A survey online was administered from the 28th May to 23rd August 2020. The study was introduced to parents by pediatric pulmonologists during a check-up phone call scheduled in April-May 2020 for a reassessment of asthma. Families who agreed to participate were sent an email including the link for the survey and an alphanumeric code to insert at the beginning of the form. Children completed their part immediately after their mothers’ one and each section took about 20 minutes. To begin with, mothers were asked about their socio-demographic characteristics (for example gender, age, schooling, and employment). Secondly, mothers and children had to fill a survey created ad hoc for our study which included questions related to the COVID-19 pandemic (e.g., how much they felt worried about the COVID-19 infection) and perceived change in physical and psychological well-being comparing a pre and post-COVID-19 period, and, specifically for children, questions about contacts with friends during and after the home confinement. Lastly, they both had to complete standardized self-report questionnaires, assessing respectively general well-being (General Health Questionnaire, GHQ-12)30,31 and COVID-19 related fears (Multidimensional Assessment of COVID-19 – Related Fears, MAC-RF)32 for mothers, and psychological adjustment (Strengths and Difficulties Questionnaire, SDQ)25,26, and separation anxiety (Separation Anxiety factor of the Spence Children Anxiety Scale, SCAS-SAD)27,28,29 for children.
As to the control sample, the study was introduced to families recruited through word of mouth. The procedure was the same as for the clinical sample. The surveys were almost identical, except for items regarding asthma.
Besides, the medical team provided clinical data regarding the control (Asthma Control Test, ACT22,23, Global Initiative for Asthma (GINA) score24) and the severity of asthma (GINA therapeutic steps24), obtained during asthma reassessment in April-May 2020.
The project was approved by the Institutional Ethical Committee of Padua (Prot. n. 3671). The research project was performed in accordance with Ethical and Deontological codes of Italian Psychologists. A detailed informant consent needed to be signed to join the survey, both from the mother and the child if 12 years old. 45 mothers gave their consent for their own study participation. As to the 45 children an informed consent was obtained from a parent or legal guardian. Children over 12 included in this study also signed an ad hoc informed consent. No reward was offered for enrollment.
Children asthma control and severity
Asthma Control Test (ACT)22,23 is a validated screening tool completed by children (and parents for children under 12 years old) that addresses asthma control. The version for children younger than 12 years old includes 4 questions for the child (like “Do you cough because of your asthma?”) and 3 questions for parents (like “During the last 4 weeks, how many days did your child have any daytime asthma symptoms?”) rated respectively on a 4 and 6-point Likert scale, while the version for children over 12 years old is made up of 5 questions about activity limitation, shortness of breath, night-time symptoms, use of rescue limitation, and patient overall rating of asthma control over the previous four weeks. The questions are rated on a 5-point Likert scale. Higher scores indicate better-controlled asthma.
Global Initiative for Asthma (GINA) score. The Global Initiative for Asthma (GINA) guidelines24 classify asthma control through medical staff investigation of 5 factors: daytime symptoms, night awakening, need for relievers, limitation to physical activity, and spirometry parameters. Based on the GINA guidelines24, three levels of asthma control were identified: well-controlled (score 0), partially controlled (scores 1 and 2), uncontrolled (scores 3 and 4).
GINA therapeutic steps, based on the GINA guidelines24, classify asthma severity according to the pharmacological regimen needed (types of medicines, dosages, and frequencies of administration) into 5 therapeutic steps: 1 and 2 for mild asthma, 3 and 4 for moderate asthma, and 5 for severe asthma.
Children’s psychological functioning
Strengths and Difficulties Questionnaire (SDQ)25,26. The questionnaire is a validated behavioral screening tool composed of 25 items, rated on a 3-points Likert scale (from 0 = not true to 2 = certainly true) and divided into 5 subscales: emotional symptoms, conduct problems, hyperactivity and inattention, peer problems, and prosocial behaviors. By adding the first four scales, a total difficulties score can be calculated. Higher scores indicate more problematic behavioral traits26. In this study, Cronbach’s α for the total score (TDS), the internalizing symptoms scale (INT), the externalizing symptoms scale (EXT), and the prosocial behaviors scale (PROS) were respectively α(TDS) = 0.651, α (INT) = 0.490, α(EXT) = 0.636, and α(PROS) = 0.305.
Separation anxiety factor of the Spence Children Anxiety Scale (SCAS-SAD)27,28,29. The separation anxiety factor is one of the 6 factors which compose the SCAS questionnaire (the other factors are: panic and agoraphobia, fears of physical injury, social phobia, obsessive-compulsive problems, and generalized anxiety/overanxious symptoms); for the purpose of this study, only this factor was used. It includes 7 items on a 4-points Likert scale (from 0 = never to 3 = always) that assess separation anxiety symptoms. Higher scores indicate higher levels of separation anxiety symptoms. In the present study, Cronbach’s α for the separation anxiety factor was α(SCAS-SAD) = 0.731.
Mothers’ psychological functioning
General Health Questionnaire (GHQ-12)30,31. This questionnaire allows evaluating the presence of minor psychological disorder in primary care settings through the administration of 12 items rated on a 4-point Likert scale (from 1 = more than usual to 3 = much less than usual). GHQ-12 total score can be classified in three ranges: no presence of difficulties (lower scores), presence of minor difficulties, and presence of important difficulties (higher scores) which may indicate the need for professional intervention. In this study, Cronbach’s α was α(GHQ-12) = 0.701.
Multidimensional Assessment of COVID-19 – Related Fears (MAC-RF)32. The questionnaire is composed of 8 items that investigate 8 types of COVID-19 related fears: fear of the body, fear for the body, fear of others, fear for others, fear of knowing, fear of not knowing, fear of action, fear of inaction. Items are grouped into 4 subscales: fears related to the body, fears related to meaningful relationships, difficulties in cognitive monitoring of concerns, and behavioral difficulties related to fear. Respondents have to rate all 8 items on a 5-point Likert scale (from 0 = very unlike me to 4 = very like me). By adding all items’ rates, a total score is obtained. The higher it is, the more Covid-19 related fears are clinical. In this study, Cronbach’s α was α(MAC-RF) = 0.767.
2.4 Data analysis
Student’s T-test was performed to assess the differences between mothers and children of the two samples in standardized questionnaires’ scores (GHQ-12 and MAC-RF for mothers; SDQ and SCAS-SAD for children) and in some selected psychosocial variables from the survey created ad hoc for this study. As to the mentioned variables, it was verified that data are normally distributed by using the Shapiro-Wilk test.
Partial two-tailed correlations were performed between clinical parameters of asthma control and severity (GINA, ACT, and GINA therapeutic steps), mothers’ standardized questionnaires (GHQ-12 and MAC-RF), and selected psychosocial variables of the survey (e.g. worries for contagion, physical and psychological well-being). Correlations were controlled for the time passed from the end of the lockdown (May 18th, 2020) to the survey administration. In parallel, children’s medical measures were correlated with children’s psychosocial measures (SDQ and SAD factor of the SCAS) and selected indexes of the survey (e.g. worries for contagion, contacts with friends).
As to the clinical sample, a multiple linear regression model was performed to assess which variables were predictive of children’s psychological well-being. The child’s psychological well-being was used as a dependent variable, and children’s age and gender, time from the end of home-confinement, GINA scores, GINA therapeutic steps, children’s concerns for contagion and physical well-being, mothers’ psychological and physical well-being and mothers’ total MAC-RF score, as independent variables. Children’s psychological well-being variable consisted of a 3 point scale (0 = my general psychological well-being is better now than last year when I was going to school; 1 = my general psychological well-being is now the same as last year when I was going to school; 2 = my general well-being is now worse than last year when I was going to school). Higher scores indicated lower levels of well-being, during the lockdown, than the previous year. For all the analyses, a p-value < 0.05 was considered statistically significant. Statistical analysis was performed using SPSS v22.0 software package (SPSS Inc., Chicago, USA).