ‘noticeable problems’ and ‘no problems’ were calculated for the domains ‘crying/whining/sleeping’ (cut-off value: 1.84, sensitivity: 87%, specificity: 92%) and ‘feeding’ (cut-off value: 1.27, sensitivity: 57%, specificity: 77%). The CSF also comprises questions to identify excessive crying as defined by the Wessel criterion (‘rule of three’) (46). The validity of the questionnaire has been confirmed by the high internal consistency of the scales as well as by correlations with behavior diaries and clinical diagnoses (45).

Emotional and behavioral problems of toddlers and pre- and primary schoolers

For toddlers (2–4 years) and pre- and primary schoolers (from 5 years), the Strengths and Difficulties Questionnaire (SDQ, short form of the German Version; (47)) was used to examine emotional and behavioral problems. Parents received the version that was appropriate for their child’s age (i.e., 2–4 years or older than 4 years). Parents were asked to classify the individual characteristics as not true, somewhat true or certainly true for their child in four domains (‘emotional symptoms’, ‘conduct problems’, ‘hyperactivity/inattention’, and ‘peer relationship problems’), resulting in a score ranging from 0–40 points. The cut-off values indicated that the child’s behavior was ‘no problems’ (0–13 points), ‘borderline’ (14–16 points) or ‘noticeable problems’ (17–40 points). The internal consistency has been shown to range between α = 0.73 and α = 0.86. By means of comparison with other corresponding scales (e.g., the Child Behavior Checklist), the validity of the instrument can be assumed to be acceptable (48, 49).

Statistical analyses

For analyses, children were divided into three groups according to their U examination: “infants” (U4-U6, i.e., aged approximately 0–24 months), “toddlers” (U7-U8, i.e., aged approximately 2–4 years), and “pre- and primary schoolers” (≥ U9, i.e., aged 5 years and older). Since the submission of questionnaires was possible only when all the items were completed, there were only a few missing values. Subjects with missing values were excluded from the analyses where necessary (see individual table descriptions). A descriptive analysis was performed on parenting stress (EBI), parent mental health (PHQ), as well as infant crying, sleeping, feeding (CSF), and behavioral and emotional (SDQ) difficulties. For the evaluation regarding societal challenges, the response options 'not at all stressful' and 'not stressful' were combined into 'not (at all) stressful,' and 'very stressful' and 'stressful' were combined into '(very) stressful'.

To include certain variables in the regression analyses, these variables were dichotomized as follows: education status was dichotomized into high (university degree and high school diploma) and low (secondary and lower secondary school diploma), and those cases whose response referred to ‘other qualification’ and thus could not be allocated to either of the groups were excluded from the analyses. Financial status, as measured by participants’ subjective perception that additional purchases are possible after basic needs are met, was also dichotomized into high (‘family income generally allows for very large additional purchases’ and ‘family income generally allows for large additional purchases’) and low (‘family income generally allows for only small additional purchases’, ‘family income generally allows for only very small additional purchases’, and ‘family income not sufficient to meet basic needs (no additional purchases possible)’). Participants who did not want to provide an answer regarding their current financial status were excluded from the analyses related to this outcome variable. Multiple linear regression models were constructed for the outcomes EBI total score (i.e., parenting stress) and PHQ total score (i.e., parental mental health symptoms). Within the framework of the regression analysis, six models were developed to anticipate the two parental outcomes across all three distinct age groups (i.e., infants, toddlers, and pre- and primary schoolers). The following predictors were included: sociodemographic factors (education status, financial status, child age, having more than one child (i.e., having a sibling), being a single parent (i.e., raising the child almost alone), child chronic illness and/or disability, perceived global psychosocial stressors (sum score of perceived burden of climate change, inflation, social division, Russia-Ukraine War and Covid-19 pandemic), CSF crying/whining/sleeping problem score, CSF feeding problem score, SDQ 2–4 years total score and SDQ age 5 + total score (i.e., child mental health problems). The models resulted in the calculation of standardized beta weights and their p values for corresponding predictor variables. The requirements for calculating multiple linear regression models were met. All the described results were based on an alpha level of 5%. To control for multiple testing (n = 6), Bonferroni correction was performed. Analyses were performed in IBM SPSS Statistics Version 28.0 for Windows (50).

Sample characteristics

The final cohort comprised 17,333 families. The average age of the parents was 35.2 years (SD = 5.3), with mothers averaging 35.0 years (SD = 5.2) and fathers 38.0 years (SD = 5.9) (Table 1).

Table 1: Characteristics of the participants

Notably, 93.9% of the participants were mothers. The infants were, on average, 5.0 (SD = 4.2) months old, the toddlers were 30.9 (SD = 10.1) months old, and the pre- and primary schoolers were, on average, 82.0 (SD = 21.7) months old.

Siblings were present in 57.7% of the families. More than half of the parents (55.4%) had attained at least a high school diploma, and 42.5% reported a perceived high financial status. In contrast, 47.1% of the families reported a low perceived financial status, and an additional 2.1% of the families indicated that their current financial status cannot cover the costs of basic necessities.

Most of the children (95.9%) had both parents or at least one parent born in Germany, and 99.4% of the children had resided in Germany since birth. Additionally, German was the predominant language within households, with 94.6% of the surveyed families indicating that German was spoken mainly at home.

Perceived societal challenges

Financial inflation was perceived as "stressful" or "very stressful" by almost two-thirds (59.3%) of the respondents, whereas social division and radicalization were deemed (very) stressful by 49.3% of the parents (Figure 1). Further challenges were perceived as (very) stressful by 37.9% (Russia-Ukraine War), 31.8% (climate change), and 31.6% (COVID-19 pandemic) of the parents.

Figure 1: Perceived societal challenges

Parenting stress

According to the EBI (Table 2), 37.4% of the parents were ‘stressed’, and 16.3% were ‘strongly stressed’. Among the individual subscales of the EBI in the overall sample, ‘depression’ and ‘health’ stood out, with 68.7% and 58.9% of the participants scoring above the cut-off value for being ‘stressed’ or ‘strongly stressed’, respectively.

Parental mental health

Regarding their overall mental health, 48.6% of the parents reported concerns. Among them, 37.6% presented mild symptoms, 8.1% moderate symptoms, and 2.9% severe symptoms (Table 2). When the subscales were evaluated separately, 13.5% had symptoms of depression, and 14.6% had symptoms of anxiety. The overall mean PHQ-4 score was 2.82 (SD: 2.31).

Table 2: Parenting stress and parent mental health

Child mental health

According to the CSF, 35.5% of the infants showed feeding problems, 34.9% had noticeable crying/whining/sleeping problems, and 6.1% met the Wessel criterion for excessive crying (Table 3). The overall SDQ for toddlers (pre- and primary schoolers) revealed that 8.8% (9.8%) of the children were in the ‘borderline’ range and that 10.4% (8.7%) were in the ‘noticeable’ range with respect to emotional and behavioral problems. In terms of the SDQ subscales, 15.2% (11.5%) of the parents reported peer problems, 10.0% (12.5%) reported hyperactivity, 12.2% (23.3%) reported emotional problems, and 26.0% (16.5%) reported problems for their children.

Table 3: Child mental health

Predictive Factors of Parenting Stress and Mental Health

Across all age groups, consistent and strong predictors of EBI emerged (Table 4). The strongest predictors were crying/whining/sleeping problems in infants (ß = 0.386, p < 0.001), emotional as well as behavioral problems in toddlers (ß = 0.361, p < 0.001) and pre- and primary schoolers (ß = 0.386, p < 0.001). Similarly, societal challenges consistently predicted higher parenting stress levels across all age groups (for parents of infants: ß = 0.169, p < 0.001; toddlers: ß = 0.174, p < 0.001; and pre- and primary schoolers: ß = 0.198, p < 0.001). External childcare was consistently associated with higher levels of parenting stress across different age ranges (for parents of infants: ß = 0.034, p = 0.012; toddlers: ß = 0.144, p < 0.001; and pre- and primary schoolers: ß = 0.147, p < 0.001).

Significant predictors of a higher total PHQ score across all age groups were infant crying/whining/sleeping, respectively, and children’s emotional and behavioral problems. These factors had the highest effect sizes (ß = .28 - .29), followed by societal challenges (ß = .16- .20). Being a single parent (ß = .05 - .09) and using external care (ß = .05 - .07) were also significantly associated with the total PHQ score. Parental age (ß = .006 - .05) and financial status (ß = -.02 - -.07) were negatively associated with the total PHQ score.

Table 4: Hierarchical regression analysis to predict the EBI total score T value and PHQ total score

This cross-sectional study of approximately 17,000 families revealed that more than half of the parents experienced moderate or high parenting stress, and 11% experienced moderate to strong depression and anxiety symptoms. One-third of the infants reported crying/whining/sleeping problems, more than one-third reported feeding problems, and some 10% of the older children reported emotional and behavioral problems. Child behavior and current societal challenges (e.g., economic inflation, the Russia-Ukraine War and climate change) were significantly associated with parenting stress and parental mental health symptoms.

A previous study examined a comparable population during the COVID-19 pandemic and reported a high prevalence of parenting stress compared with prepandemic data (51), which further increased from 38 to 51% during the pandemic, independent of restrictions (25). This was confirmed by another pandemic study (52). The present study revealed that more than 53% of the parents experienced parenting stress. This might indicate that the proportion of (strongly) stressed parents continues to increase or at least has not yet relaxed. In particular, the proportion of “strongly stressed” parents was significantly greater in the present survey (16%) than in a previous study (11% during the pandemic) (data not shown). Additionally, as already observed in previous studies, most parents were affected by the subscales “health” and “depression”. High values on the “health” subdomain, as seen in 58% of the parents, indicate physical exhaustion and less energy. High values on the “depression” scale were present in more than two-thirds of the parents and indicated feelings of parental insecurity and guilt. This might lead to the risk for an impaired parent‒child relationship (40), as indicated in a third of the families (“attachment” subscale).

According to the PHQ subscales, 14.6% of the parents reported having anxiety symptoms, and 13.5% reported having depression symptoms. This figure is approximately 4% greater than that in the prepandemic general German population (53). A German prepandemic study reported a mean PHQ-4 score of 1.58 for parents of children up to 4 years of age (54). Another study reported a significant increase in the mean PHQ score from 2.3 to 2.5 in the first year of the pandemic in adults (55). The present postpandemic study population had a mean value of 2.82. Thus, it can be assumed that there has been no improvement in depression or anxiety symptoms since the COVID-19 pandemic, and the prepandemic level has been far exceeded. As initially expected, these findings indicate that pandemic-related stressors may have manifested and impacted long-term mental health in the population. Most likely, the current crises might additionally contribute to the constantly high parental strain.

Overall, our data point towards certain restrictions in parental functioning, which might have negative consequences for a healthy parent‒child relationship and sensitive parenting behavior (20). This, in turn, could lead to mental health problems in children. In this study, more than one-third of the parents reported behavioral problems in their infants. Excessive crying was present in 6.1% of the infants, which is within the normal range(56, 57) and slightly greater than that reported in a previous study in which the same measurement tool was used (25).

Problems pertaining to sleeping and whining were observed in almost 35% of the infants, which is comparable to the findings of a previous study, where the proportion of these problems increased during the pandemic to 35.5% (25). These higher rates are associated with higher rates of the abovementioned parenting stress and parental mental health, leading to the assumption that this parenting stress and mental health issues favour infant crying/whining/sleeping problems or vice versa. Feeding problems were present in approximately 35% of the infants, which is similar to pandemic data (30, 25), suggesting that feeding problems may be more based on multiple risk factors (e.g. sensory aversion or sensitivity in the throat area).

Taken together, the rates of parenting stress, parental mental health symptoms and infants’ crying/whining and sleeping problems are higher than those before the pandemic and have not decreased afterwards. This suggests that a plateau might have been reached. Constantly elevated stress levels due to the pandemic and subsequent ecological problems, the societal division added by the Russia–Ukraine war, climate change and global political troubles might hinder the relaxation of stress exposure. Hence, there is no peak, but there is a plateau of familial burden.

In contrast, children aged 2 years and older did not have higher values of emotional and behavioral problems than did those in previous studies. The SDQ yielded 19.2% of the toddlers showing at least borderline behavior, which is in the normal range and almost at a prepandemic level (17–18%) (58). Among pre- and primary schoolers, 18.5% reported behavioral conspicuities, which is less than during the pandemic (25), suggesting that a prepandemic level might be reached soon. The constantly inconspicuous rates of emotional and behavioral problems might be a result of children being older, being less dependent on their parents and potentially being less vulnerable to parenting stress than infants are. Additionally, it cannot be ruled out that the application of the SDQ, which aims to screen for psychiatric disorders more than observing smaller changes in child behavior, is the reason for the constant rates (47). However, this should not be a reason to lose sight of these children, since current studies on children aged 11 years and older reported high levels of stress and worries due to the pandemic, climate change and the Russia-Ukraine-War (32, 23). Therefore, preventive measures to avoid the occurrence of mental health problems in this generation should be initiated.

Although the population under study had average to high income (59), almost 60% perceived economic inflation as stressful or very stressful. A perceived good financial situation seems to be protective against mental health problems since it was negatively associated with parental mental health symptoms in parents of children up to 4 years of age. Surprisingly, this phenomenon occurred in parents of pre- and primary school-aged children, where a perceived good financial situation was positively associated with parenting stress. It is conceivable that a higher workload (i.e., more responsibilities in the job, compatibility of career and family) results in a greater burden and hence more parenting stress. Furthermore, radicalization and social division were among the most stressful current societal challenges (49.3%), followed by the Russian-Ukraine-War. These problems may touch families rather indirectly and are therefore not as challenging as direct-acting economic inflation. To date, only a few studies have focused on the postpandemic period. However, these findings already show that societal challenges are increasingly stressful, especially for the younger generation (32, 23).

As shown in the regression analyses, parenting stress and mental health symptoms had the strongest associations with child behavior problems and societal challenges across all age groups. There is evidence confirming the association between child psychological problems and parenting stress (20) since conspicuous child behavior may require more parental resources, leading to less energy and emotional availability, as indicated in the EBI subscales. However, child behavior problems are measured by parent reports and might hence be overestimated by burdened parents. It cannot be ruled out that, vice versa, parenting stress and mental health symptoms may impact a child’s behavior, as shown in previous studies (20).

Additionally, across all age groups, societal challenges were strongly associated with both parenting stress and parental depression and anxiety symptoms. These challenges potentially impact the family system directly, such as pandemic-related measures or increased expenses, and indirectly, such as increased anxiety due to armed conflicts. To date, there has been weak evidence on the relationship between environmental factors and parenting stress. Thus, the results cannot be compared with other findings, which makes further research indispensable.

In parents of children aged 2 years and older, both parenting stress and mental health were significantly associated with external care. It is conceivable that parents are stressed because economic inflation forces them to work more hours, which in turn forces them to send their children to external care for a longer period of time. On the other hand, a recent study revealed that parenting stress was greater when external care was “formal”, i.e., not performed by family members (such as grandparents), and thus was independent from external rules and pressure (60). This cannot be proven on the basis of our data. However, external care was highly correlated with parental working hours (data not shown), suggesting that more working hours may lead to increased parenting stress.

Being a single parent was significantly associated with parental mental health symptoms, which can be interpreted bidirectionally: mentally burdened parents might have more family conflicts, resulting in separation or divorce. In contrast, single parents have a greater mental load (61), which might cause symptoms of depression or even anxiety.

In summary, young families have experienced certain challenges and changes at different levels in recent years. According to Bronfenbrenner theory (62), such changes might influence a child’s development. For example, high parenting stress impacts a child’s microsystem. The macrosystem, i.e., culture, ideology, laws, etc., has changed due to the pandemic, the Russia–Ukraine War, and climate change because all these challenges have caused fear of the future, political debates, uncertainty, and division in society. Hence, an impact of the surrounding systems on a child’s psychological development cannot be ruled out.

Strengths and Limitations

The study has a very large sample size, applied validated questionnaires and had very few missing data. This is the first study on the impact of multiple crises on families with infants and toddlers. With a sample size of n = 17,333, even very small effects could be found with a statistical power of .9 and a significance level of α = .05.

However, selection bias cannot be ruled out: the population comprised only app users and were almost exclusively German citizens living in Bavaria. Nevertheless, the population had an education level similar to that of the average German population (63) but a rather high income, which limits generalizability and might lead to a slight underestimation of our results. To explore the direction of certain effects, a cross-sectional survey is not appropriate, but a follow-up survey is ongoing and will shed light on some open questions.

Families’ psychosocial stress rates were high during the pandemic and have not decreased ever since. Infants’ crying/whining/sleeping problems seem to be strongly correlated with their parenting stress and parent mental health, and both should be focused on prevention and support programs. Although toddlers and children at preschool and primary school age did not show high rates of conspicuous behavior, the families’ psychosocial wellbeing treads on thin ice because the whole macrosystem (environment) is changing and therefore touching each individual’s life. The significant associations between external childcare, parental working hours, and parenting stress should be a focal point of future analyses.

CSF: Questionnaire for Crying, Sleeping and Feeding

EBI: Eltern-Belastungs-Inventar (German Version of the Parenting Stress Index (PSI))

SDQ: Strengths and difficulties questionnaire

PHQ 4: Patient Health Questionnaire 4

Acknowledgements

First, we thank all the pediatricians and families who participated in the JuFaBY study despite these challenging and particularly stressful times. This study could not have been realized without the support of BVKJ Bayern (Professional Association of Pediatricians in Bavaria) and Paednetz Bayern—represented by Dominik Ewald, Otto Laub and Gabi Haus—as well as Monks Aerzte-im-Netz GmbH and BVKJ Service GmbH, who also made the implementation of this digital study possible.

Ethics approval and consent to participate

The study protocol was approved by the Ethics Committee of the Technical University of Munich (vote no. 2022-483_1-S-KH). Study invitations and detailed information were presented via an app. Subsequent informed consent was given via the app.

Consent for publication

Not applicable.

Data availability

The datasets generated and/or analysed during the current study are not publicly available but are available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Contributions

KR participated in the data collection, statistical analysis, writing the manuscript and holds the principal authorship of the manuscript. CB participated in the development of the study design, literature review, instrument creation and selection, critical manuscript revision and proofreading. MA participated in the statistical analysis, critical revision of the manuscript and proofreading. AF was a major contributor in creating the study design, participated in the literature review, instrument creation and selection, critical revision and final proofreading of the manuscript. VM was a major contributor to creating the study design and critically revised the manuscript. IN participated in the development of the study design, literature review, instrument creation and selection, and statistical analysis and was a major contributor to the writing of the manuscript, critical revision and proofreading. All the authors have read and approved the final manuscript.

Funding

The authors declare that financial support was received for the research, authorship, and/or publication of this article.

This study was supported by the Bavarian State Ministry of Family, Labour and Social Affairs (Bayerisches Staatsministerium für Familie, Arbeit und Soziales).

The project was funded by the Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung, BMBF) as part of the German Center for Child and Adolescent Health (DZKJ) under the funding code 01GL2406B.

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Table 1

Characteristics of participants

Parents	%	n
Mothers	93.9	16279
One or both parents born in Germany	95.9	16616
Single Parent	9.3	1615
Level of education
University degree	37.4	6475
High school diploma	18.0	3112
Secondary school diploma	32.0	5543
Lower secondary school diploma	10.1	1753
No diploma (yet)	0.8	131
Other qualifiations	1.8	307
Perceived Financial status
Very large additional purchases possible	6.8	1183
Large additional purchases possible	35.7	6186
Small additional purchases possible	36.6	6337
Very small additional purchases possible	10.5	120
No additional purchases possible	2.1	370
Not specified	8.2	1422
Monthly household income
Less than 1500 €	2.8	489
1500 – 2499 €	9.6	1663
2500 – 3499 €	17.7	3076
3500 – 4499 €	21.3	3698
4500 – 5499 €	15.2	2626
5500 € or more	13.4	2327
Not specified	19.9	3454
External care
Not at all	31.1	5386
Up to 10 h per week	17.3	2993
Up to 20 h per week	14.9	2580
Up to 30 h per week	21.9	3803
More than 30 h per week	14.8	2571
Children
Infants	25.9	4489
Toddlers	40.8	7079
Pre- and primary schoolers	33.3	5765
Boys	51.4	8909
German mother tongue	94.6	16397
Chronic illness and/or disability	5.8	1002
Siblings	57.7	10000

Note. N = 17,333

Table 2

Parenting stress and parent mental health

	Parenting Stress Inventory (EBI)	%		N
	Categorial evaluation of the parent domain^a
	No findings	46.3		7705
	Stressed	37.4		6216
	Strongly stressed	16.3		2713
	Subscales (above cut-off)
	Attachment	33.8		5821
	Isolation	53.3		9186
	Parent competence	47.0		8099
	Depression (worries and negative thoughts due to the parental role)	68.7		11826
	Health	58.9		10142
	Role restriction	47.7		8224
	Spouse related stress^a	47.8		7957
Parent mental health (PHQ)
Total
None		51.4	8851
Low		37.6	6477
Moderate		8.1	1397
Strong		2.9	499
	Depression
	Inconspiciuous/normal	86.5	14895
	Noticeable/abnormal (probable)	13.5	2329
	Anxiety
	Inconspiciuous/normal	85.4	14706
	Noticeable/abnormal	14.6	2517

Note. ^a N = 16,634.

Table 3

Child mental health

Child mental health (CSF and SDQ)	%	n
Infants: Noticable crying, feeding & sleeping problems
Excessive crying (Wessel criterion)	6.1	274
Crying/Whining/Sleeping	34.9	1529
Feeding	35.5	1536
Toddlers: Emotional and behavioural problems (Categorial evaluation of SDQ total score)
Inconspiciuous/normal	80.8	5764
Borderline	8.8	508
Noticeable/abnormal	10.4	598
Pre- and primary schoolers: Emotional and behavioural problems (Categorial evaluation of SDQ total score)
Inconspiciuous/normal	81.4	5764
Borderline	9.8	696
Noticeable/abnormal	8.7	617

Note. n_infants= 4489, n_toddlers= 7079, n_{pre- and primary schoolers}= 5765

Table 4

Hierarchical regression analysis to predict the EBI total score T value and PHQ total score

Outcomes	EBI total score T value				PHQ total score
	Infants
	B	SE B	ß	p	B	SE B	ß	p
	R²= .270 F (11) = 150,214 p = <.001				R²= .205 F (11) = 104,998 p = <.001
Parent Age	-.025	.029	-.012	.391	-.025	.007	-.052	<.001*
Single Parent	.801	.487	.021	.100	.419	.114	.050	<.001*
Siblings	2.124	.284	.103	<.001*	.274	.066	.059	<.001*
External care	.386	.153	.034	.012	.136	.036	.053	<.001*
Child chronic illness or impairment	-.275	.901	-.004	.760	.403	.211	.026	.056
Parent education (dichotomized)	-.3.005E-5	.001	.000	.973	.000	.000	.007	.587
Financial situation (dichotomized)	.471	.258	.024	.068	-.286	-.286	-.065	<.001*
Child Age	.107	.030	.047	<.001*	.015	.015	.029	.038
Social challenges	.476	.037	.169	<.001*	.100	.100	.157	<.001*
Infant crying, whining, fussing	10.011	.358	.162	<.001*	1.605	1.605	.276	<.001*
Infant feeding	5.102	.432	.386	<.001*	1.257	1.257	.178	<.001*
	Toddlers
R²= .191 F (10) = 167,248 p = <.001					R²= .153 F (10) = 127,975 p = <.001
Parent Age	.043	.022	.022	.051	-.009	.006	-.018	.123
Single Parent	.237	.355	.007	.504	.615	.094	.073	<.001*
Siblings	.343	.203	.019	.092	.101	.054	.021	.061
External care	.959	.076	.144	<.001*	.114	.020	.066	<.001*
Child chronic illness or impairment	-.355	.479	-.008	.458	.199	.127	.017	.116
Parent education (dichotomized)	.001	.001	.020	.065	.000	.000	.014	.210
Financial situation (dichotomized)	.158	.203	.009	.437	-.342	.054	-.072	<.001*
Child Age	-.047	.010	-.053	<.001*	-.001	.003	-.006	.628
Societal challenges	.463	.029	.174	<.001*	.114	.008	.165	<.001*
Child emotional and behavioral problems	.680	.021	.361	<.001*	.143	.005	.295	<.001*
	Pre- and primary schoolers
R²= .225 F (10) = 167,384 p = <.001					R²= .170 F (10) = 117,702 p = <.001
Parent Age	.062	.024	.032	.011	-.003	.006	-.006	.666
Single Parent	.761	.364	.025	.037	.656	.091	.090	<.001*
Siblings	.1.109	.290	.045	<.001*	.042	.072	.007	.561
External care	1.055	.092	.147	<.001*	.090	.023	.052	<.001*
Child chronic illness or impairment	-.830	.385	-.026	.031	.327	.096	.042	<.001*
Parent education (dichotomized)	.001	.001	.007	.530	.000	.000	-.023	.056
Financial situation (dichotomized)	1.078	.243	.054	<.001*	-.105	.061	-.022	.083
Child Age	-.021	.006	-.048	<.001*	.004	.002	.034	.013
Societal challenges	.564	.034	.198	<.001*	.127	.008	.184	<.001*
Child emotional and behavioral problems	.694	.002	.386	<.001*	.128	.006	.294	<.001*

Note. *p ≤ .0083 (Bonferroni adj. Alpha).

No competing interests reported.

Psychosocial stress in young families after the pandemic: no time to rest

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Background

Methods

Study design

Participants

Measures

Perceived societal stress factors

Parenting stress

Parental mental health

Infants’ crying, sleeping and feeding problems

Emotional and behavioral problems of toddlers and pre- and primary schoolers

Statistical analyses

Results

Discussion

Strengths and Limitations

Conclusion

Abbreviations

Declarations

References

Tables

Additional Declarations

Status:

Version 1