An audit of the impact of Covid-19 pandemic on the emotional wellbeing of children and parents with problematic severe asthma

Our findings suggest that there were significant anxieties associated with the ability to access primary and secondary care services, medication during the pandemic – lockdown, as well as the psychological impact of social distancing and missing school work for this cohort. There was a common perception that this had adversely impacted their asthma control, although this was not clinically correlated.


Introduction
The clinical features of acute SARS-COV-2 infection in children are generally mild; accounting for <2% of cases that have required hospitalization 1 . Furthermore, children with asthma have not been severely affected, with a reduction in admissions due to wheeze attacks having been observed during the pandemic period 2 . These epidemiological characteristics were not clear early in the course of the pandemic. Indeed, children with asthma were perceived to be at a higher risk of suffering from Nadia Audi MBBS 1* , James Cook MBBS 1* , Becky Tomlin BSN 1 , Sarah Latham BSN 1 , Sulagna Chakrabarti MBBS 2 , Prasad Nagakumar[Res] 3 , Atul Gupta MD[Res] 1 severe disease; a prospect that would reasonably be associated with high levels of anxiety in both children and parents.
Anxiety and stress, are associated with poor asthma control and can trigger wheeze attacks 3 . Moreover, parental stress can exacerbate a child's asthma symptoms 3 . We hypothesized that the effect of social distancing measures and uncertainties around the SARS-COV-19 infection during the peak of the pandemic would result in detrimental effects on the emotional wellbeing of children with problematic severe asthma, impacting symptom control.

Method
Children and young persons (CYP) diagnosed with severe asthma 4 , currently attending a tertiary level multidisciplinary difficult asthma clinic serving South London and South East England were identified.
Two questionnaires were developed to assess themes related to the COVID-19 pandemic which were considered important influences on emotional wellbeing and potentially on asthma control. One questionnaire was designed to be answered by parents and the other to be answered by CYP. Answers to each question were recorded on a categorical scale; never/sometimes/ often/always.
Printed copies of the questionnaires were sent by recorded delivery to the address of each patient on 5 th of June 2020. The questionnaires were completed anonymously and returned by post in pre-paid envelopes to the investigators. Questionnaires returned by 29 th of June 2020 were included in the analysis.
These questionnaires were registered with the local audit department as a service evaluation project.

Results
Questionnaires were sent by post to the households of the 58 CYP identified. 20 questionnaires completed by parents, and 14 questionnaires completed by CYP were returned. The median age of CYP was 11 years (range 4 to 18), 39 of 58 were males. A summary of the responses to each question are presented in table 1 and table 2 (appendix)

Parental Questionnaire
The majority of parents 17/20 (85%) were worried about their child having an asthma attack during the pandemic, with a particular contributory factor being concerns around access to normal healthcare services. Indeed, 16/20 (80%) were concerned about accessing primary care services, 15/20 (75%) were concerned about accessing hospital services and 14/20 (70%) were concerned about accessing regular prescriptions.
Parents reported that the emotional wellbeing of their child was impacting on asthma symptoms. The main contributory influences affecting asthma control were the impact of social distancing 14/20 (70%), worry about school work 12/20 (60%), and their child's anxiety around COVID-19 12/20 (60%).
Parents' perception of the emotional welling being of their children was explored in further detail. 14/20 (70%) reported observing feelings of sadness and irritability in their child, and 16/20 (80%) observed increased levels of anxiety and lack of concentration. Changes in physical behaviors reflective of emotional changes were also reported; low energy 18/20 (90%), restlessness 17/20 (85%) and difficulty in sleeping 12/20 (60%).

Children's Questionnaire
The majority of CYP 9/14 (64%) were worried about an asthma attack during the pandemic. Accessing healthcare during an attack was of concern with 11/14 (78%) worried about the prospect of a hospital visit. In contrast to their parents only 4/14 (28%) were concerned about accessing regular prescriptions.
In common with their parents, CYP reported that their emotional wellbeing had influenced asthma symptoms. Factors reported to be impacting symptoms included impact of social distancing 7/14 (50%), and concerns regarding school work 7/14 (50%). A minority 4/14 (29%) felt that concerns regarding COVID-19 had influenced their asthma symptoms.

Main findings
The emotional impact of the COVID-19 pandemic on CYP with severe asthma appears significant. Our questionnaires have highlighted that anxiety around the challenges of accessing appropriate healthcare services, impact of social distancing measures and worry about school work impacted on emotional wellbeing. In turn these influences appeared to manifest as physical symptoms including reported worsening asthma control.

Interpretation
The role of stress and anxiety on asthma control is well described 5 . The emotional impact of COVID-19 on children is beginning to emerge and themes identified using this questionnaire have been reflected in other reports. As access to support networks at school and within the wider community of family and friends have been disrupted, stressors have accumulated and become amplified. Uncertainty about the future including worries about health, cancellation of exams, applications to college and financial security have all been reported as contributing to the experience of anxiety.
The charity, Young Minds, identified 83% of CYP as having experienced a worsening of their mental health 6 . Furthermore, specific concerns regarding accessing healthcare became apparent early on in the course of the pandemic with a sharp decline in paediatric emergency department attendances recorded, and concerns raised regarding delayed presentation of severe illness 7 .

Limitations
We acknowledge important limitations to this study. The sample size was small with a low response rate and the patients identified were all from the same tertiary regional clinic. It is possible the results may have differed in different parts of the UK. In addition there was no measurement of adherence or asthma control test score.

Conclusion
There has been a significant emotional impact of the COVID-19 pandemic on CYP with severe asthma, which is associated with a perception of worsening asthma control. An improved understanding of these factors amongst professionals involved in caring for these CYP may help with recognition of how the pandemic may be influencing asthma symptoms. Further research of a larger population, taking in to consideration correlation with asthma control, adherence to therapy, the additional impact of socioeconomic factors and demographics would be important.  All authors reviewed and approved the final version of the manuscript Funding Source: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

COVID-19 SURVEY FOR CHILDREN AND ADOLESCENTS ATTENDING SPECIALIST ASTHMA SERVICE
We are getting in touch with you because you attend our service at Kings College hospital and we wanted to know how you have been during the COVID -19 pandemic.

Please tick the most appropriate answer (ask your parent if you need help)
Asthma Symptoms -during the COVID-19 outbreak:

COVID-19 SURVEY FOR PARENTS OF CHILDREN AND ADOLESCENTS ATTENDING SPECIALIST ASTHMA SERVICE
We are getting in touch with you because you attend our service at Kings College hospital and we wanted to know how you and your child have been during the COVID -19 pandemic.

Please tick the most appropriate answer
Asthma Symptoms -during the COVID-19 outbreak: