PARENTAL STRESS AND CHILD ANXIETY AND DEPRESSION

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PARENTAL STRESS AND CHILD ANXIETY AND DEPRESSION

A cross-sectional survey study in Sweden and Switzerland

FÖRÄLDRARS STRESS OCH BARNS ÅNGEST OCH

DEPRESSION

En tvärsnitts-enkätundersökning i Sverige och Schweiz

Bachelor Degree Project in Public Health Science

Level 180 ECTS Spring term 2020

Author: Linda Breitkreuz Chauvet

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ABSTRACT

Title: Parental Stress and Child Anxiety and Depression - A cross-sectional survey study in Sweden and Switzerland

Author: Breitkreuz Chauvet, Linda

Dept./School: Department of Biomedicine and Public Health, School of Health Sciences, University of Skövde

Course: Bachelor Degree Project in Public Health Science G2E, 15 ECTS Supervisor: Stark Ekman, Diana

Examiner: Gustafson, Deborah

Pages: 49

Keywords: parental stress, child anxiety, child depression, RCADS, work-family conflict

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Introduction: The shift from single- to dual-earner households means that, often, both parents have joined the paid labor force. The demands of work and family can conflict, and this conflict can be a major stressor to parents in today’s high-income countries. Parental stress has been connected to child anxiety and depression, known precursors for mental disorders later on in life. Aim: The aim of this study is to describe differences between convenience samples of Swedish and Swiss parents, exploring the relationship between parental stress (high and low stress parents) and perceived symptoms of anxiety and depression in their children. Methods: A cross-sectional comparative survey was conducted among convenience samples of n=45 Swedish and n=30 Swiss parents of children ages 7-10 years. Parents were categorized as having high (> weekly) or low stress (< weekly). Raw scores from the Revised Children's Anxiety and Depression Scale (RCADS) 25 parent version were calculated as the outcome. Data were analyzed using t-tests and Chi-square tests using SPSS-25. Results were considered significant at p<0.05. Results: There was a significant correlation between high parental stress and RCADS-25-P scores. Swedish parents reported having to make priorities between activities in the family schedule more often than Swiss parents. Household chores correlated positively with parental stress.

Conclusion: Families in both countries report stressors, and there was observed a relationship between parental stress and perceived symptoms of anxiety and depression among their 7-10 year old children. Social support, in the form of family-friendly workplace policies, may be useful in addressing these determinants of health.

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SAMMANFATTNING

Titel: Föräldrars stress och barns ångest och depression - En tvärsnitts- enkätundersökning i Sverige och Schweiz

Författare: Breitkreuz Chauvet, Linda

Avdelning/Institution: Avdelningen för biomedicin och folkhälsovetenskap, institutionen för hälsovetenskaper, Högskolan i Skövde

Program/kurs: Folkhälsovetenskapligt program, Examensarbete i folkhälsovetenskap G2E, 15 hp

Handledare: Stark Ekman, Diana Examinator: Gustafson, Deborah

Sidor: 49

Nyckelord: föräldrars stress, barns ångest, barns depression, RCADS, work- family conflict

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Introduktion: Skiftet från enförsörjar- till tvåförsörjarhushåll innebär numera ofta att båda föräldrarna sysslar med förvärvsarbete. Det kan uppstå konflikt mellan kraven från arbete och familj, och den här konflikten kan utgöra en stor stressfaktor för föräldrar i dagens höginkomstländer. Föräldrastress har kopplats till ångest och depression bland barn, kända förelöpare till mental ohälsa senare i livet. Syfte: Syftet med den här studien är att beskriva skillnader mellan bekvämlighetsurval av svenska och schweiziska föräldrar, för att undersöka sambandet mellan föräldrastress (hög- och lågstressade föräldrar) och upplevda symptom av ångest och depression hos deras barn. Metod: En jämförande tvärsnitts- enkätstudie utfördes på ett bekvämlighetsurval av n=45 svenska och n=30 schweiziska föräldrar till barn i åldrarna 7-10 år. Föräldrar kategoriserades utefter om de upplevde hög (> varje vecka), samt låg stress (< varje vecka). En råpoäng räknades ut från Revised Children's Anxiety and Depression Scale (RCADS) 25 föräldraversion som utfall. Data analyserades genom t-tester och Chi2-tester i SPSS-25. Resultaten ansågs signifikanta vid p<0,05. Resultat: Det fanns ett signifikant samband mellan föräldrars höga stressnivåer och förhöjda RADS-25-P råpoäng. Svenska föräldrar rapporterade att de oftare behövde prioritera i familjens schema än schweiziska föräldrar. Hushållssysslor korrelerade positivt med föräldrars förhöjda stressnivåer. Slutsats: Familjer från båda länderna rapporterade upplevda stressorer, och studien visar att det finns ett samband mellan föräldrastress och upplevda symptom av ångest och depression hos deras barn i åldrarna 7-10 år. Socialt stöd, i form av familjevänliga arbetsplatspolicyer, skulle kunna vara användbara för att adressera dessa bestämningsfaktorer för hälsa.

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GLOSSARY

Work-family conflict - having one’s workload spill over into family life and vice versa.

Parenting mindfulness - present, compassionate and non-judgmental parenting approach.

Parenting self-regulation - controlling emotions and behaviors when interacting with the child.

Work-related stress – stress caused for example by work-load, schedule or career goals.

Parenting stress - stress and distress parents may experience because of the parental role.

Stress - a physical reaction to change, the body responds by either physical, mental or emotional reactions.

Stressor - something that causes a state of strain or tension.

Mental disorder - mental health issues characterized by emotional or behavioral problems, abnormal thoughts or difficult relationships with others.

Secure attachment - parent-child relationship where the parent is sensitive to the child’s needs by responding to his or her demands for care.

Insecure attachment – parents lacking sensitivity toward their child’s needs, or are inconsistent in their responses, leading the child to feel insecure and lack crucial proximity with the caregiver.

Social support – helping others cope with stressors.

Positive parent-child relationship - a parent’s sensitive and responsive care that is predictable to the young child, providing them with important emotional, behavioral and communicative skills for life.

Negative affectivity - people suffering from negative affectivity tend to have an abnormally strong perception of, and reaction to stress.

Harsh parenting – punitive and strict parenting, often involving a lot of screaming and sometimes even verbal or physical abuse.

Model anxious behavior – a display of anxious behavior that might be repeated by children.

RCADS-25-P – The Children’s Anxiety and Depression Scale 25 item parent and caregiver version.

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INTRODUCTION

Parents today are faced with great challenges in combining work and family life, and the imbalance between the two may increase parental stress and lead to states of anxiety and depression, negatively influencing parenting behaviors (Moreira et al., 2019). This, in turn may have an impact on their child’s mental health (Le et al., 2017; Platt et al., 2016).

From single- to dual-earner households

There has been a work-family shift over the last half-century. The past pattern of majority single-earner households or one family provider, has now become a dual-earner model. In dual earner households, paid labor is split (however not necessarily evenly) between the parents (Abbot, 2013). In addition, single-parent households are more common now than during the last century. Along with this workforce shift, traditional gender roles have gone through a revolution, and the distribution of household- and family-related tasks have correspondingly changed as well (Abbot, 2013). Consequently, parents’ schedules and managing both work and family, are busier than ever. In households with two parents, both caregivers must now invest their time both in paid and unpaid labor (such as childcare and household chores), as well as responsibility for parenting and creating quality time with their families. There is, however, a lagged adaptation of the paternal role when it comes to following the labor market changes, and there are still marked sex/gender differences in parents’ roles between countries (Abbott, 2013).

Stress and burnout

Stress can be defined as a physical reaction to change, and the body’s responses can be physical, mental or emotional strain. These changes can be positive or negative in origin, and stress is a normal product of life events, thoughts and numerous factors within everyday life (Cleveland Clinic, 2015). Although stress may be beneficial to the body as an immediate reaction to threat by providing an energy boost that will raise alertness, long-term stress has been shown to contribute to a multitude of illnesses. Everyday stressors intensify and/or multiply when unaddressed, and may lead to a state of chronic stress that extends over long periods of time and could seriously impair the individual, both psychologically and physically. The body’s natural defense mechanisms are not equipped to withstand constant and long-term exposure to stress, and a lack of recovery will eventually take an emotional toll. Emotional reactions to stress co-occur with physical reactions and may in more severe cases, result in adverse health outcomes such as anxiety, insomnia, depression, burnout, heart disease and obesity. Prolonged stress-exposed individuals might also resort to the abuse of addictive substances and run a higher risk of suicide (American Psychological Association

APA, n.d.).

Stressors

A stressor can be defined as something that causes a state of strain or tension (“Stressor”,

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or co-workers (Canadian Centre for Occupational Health and Safety CCOHS, 2018;

Thomas et al., 2003).

Although work-related stress has been found to be the single most significant contributor to family stress and that work-related stress often spills over into family life, parents also have to deal with family stress (Thomas et al., 2003). The term parenting stress refers to the stress and distress parents may experience because of their parental role (Le et al., 2017). This stress can be described as two types; childrearing stress and personal distress. Both types of stress are important to parenting behavior. Parents can experience childrearing stress from the relationship with their child. Parents may find their children moody or difficult when interacting with them, which might push parents into harsh parenting behavior. Personal distress on the other hand has less do to with the parent-child relationship and more to do with the parenting role in itself where one’s freedom is lost, and caregiving demands increase. This personal distress can lead to coping problems and also result in harsh parenting and spousal or partner relations, even though the origin of the stress is the personal distress and not the relationship with child, spouse or partner (Le et al. (2017).

Household-related stress

Household chores have also been identified as a major contributor to family stress (Thomas et al., 2003) especially in dual-earner families, where both parents take part in both paid labor and unpaid family work (Bowden & Greenberg, 2010). A study of dual-earner couples by Saxbe (2011), showed that a high number of household chores that had to be done after work had a negative impact on the spouses’ recovery time from work stress, as opposed to leisure time activities that positively influenced the recovery time. Being able to recover from everyday work stressors is important to avoid permanent stress that has a negative impact on family life and might also eventually lead to mental disorders. According to the OECD (2020) and Federal Statistical Office (n.d.d.); Swedish women spend approximately 16 hours per week and Swedish men about 13 hours per week, on unpaid housework and family labor. In contrast, Swiss women spend about 31 hours per week and Swiss men about 19 hours per week on housework and family labor.

Parent employment status as a potential stressor for families

Sweden and Switzerland are two fairly similar European high-income countries, with roughly 10.1 million and 8.5 million habitants, respectively (World Bank, n.d.). In 2018, an average of 61% of children in OECD countries lived in couple households where both adults were working. In Sweden, this accounted for 82% of all children, whereas only 12% lived in couple households with only one working adult, compared to a 31% OECD average. The OECD average couple households with two full-time working adults amounts to 47%, accompanied by another 16% of households where one adult works full-time and the other part-time. Comparatively, in Sweden, as many as 71% of parents living as a couple work full-time and around 7% work part-time. On average, only 8% of OECD couple households consist of two non-working parents, a number that is even lower in Sweden, by 4%. When it comes to single-parent households, as many as 77% of children in Sweden live with one parent working full-time, compared to an OECD average of only 54%. Throughout the rest of the OECD countries, single parents are often either jobless or working part-time only (OECD, 2019).

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In Switzerland however, while on a steady fall since the 1990’s, many mothers of young children are still likely to be stay-at-home-mothers, especially if the youngest child is under the age of 4 years (when children start school in Switzerland). In 16% of couple’s households with children, the woman earns no income, a percentage that increases the younger the children. In Swiss two-parent households a majority of fathers hold full-time jobs and a majority of mothers (54.2%) hold part-time jobs. Single mothers however are more likely to work and work at a higher percentage of full-time employment (Federal Statistical Office, n.d.a; Federal Statistical Office, n.d.b.). In the Swiss French speaking region, only 19.6% of couple’s households are comprised of two full-time working parents, and about 13% of mothers contribute to at least half of the income from paid labor in these households.

Differences in childcare systems

In Switzerland, a vast majority of childcare solutions are found in the private sector and generally prove to be a costly business, representing, in 2015, a gross 70% of the average earnings, while in Sweden the number is around 7% for full-time care of two children. The OECD average is just over 27% (OECD, 2017). Many Swiss families (about 40%) therefore rely on nearby family and friends, most often grandparents, to watch over their children at least part-time. Only 20% of Swiss parents use day kindergartens exclusively, and another 17% use a combination of kindergarten and another childcare solution (Federal Statistical Office, 2019). In Sweden, childcare is more affordable, and 94% of the country’s 3-5 year- olds attend kindergarten before starting school (Statistics Sweden, 2019b).

Work-family conflict

A sense of constantly being pulled in all directions and having one’s workload spill over into family life and vice versa, can be defined as work-family conflict, a major stressor for today’s parents. The work-family conflict represents the difficulties many parents encounter in combining a career with family responsibilities. Increasing and changing work demands need to be met, work and daycare schedules need to be timed, both budget and leisure time needs to be arranged around childcare and sports and leisure, all while being present and spending quality time both with family and friends. Dealing with the incompatible demands both of family and work often creates an inter-role conflict where the pressure from one role impacts negatively on the other one, and vice versa (Han et al., 2018; Moreira et al., 2019).

Moreira et al. (2019) have found connections between parents’ work-family conflict and their parenting mindfulness; their ability to be present, compassionate and non-judgmental in their interactions with the child. The findings showed that higher levels of work-family conflict were associated with increased parenting stress and symptoms of anxiety and depression, at the expense of their parenting behaviors. The greater levels of work-family conflict were found amongst shift working parents (versus fixed) as well as those working full-time or more (versus part-time), and results applied to all parents and children, independently of age groups. On the other side of the spectrum, part-time workers and those with a fixed schedule seem to experience lower stress levels, while a flexible work schedule was associated with higher abilities of self-regulation (controlling emotions and behaviors when interacting with the child) in parenting (Moreira et al., 2019).

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Symptoms of stress

Stress can manifest itself in a multitude of ways. Many symptoms are psychological, such as feelings of anger, irritability and frustration, or guilt, anxiety, feeling overwhelmed and lonely, depressed or in some cases even suicidal. These symptoms may become crippling not only in a person’s profession but also in their private sphere, as they might lead to insomnia and nightmares, difficulties concentrating or learning new information, mood swings and increased hostility, or even problems with punctuality or communication.

Psychological symptoms are often accompanied by physical ones. Many of them might be tension related, such as teeth grinding or jaw clenching, and could in turn provoke frequent headaches or muscle pain, and neck and back aches. The body could also react with constipation or diarrhea, stomach pain or nausea, and frequent colds and other illnesses (The American Institute of Stress AIS, n.d.). When stress becomes chronic, the individual might experience symptoms such as lightheadedness, panic attacks, chest pain, difficulties breathing and a disabling weakness and fatigue. It is not unusual to develop coping strategies such as OCD (obsessive compulsive disorder); addictions such as smoking, alcohol and/or substance abuse; eating disorders; or the individual might withdraw and socially isolate themselves (AIS, n.d.). See Table 1.

Table 1. Common symptoms of stress

Physical symptoms of stress Mental/emotional symptoms of stress

Headache Difficulty concentrating

Dizziness Indecisiveness

Muscle tension or pain Feelings of being overwhelmed

Neck or back pain Constantly worrying

Stomach pains Forgetting things

Chest pain Irritability or anger

Faster heartbeat Frustration

Sexual problems Guilt

Teeth grinding Anxiety

Jaw clenching Feelings of loneliness

Constipation or diarrhea Depression

(AIS, n.d.; National Health Services [NHS], n.d.).

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Stress-related outcomes

Stress is a major predictor of a range of mental disorders, including anxiety disorders, along with depression. “Mental disorders” is a term describing mental health issues characterized by emotional or behavioral problems, abnormal thoughts or difficult relationships with others, that usually co-exist in different combinations. Mental disorders are comprised of a wide range of disorders, and also include personality disorders or intellectual disabilities, or disorders caused by substance abuse (WHO, n.d.c.).

Many risk factors associated with stress have been shown to be related to burnout, including gender, educational levels, type of work, and age. However, generally burnout syndrome is caused by a combination of many risk factors, the main one being long-term exposure to stress without sufficient recovery (Cañadas-De la Fuente et al., 2014; Åsberg et al., 2010).

Many psychosomatic problems have been associated with burnouts, such as anxiety and depression, fatigue or apathy, or even aggressiveness, irritability and hostility (Cañadas-De la Fuente et al., 2014).

Anxiety disorders, depression and other related mental health disorders are not only crippling by themselves, but are also major predictors of other public health issues such as heart disease and substance abuse (APA, n.d.). Mental disorders also largely affect not only the afflicted individuals themselves, but also their families, who may all become vulnerable subjects to social stigma and discrimination (WHO, 2013).

Parental stress and how it may affect children

Parental burnout can have implications for children, as parents might engage in neglectful behavior, physical or psychological aggression, and in some cases the parent may even wish to leave the parenting enterprise and the stressors that come with it (Mikolajczak et al, 2019).

According to Le et al. (2017), stress may provoke similar effects on parenting behavior as would depressive states. People suffering from negative affectivity tend to have an abnormal perception of, and reaction to stress, and even objectively speaking mild stressors can be perceived excessively negative by a person who is high in negative affect. This excessive negativity will create higher subjective stress levels. Such negative affectivity has been associated with harsh parenting and using more discipline (Le et al., 2017). Harsh parenting typically describes a controlling and punitive parenting style that often includes criticism and screaming and has been linked to child anxiety (Brooker & Buss, 2014; Le et al., 2017).

Stressed or anxious parents may also model anxious behavior to their child, showing off their lack of stress coping skills either verbally or by action (Platt et al., 2016), or even demanding reassurance from their children to help with their own insecurities, placing a heavy responsibility on their child (The Mental Health Foundation, 1997). Dysfunctional parent-child interaction has been shown to impair children’s abilities to handle stressful life events and also to raise children’s anxiety levels (Platt et al., 2016).

International statistics and Global Burden of Disease

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both major depressive disorder and anxiety disorders were ranked in the top 50 of the most prevalent diseases globally. Anxiety disorders alone contributed to 3.5% of all YLDs (Vos et al., 2012). The projected longer life expectancies due to the world’s demographic evolution suggest that this burden will increase further (Trautmann et al., 2016).

Mental Health and United Nations Sustainable Development Goals (SDG)

In 2015, the United Nations adopted the 2030 Agenda for Sustainable Development Goals (SDG). This agenda contains 17 goals aiming to end poverty, protect the planet and improve the lives and prospects of everyone, everywhere (UN, n.d.a.). Goal 3 concerns health and well-being and also the promotion of mental health and well-being (target 3.4). Reducing family stress would contribute to this goal and promote WHO’s definition of health as a concept made of complete physical, mental and social well-being (WHO, n.d.b.), with the goal to reduce by one third the global suicide mortality rate (indicator 3.4.2) (UN, n.d.b).

The WHO is optimistic that by including mental health as one of the SDG, more resources will be allocated and incorporated into country development plans (WHO, n.d.b.).

Child and youth mental disorders, symptoms and associated risk factors

Mental disorders are the leading cause of disability among children and adolescents globally, affecting about 10-20% of young people (WHO, n.d.a.). Anxiety is the most common psychopathology in both children and adolescents. Risk factors include the child’s personality, temperament and genetic factors, as well as numerous external elements that have great impact on a child’s mental well-being. Children are affected not only by their own learning experiences, but even more so by their closest family members. The parent- child relationship and the family’s functioning, also play great roles in creating (or not) conditions for anxiety in vulnerable children. For example, an association has been found between early age separation distress, a state where the young child becomes excessively unsettled and anxious from being separated from the caregiver (American Academy of Pediatrics (n.d.) and anxiety disorders later on in life (Colonnesi et al., 2011; Ebesutani et al., 2017). Children often experience emotions more strongly than adults and are sensitive to changes and events in their environments. They might also have feelings of guilt when something bad happens at home or to a person important to them, such as an adult not feeling well (The Mental Health Foundation, 1997).

The Mental Health Foundation (1997) described how anxiety in children might manifest in different ways than for adults. Crying or excessive clinginess is common, and school age children could show shyness or have relational problems with peers. The constant worrying and negative thoughts can be expressed through uncontrollable outbursts, trouble sleeping and concentrating, and also through physical problems such as not eating properly, gastrointestinal distress leading to and incontinence, stomachaches or being generally tense.

There are also records of children experiencing shortness of breath and panic attacks because of anxiety. The Mental Health Foundation (1997) explained how childhood anxiety might be misinterpreted by parents as demanding and difficult behavior, causing them to respond with incomprehension or even anger. This can result in child feelings of being ignored and misunderstood, exacerbating anxious behaviors.

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Attachment theory

One measure of children’s anxiety is their attachment to parents. Secure attachment is defined as a parent-child relationship where the parent is sensitive to the child’s needs by responding to his or her demands for care. This allows the child to perceive their primary caregiver as representing safety, making secure attachment a preventive factor. Insecure attachment, on the other hand, refers to the opposite scenario, where parents lack sensitivity to their child’s needs, or are inconsistent in their responses. This leads the child to feel insecure and lack crucial proximity with the caregiver (Colonnesi et al., 2011). Parental stress has been related to insecure attachment in children (Tharner et al., 2012).

Factors related to wellbeing in families with working parents

A positive parent-child relationship can be defined as a parent’s sensitive and responsive care that is appropriate to the young child, providing him/her with important emotional, behavioral and communicative skills for life (National Center on Parent, Family, and Community Engagement [NCPFCE], 2013). The positive parent-child relationship works as a major preventive factor to child anxiety, since a warm and nurturing parenting style will be supporting and absorb child anxiety. Parental acceptance of a child’s emotional spectra and parental coping skills therefore work as means of social support for the child.

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The present study

Figure 1. Study conceptual model of the work-family conflict, parental stress, negative parenting behavior and child anxiety and depression.

As shown in Figure 1, the main idea behind the present study is that parents are exposed to stressors both at work and in their parenting role, an imbalance that may provoke a state of chronic parental stress. Parental stress can, either directly or indirectly through its linked potential outcomes such as burnout, anxiety and depression, lead to negative parenting behavior such as harsh parenting, insecure attachment or modelling anxious behavior. Such parenting behavior has been linked to child anxiety and depression.

Relevance to public health

From a public health perspective, family stress originating from work-family conflict, must be addressed on a public policy level. Such policies could involve family friendly work- places where companies are encouraged to create flexible solutions for parents of young children. Policies could also include affordable childcare services with extended availabilities to provide access for everyone. On an inter-personal level, stress prevention programs promoting mindful parenting could be offered. Reducing family stress is ultimately about improving mental health and quality of life for today’s children, and thus diminishing future mental health problems. Promoting mental health is not only a human right but also a prerequisite for sustainable economic development, as mental disorders are connected in a reciprocal relationship with unemployment (Rodrigues, 2017).

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AIM

Public health problem and study question

Working adults in today’s high-income countries are exposed to a number of work-related stressors, and working parents are under even more pressure. The evolution toward dual- earner households means that both the work- and family responsibilities are now often shared (not necessarily evenly) between adults in the household. The pressures from both the corporate and the family spheres are pulling parents in multiple directions, creating work- family conflict, a major stressor to parents today (Han et al., 2018; Moreira et al., 2019).

Stress can be detrimental and has been associated with burnout and other mental disorders such as anxiety and depression (Cañadas-De la Fuente et al., 2014; Åsberg et al., 2010).

Being exposed to stress or suffering from stress-related mental disorders has been shown to negatively affect parenting abilities and lead to behavior changes where parents might engage in harsh parenting, model anxious behavior to their child, or even create a state of insecure attachment. These parenting behavior changes could impair children’s cognitive and emotional development and possibly lead to child mental disorders (Brooker et al., 2014;

Colonnesi et al., 2011; Le et al., 2017; Platt et al., 2016; Tharner et al., 2012). Previous research has shown that suffering from anxiety disorders at a young age is also a predictor for adult anxiety, depression and other mental disorders (Ebesutani et al., 2017) and related issues such as substance abuse.

Helping parents dealing with the never-ending demands of combining parenthood with a career by providing early support could be beneficial for the mental health of the whole family. By understanding parental stress and its associated risk factors, policies could be established to promote family friendly work places as well as available and affordable childcare solutions and other logistical support for parents, which in turn can help meet sustainable development goals for improved mental health.

Aim of the study

The aim of this study is to describe differences between convenience samples of Swedish and Swiss parents, exploring the relationship between parental stress (high and low stress parents) and perceived symptoms of anxiety and depression in their children.

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METHODS

The is a descriptive cross-sectional study, comparing two convenience samples of Swedish and Swiss working parents, and investigating the relationship between parental stress and parents’ perceptions about the presence of anxiety and depression in their children. The data was collected through an online survey which was shared on social media. We hypothesize that high stress parents will also perceive that their children experience more depressive symptoms and anxiety.

Study population and sample

The study population was defined as parents of children aged 7-10 years, living in Sweden, or in the French speaking part of Switzerland and speaking either Swedish or French.

Because of the limited time frame of the study, a convenience sample was chosen (Lavrakas, 2008). The study’s recruitment criteria were clearly stated to include only respondents who met study criteria. As the two surveys were restricted to individuals speaking either Swedish or French, this excluded any respondents not speaking the aforementioned languages. Given the anonymity of the surveys, and the open recruitment method, there are no guarantees that all of the respondents actually live in Sweden or the French speaking part of Switzerland.

Data collection

The data was collected using Easyquest ©, a web-based survey tool that can be accessed not only via a web browser but also through a smartphone. Using a web-based option was selected based on two features. The first was the short time to collect and process the data.

The second was reducing costs. In addition, it was also the environmentally responsible option. Easyquest provided an option that eliminated printing and postal costs, reduced handling times, and increased participant response rates thanks to its user-friendly format.

Easyquest also meets GDPR standards (Easyquest, n.d.).

Participants were provided with a link accompanied by a cover letter, as recommended by Bowling (2014), briefly explaining the content and aim of the study, as well as technical information on how to best fill in the survey. The cover letter was made available without having to open the link, and was also repeated inside the survey, whereupon informed consent was demanded before entering the survey. The collected data were then stored on the Easyquest password-protected online account.

Using an online survey was considered appropriate for this study. Bowling (2014) deems written questionnaires (as opposed to interviews) particularly suitable when using standardized tools (in this case the RCADS-25-P), as well as to describe populations and explore associations between variables. Written and computerized questionnaires are administered differently, but are otherwise largely similar (Finegan & Allen, 1994).

Study questions

The survey (Appendices 2 & 4) contained two sets of questions, the first set of questions measured parental stress and covered family composition, parent work load and leisure time.

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These questions were decided on following the initial literature search. The second set of questions comprised the RCADS-25-P. All items in both family- and RCADS-25-P sections used a closed and pre-coded question design, with questions developed by the researcher (Bowling, 2014).

The first set of questions

The demographic items: 1) Which of the following best describes your marital status? 2) How old is your child? 3) How many children do you have in total? 4) Are you working or studying? and 5) Which option best describes your work schedule? were provided with multiple response options (Bowling, 2014).

The following questions had scaled response options (Bowling, 2014): 1) How many times per week do the family members (children and adults) engage in leisure time activities? 2) How many times per week do you have to drive your child to school or leisure time activities?

3) How often do you experience having to choose between different activities to fit your schedule? 4) How often do you experience difficulties in finding time for household chores?

And 5) How often do you experience stress because of the combined demands from work, family and everyday life? Weekly and monthly response options were provided.

The second set of questions

The second part of the survey consisted of the shorter, 25-item parent and caregiver version of the Revised Children's Anxiety and Depression Scale (RCADS)©, a widely-used and validated anxiety and depression scale. The scale was originally inspired by the Spence Children’s Anxiety Scale (SCAS), but was transformed in order to fit the following DSM- IV anxiety disorders: separation anxiety disorder, social phobia, generalized anxiety disorder, obsessive-compulsive disorder and panic disorder. Major depressive disorder was also added as a subscale. The scale’s concurrent validity has been tested against comparative traditional measures of child anxiety and depression, such as the Anxiety Disorder Interview Schedule for DSM-IV, the Children’s Depression Inventory and the Revised Children’s Manifest Anxiety Scale, generally showing better diagnostic syndrome correspondence (Chorpita et al., 2005). A test-retest was done by the original authors that proved the scale’s reliability (Chorpita et al., 2000). The original 47-item scale has since been shortened to a 25-item version measuring only anxiety and depression, which has also shown to be effective and reliable, but demanding less time and effort from respondents (Ebesutani et al., 2017).

Both the long and short versions of the RCADS exist in a child self-completion version as well as a parent and caregiver version, of which the latter has been used in this study. Both RCADS versions, as well as its subscales, have been widely used internationally and in a multitude of languages, some recent examples are Donnelly et al. (2019) in a sample of Irish adolescents, Skoczeń et al. (2019) in Polish children, and Gormez et al. (2017) who tested the parent version on Turkish children and adolescents.

With permission from one of the original authors, Bruce Chorpita (personal communication, April 3rd 2020), the scale was used in its entirety without modifications. The scales’ items were presented as individual statements to which the caregiver (in this case the parent) was presented with the pre-coded response options Never, Sometimes, Often and Always in order to show the frequency of certain symptoms and signs of anxious or depressive behaviors in their child (Ebesutani et al., 2017). See Figure 2.

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Figure 2. The Revised Children's Anxiety and Depression Scale (RCADS) 25-item parent and caregiver version. Used with permission from author.

At the end of the survey, participants were presented with an open-ended question, asking them to explain in their own words what it is that they feel caused the most work-life stress.

Bowling (2014) warns that open-ended questions often seem demanding for the respondent and might also complicate the analysis, but clarifies that following a closed-question survey, they are a good tool for deeper clarifications and explanations.

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Pilot study

After the survey instrument was refined, a pilot study was conducted in both languages, starting with the Swedish-speaking group. A convenience sample of n=9 respondents were asked to fill out the survey anonymously, and provide comments regarding the comprehensibility of the items, the length of the questionnaire and any other questions or objections they might have surfaced while taking the survey. The Swedish survey then underwent some minor adjustments before its distribution. A French translation of the survey questions as well as the accompanying letter were then created and another pilot study was performed on a convenience sample of n=5 Swiss respondents, following some minor language improvements to the set of items concerning the family. An important error was reported by the Swiss pilot group; the absence of a Parental work status option for households with one parent working full-time and the other not participating in paid labor.

As the Swedish version of the survey had already been distributed and no alterations could be made, the decision was made to leave the Swiss version of the item untouched as well.

The RCADS part of the surveys was not altered at all, as per the terms of use (Chorpita et al., 2015). It was however translated into French, with permission of the authors, given that a French parent and caregiver version was not available at the time.

Recruitment

As participants were composed of a convenience sample (Lavrakas, 2008), recruitment was made partly through a personal network, and partly from public postings on social media such as Facebook and Instagram.

Analysis

At first, RCADS-25-P raw scores were calculated individually using the RCADS-25 Parent Version Scoring Program 3.1 (UCLA, n.d.), which took into consideration potential missing items. The raw total anxiety and depression scores were then merged to the remainder of the survey items and imported to SPSS version 25. All data were password-protected.

Descriptive analyses were performed regarding the demographics and characteristics of Swedish and Swiss parents. Mean values of each item are shown in Table 2, by country.

Some key frequency distributions are illustrated using bar charts. Following these frequency distributions, a systematic series of t-tests were performed to explore if there were any statistically significant differences in the mean values between the two countries.

The RCADS-25-P raw scores were quartiled and tested for associations with country, as well as with parental perceived stress levels, using Chi-square tests. As some of the cell counts for the item How often do you experience stress because of the combined demands from work, family and everyday life? were too small to be able to perform accurate tests, the parent group was dichotomized into low stress and high stress parents.

To determine the definition of low and high stress parents, the response options were divided into two groups. The low stress group included responses rarely or never and a few times

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week or more. Additional Chi-square tests were then performed in order to explore if there was any connection between parental low or high stress and family activities.

In order to investigate our hypothesis, the significance level of this study was set to p < 0.05, which is a traditional cut-off in science (Bowling, 2014; Bryman, 2011). This p-value indicates that there’s <5% probability that the observed associations are due to chance.

Ethical considerations

Both surveys were accompanied by cover letters (appendices 1 & 3) briefly explaining the content and aim of the study, making it clear to participants that their participation was voluntary and that they had the option of aborting the survey at any moment, deleting their data. The information was repeated (in the event that some participants had not read the letter) at the very beginning of the survey followed by a mandatory question asking for informed consent, all of this in accordance with Swedish guidelines for research ethics (Vetenskapsrådet, n.d). Both cover letter and survey design were approved by the student supervisor before publication. In order to protect the respondents’ identity, the survey included no questions regarding personal data or any other information possibly leading to their identification. Furthermore, the website housing the survey, Easyquest, is GDPR (General Data Protection Regulation) compliant. Confidentiality (Vetenskapsrådet, n.d) as well as guaranteeing that no data have or will be used outside of the present study was promised all participants, and all collected data have been password protected until their destruction upon acquisition of the Bachelor’s degree.

The Revised Children’s Anxiety and Depression Scale (RCADS) 25-item short version is available in two different versions (as is the 47-item original version); a child and youth self- completion questionnaire, as well as a parent or caregiver questionnaire. Given the sensitive nature of the items and ethics regarding research with underage populations, the choice was made to survey parents instead of children.

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RESULTS

The results outline demographics of convenience samples of Swedish and Swiss parents of 7-10 year old children. It also reports group differences in average scores related to stressors that have to do with variables describing conflicts associated with managing family schedules and children’s activities. Finally, the results of comparisons of parental stress and parents’ perceived children’s RCADS-25-P scores are shown.

Group characteristics

Table 2. Characteristics of Swedish and Swiss parents.

Variable Swedish parents Swiss parents

Number of participants 45 30

Family size, average N 2.4 2.1

Number of family activities per week, average

2.9 3.0

Number of times per week spent driving children to school and activities per week, average

3.2 3.5

Number of times per month where parents need to select between children’s and parents’ activities in family schedule, average

2.0 1.5

Number of times per month when parents feel they lack time for household chores, average

2.9 2.4

Number of occasions per month when parents feel stressed, average

2.9 2.8

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A total of 75 individuals responded to the online survey, n=45 to the Swedish version and n=30 to the Swiss version (Table 2). As the survey was made publicly available through an open invitation, a non-response rate could not be computed.

Parental marital status

The results show that a vast majority of the responding parents in both countries, 88% (n=66) lived in a two-parent household, while only 12% (n=9) were either single or separated.

Stratifying marital status by country showed a very similar distribution with 86.7% of Swedish parents and 90% of Swiss parents living in couple’s households, while 13.3% (n=6) of Swedish and 10% (n=3) of Swiss parents either single or separated.

Family size

Chart 1. Family size, by country. N of responding parents = 75 (100%).

Of the total number of respondents, a majority of 53.3% (n=40) reported having two children, while 37.3% (n=28) had three children or more and only 9.3% (n=7) of the respondents reported having one child.

When comparing the two nations however, the results differ significantly. As Chart 1 shows, 48.9% (n=22) of Swedish parents reported having three or more children, 44.4% (n=20) had two children and only 6.7% (n=3) reported having one child. The Swiss data presented a different picture, as the vast majority, 66.7% (n=20) of parents replied having two children, followed by 20% (n=6) three or more and 13.3% (n=4) one child.

6.70%

44.40% 48.90%

13.30%

66.70%

20%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

1 child 2 children 3 children or more

Family size, by country

Sweden Switzerland

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Age range of the selected child

Chart 2. Age of the selected child, by country. N of responding parents = 75 (100%).

The current study consisted of parents of children in a range of 7 to 10 years of age. Parents with several children of different ages were asked to answer for the child who fell in the specific age range, and if more than one child did, to choose the oldest. The most frequently reported age was 7 years by 37.3% (n=28), which represented 35.6% of the Swedish children and 40% of the Swiss children. A total of 25.3% (n=19) were 10 years old, 20% (n=15) were 9 years old and 17.3% (n=13) were 8 years old (Chart 2).

Parental work status

Chart 3. Couples’ household work status, by country. N of responding parents = 64 (85.3%).

35.60%

17.80% 17.80%

28.90%

40%

16.70%

23.30%

20%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

7 years old 8 years old 9 years old 10 years old

Age of the selected child, by country

Sweden Switzerland

0%

10%

20%

30%

40%

50%

60%

70%

80%

Both working full-time 1 working full-time and 1 part-time

Both working part-time Missing/error participant

Couples' household work status, by country

Sweden Switzerland

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working full time and the other part time. Data from the Swiss survey however, showed a different pattern, with 70.4% (n=19) of parents living in a household where one was working full-time and the other part-time, followed by 14.8% (n=4) of families where both parents worked full-time. Only 5% of Swedish and 11.1% of Swiss parents reported both working part-time (Chart 3).

Single and separated parents were excluded from further analyses in this study, for two reasons. Firstly, the majority (88%) of respondents were from couple’s households, and secondly, there was a high percentage of errors and missing data (50% for the Swedish survey and 72.8% for the Swiss) among single and separated parents.

Parental stressors related to managing family schedules and children’s activities

In this section, differences in average scores of Swedish and Swiss parents and by high and low stress parents are compared, as relating to responses to questions regarding stressors related to managing family schedules and children’s activities. Independent samples t-tests were used to compare differences in proportions by country.

Family activities

Chart 4. Response overview of family activities, by country. N of responding parents = 75 (100%).

Each response was ranked by frequency (Rarely or never = 1, 1-2 times per week = 2, 3-4 times per week = 3, 5-6 times per week = 4 and daily = 5). M defines the average group frequency. There was no significant difference in family activity frequency, t(73) = -0.27, p

= 0.103, despite Swiss parents (M = 3.0, SD = 0.9) reporting higher activity levels than Swedish parents (M = 2.9, SD = 1.2).

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

Rarely or never 1-2 times per week 3-4 times per week 5-6 times per week Daily

Family activities, by country

Sweden Switzerland

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Driving children to school or leisure time activities

Chart 5. Number of times per week driving children to school or leisure time activities, by country. N of responding parents = 75 (100%).

Each response was ranked by frequency (Rarely or never = 1, 1-2 times per week = 2, 3-4 times per week = 3, 5-6 times per week = 4, daily = 5 and several times per day = 6). M defines the average group frequency. There was no significant difference in how often Swedish versus Swiss parents had to drive their children to school or leisure time activities, t(73) = -1.2, p = 0.359, despite that Swiss parents (M = 3.5, SD = 1.4) reported doing so more frequently than Swedish parents (M = 3.2, SD = 1.2).

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

Rarely or never 1-2 times 3-4 times 5-6 times Every day Several times per day

Driving children to school or leisure time activities?

Sweden Switzerland

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Having to make priorities in the family schedule

Chart 6. Having to choose between activities in order to fit the family schedule, by country.

N of responding parents = 75 (100%).

The 45 Swedish parents (M = 2.0, SD = 0.85) compared to the 30 Swiss parents (M = 1.5, SD = 0.63) showed significantly more frequent reports of having to make priorities in the family schedule, t(73) = 2.5, p = 0.014.

35.60% 35.60%

26.70%

2.20% 0%%

56.70%

36.70%

6.70% 0% 0%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

Rarely or never A few times per month

Every week Several times per week

Every day

Having to choose between different activities to fit family schedule, by country

Sweden Switzerland

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Household chores

Chart 7. Difficulties in finding time for household chores, by country. N of responding parents = 75 (100%).

There was no significant difference in how often Swedish versus Swiss parents experienced difficulties in finding time for household chores, t(73) = 1.7, p = 0.096, even though Swedish parents (M = 2.9, SD = 1.1) reported reporting so more often than Swiss parents (M = 2.4, SD = 1.1).

Chart 8. Difficulties finding time for household chores, by low and high stress parents.

N of responding parents = 74 (98.7%).

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

Rarely or never A few times per month

Every day

Difficulties in finding time for household chores, by country

Sweden Switzerland

25%

46.90%

21.90%

6.30% 0%

4.80%

21.40%

42.90%

16.70%

14.30%

0%

10%

20%

30%

40%

50%

Rarely or never Several times per month

Every day

Difficulties finding time for household chores, by low and high stress parents

Low Stress High Stress

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Parental perceived stress

Chart 9. Responses to the item How often do you feel stressed? by country. N of responding parents = 75 (100%).

There was no significant difference in how often Swedish (M = 2.9, SD = 1.3) and Swiss parents (M = 2.8, SD = 1.2) reported feeling stressed, t(72) = 0.13, p = 0.893.

13.30%

28.90% 31.10%

11.10%

15.60%

10.30%

34.50%

27.60%

17.20%

10.30%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

Rarely or never Several times per month

Every day

How often do you feel stressed?, by country

Sweden Switzeland

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Results of exploratory analysis between parental stress and the perceived symptoms of anxiety and depression in their children

In this section chi-square tests were performed to explore the relationship between parental stress and children’s symptoms of anxiety and depression.

RCADS-25-P total anxiety and depression raw score descriptive

All of the respondents (n=75) completed a full RCADS-25-P to calculate a raw score for anxiety and depression combined, as well as separate anxiety and depression scores. In this study, only the combined anxiety and depression raw score was used. The mean value observed was 11.1, Standard deviation, 6.5, and the median value was 11 (ranging from 1 to 37).

The percentile distribution of RCADS-25-P scores was similar between Sweden and Switzerland (appendices 5 and 6). The second and third quartiles were identical, while perception of children’s mental health by Swiss parents showed a slightly higher score (36.7%) in the first quartile compared to Swedish parents (33.3%). Swedish parents’

perception, on the other hand, show a slightly higher score (20%) than Swiss parents (16.7%) in the fourth quartile.

The RCADS-25-P raw scores were dichotomized using the mean value (M = 11.1, SD = 6.5). The low anxiety and depression group (n=36) consisted of raw scores ranging between 1 and 10, and the high anxiety and depression group (n=38) consisted of raw scores ranging from 11 to 37.

A chi-square test of independence showed that there was no significant association between nationality and parents’ perceptions of their children’s anxiety and depression raw scores., X2 (3, N = 75) = .17, p = .98.

Considering that the RCADS-25-P raw score and its related factors were the main focus of the study, we combined all parents and dichotomized them by low (feeling stressed less than weekly) and high stress (feeling stressed weekly or more) groups. See chart 9.

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RCDAS-25-P raw scores and parental stress

Figure 3. Crosstabulation of high/low RCADS-25-P raw score and high/low parental stress.

The association between parental stress and parents’ perceptions of their child’s symptoms of anxiety and depression is statistically significant, X2 (1, N = 74) = 4.3, p = .037.

The main finding of this study is that there was a connection between parents self-reported stress levels and the perceived symptoms of anxiety and depression in their children (Figure 3, which is consistent with the foregoing literature search. The results also show that experiencing difficulties in finding time for household chores seemed to be a major stressor to parents. Family activity levels on the other hand, could not be proven to influence parental stress levels.

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DISCUSSION

Results discussion

Demographic comparisons between Swedish and Swiss parents

The majority of parents comprising these convenience samples from both Sweden and Switzerland, reported living in couples’ households. Because of the heterogeneity between the couple and single-parent groups, they were not compared. Family size also seemed to correspond to official statistics: according to World Bank data from 2017 (n.d.) Sweden has a fertility rate of 1.9 compared to Switzerland with 1.5. This is slightly less than the number of children reported in this study (2.4 and 2.0), but the mean difference remains approximately the same.

When asked about work status, both Swedish and Swiss respondents seemed to conform to their respective national averages. A majority of Swedish parents reported both working full- time, as opposed to the majority of Swiss parents who reported one parent working full-time and the other part-time. However, an over-estimation of this group is expected, as the option one parent working full-time and the other not working was not given in the survey, and the foregoing literature research showed that this group is a significant part of the Swiss parent population (Federal Statistics Office, n.d.a.; Federal Statistics Office, n.d.b.). Therefore, the results might be slightly skewed.

Time and workload pressure have previously been linked to stress among working adults (CCOHS, 2018), and even though parents are also exposed to parenting stress (Le et al., 2017), studies such as Thomas et al. (2003) show that work-related stress remains the most prominent stressor to parents. However, despite the differences in parent work status between the countries, the results in the present study did not show any significant group differences.

Swiss school and daycare

Swiss primary schools tend to be demanding for parents in terms of schedules, as children in first and second grade often only attend half days (approximately 3.5 hours or less). From the second grade onwards, children attend full days, but afternoon classes usually only last for about 2 hours, and many children go home during lunch break as school canteens are a complementary service being charged extra to parents, as is after school care. Also, Wednesdays are typically a day when most children only attend half-days or do not attend at all, and after school care is closed, parents must reduce their work hours or find private solutions (Expatia, 2020). Adding to this potential burden, childcare is costly in Switzerland and having a parent stay home is sometimes the easiest and least expensive option, especially when having more than one child (OECD, 2017).

It is worth mentioning that the Swedish school system is quite different from its Swiss counterpart. Children in Sweden do not need to return home for lunch break as they are

PARENTAL STRESS AND CHILD ANXIETY AND DEPRESSION