Coronavirus disease 2019 (COVID-19) lockdowns (stay-at-home orders) had significant mental health consequences in 2020 to 2021 for caregivers and children. Little is known about “postlockdown” periods in 2022 to 2023. We investigated the mental health experiences of Australian families throughout the 3 years of the COVID-19 pandemic (2020–2023), by demographic characteristics and lockdown length.
A total N = 12 408 caregivers (N = 20 339 children, aged 0–17 years) completed Australia’s only representative, repeated, cross-sectional, National Child Health Poll across 6 waves (June 2020–April 2023). Caregivers reported mental health for themselves (Kessler-6, poor versus not) and each child (self-rated mental health, poor/fair versus good/very good/excellent), and perceived impacts of the pandemic on own/child mental health (negative versus none/positive). Binary logistic models were fitted to predict marginal probabilities of each mental health measure by state/territory group (proxy for lockdown length), over time, adjusted for potential demographic confounders.
Poor caregiver Kessler-6 was similar between genders but more common for sole caregivers, and those with a home language other than English and lower education. Poor/fair child self-rated mental health was similar between genders and increased with child age. Perceived negative impacts were more common for females and socially advantaged caregivers. Overall, negative mental health experiences increased with lockdown length, peaking with the height of lockdown in July 2021, before declining.
Negative mental health experiences of Australian caregivers and children decreased during postlockdown periods of 2022–2023; however, social gradients persisted. These data can inform more precise mental health policies that enable better use of limited mental health infrastructure.
What’s Known on This Subject:
The coronavirus disease 2019 pandemic significantly affected the mental health of families. Almost all published data are from the first half of the pandemic (2020–2021) when stay-at-home orders (lockdowns) were common. Little is known about the postlockdown periods in 2022 to 2023.
What this study adds:
Negative mental health experiences peaked with the height of Australia’s lockdowns before recovering substantially in the postlockdown period; however, social gradients remained. These data can inform more precise mental health policies that make better use of existing health infrastructure.
The coronavirus disease 2019 (COVID-19) pandemic significantly affected the mental health of families, with many systematic reviews of studies from high-income countries identifying increased rates of stress, anxiety, depression, and overall psychological distress.1 –38 Factors contributing to poor adult and parent mental health included stay-at-home orders (lockdowns), isolation, financial difficulties, worrying about their children’s well-being, home-schooling challenges, and limited social support.13 ,15 ,17 –20 ,22 –24 The emotional distress of children and adolescents was driven by factors such as disruptions in daily routines, limited social interactions, and caregiver stress.9 ,13 ,15 ,19 ,22 ,23 ,25 –38 Despite the differences in public health responses between countries, some consistent subpopulation effects emerged. Negative mental health experiences were more common for caregivers who were female, sole parents or those who had limited social support networks, and those experiencing preexisting mental health conditions or financial hardship, as well as those who are caring for children with special needs or chronic health conditions.13 ,15 ,17 –20 ,22 –24 Children and adolescents were more likely to have poorer mental health when they were older, had preexisting mental health conditions, or experienced marginalization or adversities such as family conflict or violence.9 ,13 ,15 ,19 ,22 ,23 ,25 –38
The World Health Organization declared the end of the COVID-19 pandemic on May 5, 2023.39 Despite the abundance of pandemic mental health research in 2020 and 2021 when lockdowns were prevalent, published population-representative data on the mental health of families and children during “postlockdown” periods are scarce and we could find none that span the 3 years of the pandemic.40 Swiss data for adolescents aged 12 to 18 years (N = 553) during lockdown in 2020 and 1 year post found that pandemic-related stress decreased while proportions of poor mental health were stable over time.41 Negative effects appeared worse for females than males, and for those with preexisting mental health problems. Longitudinal data from the German COVID-19 and PSYchological Health study demonstrated that the mental health and quality of life of children and young people aged 7 to 17 years (N = 2471) improved in September to October 2022 after lockdown ended in mid-2021.40 However, proportions were higher than prepandemic measures, and some psychosomatic complaints such as headaches and stomachaches were at their highest levels. Females, adolescents, and those experiencing less socioeconomic advantage had poorer quality of life and mental health during the pandemic.40
An Italian study of mothers (N = 400) reported mixed mental health symptoms during and postlockdown for women with low psychopathology prepandemic (using the Symptom Checklist-90-R clinical cut point), while their young children (aged 5–6 years) had decreasing aggression but increasing depression postlockdown (October 2021).42 For women with psychopathological risk prepandemic, the authors found decreasing psychopathological symptoms over time, but no clear patterns of child depression or aggression.42 Mothers of young children (aged 3–12 years) from a German study (N = 3000) reported high levels of pandemic burdens when reflecting on the 2 years before February to March 2022, especially sole caregivers and those with low incomes.43
Without high-quality data spanning the length of the pandemic, it is challenging to understand subpopulation mental health experiences in the postlockdown period.4 High-quality monitoring can enable evidence-informed and precise policy responses that make better use of limited mental health infrastructure.44 Australia offers an interesting natural experiment because it had a low incidence of COVID-19 during the first 18 months of the pandemic, maintained via some of the world’s most stringent stay-at-home orders.45 Lockdowns ended in late 2021 after vaccination coverage reached 70% to 80%. Research with Australian families during this period demonstrated the negative mental health consequences related to lockdown and pandemic stress, in the relative absence of the disease.46 –48 In this study, we investigated the mental health experiences of caregivers and children during 2020 to 2023 using 6 waves of data from Australia’s only nationally representative, repeated, cross-sectional survey of caregivers with children aged 0 to 17 years. We hypothesized that the frequency of negative caregiver and child mental health experiences would increase with lockdown length (2020–2021), and decrease in the postlockdown period (2022–2023).
Methods
Design and Procedure
The Royal Children’s Hospital (RCH) National Child Health Poll comprises periodic cross-sectional surveys of ∼2000 Australian caregivers of children aged 0 to 17 years. Data collection is contracted to the Online Research Unit, which obtains written informed consent and draws a nationally representative sample of caregivers using stratified random sampling from their panel of >350 000 adults aged 18 years or older, composed of >30% caregivers, who live in Australia and have Internet access. Surveys are administered in English, with a reading level equivalent to sixth grade (the end of primary/elementary school). Responses are anonymous and respondents are remunerated with points exchangeable for department store gift vouchers.
Questions about mental health were introduced after COVID-19 began and collected in the 6 surveys conducted during the pandemic period. The first 3 surveys occurred during the “lockdown period”, when stay-at-home orders were the primary method to prevent virus spread:
June 15 to 23, 2020, after a first national lockdown (March–May 2020) eased;
September 15 to September 29, 2020, when only metropolitan residents of Victoria were in a second, stricter lockdown (July–November 2020); and
July 20 to July 29, 2021, when multiple states/territories were in and out of lockdown (June–October 2021).
The next 3 surveys occurred in the postlockdown period: (1) April 14 to April 22, 2022, (2) September 19 to October 4, 2022, and (3) April 11 to April 21, 2023. The RCH Human Research Ethics Committee approved the research (#35254).
Patient and Public Involvement
The research questions and design were informed by previous RCH poll surveys, which asked caregivers to identify child health issues of most concern and topics of future polls. At the end of each survey, participants were informed of the study Web site, where all research reports are accessible to the public. Respondents were not directly involved in the recruitment or conduct of each survey.
Measures
Each survey collected the demographic characteristics described in Table 1. To achieve high response rates and population representativeness, the surveys are intentionally brief and ask simple questions. Families were assigned the Australian Bureau of Statistics’ Socioeconomic Indexes for Areas (SEIFA) Index of Relative Disadvantage, a national area-level index derived from census data for all individuals living in a postcode, with higher scores indicating greater advantage. Table 1 describes the mental health measures and binary cut points for analysis. Caregivers self-reported their mental health with the Kessler-6 (K6),49 the mental health of each child in their care with the self-rated mental health (SRMH) item,50 and the perceived impact of the pandemic on their own and each child’s mental health (1) since the start of the pandemic and (2) in the last 30 days.51 Not all measures were collected at all 6 waves; these are described in Table 1 and denoted with a dash (—) in Tables 2 and 3, and Supplemental Tables 4–6.
Lockdown, Demographic, and Mental Health Measures
| Measure | Description |
|---|---|
| Lockdown | |
| Total length | Trichotomous variable based on total length of lockdown experienced by each state/territory (jurisdiction). By the end of COVID-19 lockdowns in October 2021, the total length was greatest for the state of Victoria (total 37 wk), followed by the state of NSW (total 25 wk) and then all other states and territories (total range 8–15 wk). The following geographical categories were used as a proxy for total length of lockdown: (1) Victorian (most), (2) NSW, and (3) other (least). |
| Demographic | |
| Age | Collected for caregivers and children, reported in y. Child age was used as a proxy for educational level and categorized to represent preschool (0–4 y), primary/elementary school (5–11 y), and high school (12–17 y). |
| Gender | Collected for caregivers and children. Response options for caregivers were male, female, other, noting other was introduced in Waves 4–6 (identified by 7 caregivers in total). Because this subgroup was too small to analyze separately, only the female and male categories are presented for the descriptive gender analyses. Child gender options were male and female only. |
| Sole caregiver | Question “Are you the sole (single) parent or carer of a child 17 y of age or younger?” Binary response options yes (1-caregiver household) compared with no (multicaregiver household). |
| Caregiver education | Question “What is the highest level of schooling/education you have completed?” Responses were trichotomized into categories that meaningfully represented education as a socioeconomic measure for Australians: 1. “y 12 or less” (response options: less than y 10, y 10 or equivalent [eg, school certificate], y 12 or equivalent); 2. “vocational training certificate” (response options: trade/apprenticeship [eg, carpenter], certificate/diploma (eg, cert IV child care); or 3. “university degree” (response options: undergraduate university degree, postgraduate university degree [eg, master’s, doctorate, PhD). |
| Home language | Question “Do you speak a language other than English at home?” Binary response options yes (other than English) compared with no (English). |
| Regionality | Australian Bureau of Statistics (July 2021–June 2026), remoteness structure, dichotomized into metropolitan (“major cities”) versus “regional/remote” (“inner regional/outer regional/remote/very remote”)63 |
| Neighborhood-level disadvantage | Australian Bureau of Statistics’ SEIFA Index of Relative Disadvantage, a national area-level index derived from census data for all individuals living in a postcode, with higher scores indicating greater advantage. Presented as quintiles: Quintile 1 represents most disadvantage and quintile 5 represents least. |
| Mental health | |
| Caregiver mental health | Six items of the K6 assessing caregivers’ self-reported anxiety and depressive symptoms encountered in the last 4 wk. Scored on a 5-point Likert scale from 1 “none of the time” to 5 “all of the time.” Summarized into (1) a continuous total score, and (2) a binary variable indicating poor mental health (total score 19 or more) compared with not (total score 6–18).49 The K6 performs strongly for screening mood and anxiety disorders according to the WHO Composite International Diagnostic Interview and 30-d Diagnostic and Statistical Manual-IV disorders (area under the curve: 0.89; 95% CI 0.88–0.90), and outperforms the General Health Questionnaire-12.49 The K6 was collected in all 6 surveys. |
| Child mental health | The single 5-point SRMH scale,50 scored on a 5-point Likert scale from poor to excellent, dichotomized into poor/fair versus good/very good/excellent.47 The poor and fair SRMH categories in adult studies have shown moderate correlations with validated mental health scales such as the Kessler Psychological Distress Scale and Patient Health Questionnaire, and associations with physical health, social determinants of health, and health service use. Published psychometric data for children and young people are lacking. The child SRMH item was collected in 4 surveys (not September 2020 or September 2022). |
| Perceived impact of the pandemic on mental health | A 5-point item adapted from United Kingdom Young Minds Matter Study,51 describing the perceived impact of COVID-19 on mental health, dichotomized into negative (“small negative/large negative”) compared with positive (“none/small positive/large positive”). Reported by caregivers for (1) themselves and (2) each child. At each survey, this was collected with reference to 2 time frames, (a) since the beginning of the pandemic, and (b) in the last 30 d. The perceived negative impact since March 2020 item was collected at 5 waves (not September 2022), and perceived negative impacts in the last 30 d was collected at 5 waves for caregivers (not June 2020) and 4 waves for children (not June 2020 or September 2022). |
| Measure | Description |
|---|---|
| Lockdown | |
| Total length | Trichotomous variable based on total length of lockdown experienced by each state/territory (jurisdiction). By the end of COVID-19 lockdowns in October 2021, the total length was greatest for the state of Victoria (total 37 wk), followed by the state of NSW (total 25 wk) and then all other states and territories (total range 8–15 wk). The following geographical categories were used as a proxy for total length of lockdown: (1) Victorian (most), (2) NSW, and (3) other (least). |
| Demographic | |
| Age | Collected for caregivers and children, reported in y. Child age was used as a proxy for educational level and categorized to represent preschool (0–4 y), primary/elementary school (5–11 y), and high school (12–17 y). |
| Gender | Collected for caregivers and children. Response options for caregivers were male, female, other, noting other was introduced in Waves 4–6 (identified by 7 caregivers in total). Because this subgroup was too small to analyze separately, only the female and male categories are presented for the descriptive gender analyses. Child gender options were male and female only. |
| Sole caregiver | Question “Are you the sole (single) parent or carer of a child 17 y of age or younger?” Binary response options yes (1-caregiver household) compared with no (multicaregiver household). |
| Caregiver education | Question “What is the highest level of schooling/education you have completed?” Responses were trichotomized into categories that meaningfully represented education as a socioeconomic measure for Australians: 1. “y 12 or less” (response options: less than y 10, y 10 or equivalent [eg, school certificate], y 12 or equivalent); 2. “vocational training certificate” (response options: trade/apprenticeship [eg, carpenter], certificate/diploma (eg, cert IV child care); or 3. “university degree” (response options: undergraduate university degree, postgraduate university degree [eg, master’s, doctorate, PhD). |
| Home language | Question “Do you speak a language other than English at home?” Binary response options yes (other than English) compared with no (English). |
| Regionality | Australian Bureau of Statistics (July 2021–June 2026), remoteness structure, dichotomized into metropolitan (“major cities”) versus “regional/remote” (“inner regional/outer regional/remote/very remote”)63 |
| Neighborhood-level disadvantage | Australian Bureau of Statistics’ SEIFA Index of Relative Disadvantage, a national area-level index derived from census data for all individuals living in a postcode, with higher scores indicating greater advantage. Presented as quintiles: Quintile 1 represents most disadvantage and quintile 5 represents least. |
| Mental health | |
| Caregiver mental health | Six items of the K6 assessing caregivers’ self-reported anxiety and depressive symptoms encountered in the last 4 wk. Scored on a 5-point Likert scale from 1 “none of the time” to 5 “all of the time.” Summarized into (1) a continuous total score, and (2) a binary variable indicating poor mental health (total score 19 or more) compared with not (total score 6–18).49 The K6 performs strongly for screening mood and anxiety disorders according to the WHO Composite International Diagnostic Interview and 30-d Diagnostic and Statistical Manual-IV disorders (area under the curve: 0.89; 95% CI 0.88–0.90), and outperforms the General Health Questionnaire-12.49 The K6 was collected in all 6 surveys. |
| Child mental health | The single 5-point SRMH scale,50 scored on a 5-point Likert scale from poor to excellent, dichotomized into poor/fair versus good/very good/excellent.47 The poor and fair SRMH categories in adult studies have shown moderate correlations with validated mental health scales such as the Kessler Psychological Distress Scale and Patient Health Questionnaire, and associations with physical health, social determinants of health, and health service use. Published psychometric data for children and young people are lacking. The child SRMH item was collected in 4 surveys (not September 2020 or September 2022). |
| Perceived impact of the pandemic on mental health | A 5-point item adapted from United Kingdom Young Minds Matter Study,51 describing the perceived impact of COVID-19 on mental health, dichotomized into negative (“small negative/large negative”) compared with positive (“none/small positive/large positive”). Reported by caregivers for (1) themselves and (2) each child. At each survey, this was collected with reference to 2 time frames, (a) since the beginning of the pandemic, and (b) in the last 30 d. The perceived negative impact since March 2020 item was collected at 5 waves (not September 2022), and perceived negative impacts in the last 30 d was collected at 5 waves for caregivers (not June 2020) and 4 waves for children (not June 2020 or September 2022). |
Cert, certificate; PhD, Doctor of Philosophy; WHO, World Health Organization.
Caregiver Mental Health Measures by Survey, Described With the Number of Respondents and Weighted Proportions (95% Confidence Intervals [CIs])
| Mental Health Measure | June 2020 (N = 2020) | September 2020 (N = 1434) | July 2021 (N = 2508) | April 2022 (N = 2035) | September 2022 (N = 2036) | April 2023 (N = 2015) | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| n | % (95% CI) | n | % (95% CI) | n | % (95% CI) | n | % (95% CI) | n | % (95% CI) | n | % (95% CI) | |
| Poor caregiver mental health (K6) | 264 | 17.4 (14.7–20.4) | 247 | 19.5 (16.5–22.9) | 541 | 18.9 (16.9–21.2) | 265 | 13.9 (12.3–15.6) | 250 | 11.7 (9.8–14.0) | 253 | 13.1 (11.1–15.4) |
| Perceived negative impact on caregiver mental health since March 2020 | 949 | 47.4 (44.0–50.7) | 708 | 50.3 (46.7–53.9) | 1490 | 60.0 (56.5–63.4) | 1173 | 57.6 (55.2–59.9) | — | — | 1080 | 54.5 (51.3–57.7) |
| Perceived negative impact on caregiver mental health in the last 30 d | — | — | 595 | 42.9 (39.3–46.6) | 1354 | 54.1 (50.7–57.4) | 770 | 37.7 (35.5–40.0) | 862 | 38.1 (33.0–43.5) | 459 | 22.6 (19.9–25.4) |
| Poor/fair child mental health (SRMH) | 271 | 6.2 (4.9–7.7) | — | 528 | 13.4 (11.6–15.5) | 326 | 8.5 (7.1–10.1) | — | — | 297 | 6.3 (4.9–8.2) | |
| Perceived negative impact on child mental health since March 2020 | 1055 | 25.6 (23.0–28.3) | 884 | 33.1 (29.9–36.5) | 1807 | 44.0 (40.9–47.2) | 1438 | 41.7 (38.7–44.8) | — | — | 1203 | 34.3 (30.3–38.4) |
| Perceived negative impact on child mental health in the last 30 d | — | — | 717 | 27.4 (24.3–30.7) | 1618 | 39.8 (36.9–42.9) | 928 | 26.6 (23.9–29.6) | — | — | 436 | 12.6 (10.3–15.4) |
| Mental Health Measure | June 2020 (N = 2020) | September 2020 (N = 1434) | July 2021 (N = 2508) | April 2022 (N = 2035) | September 2022 (N = 2036) | April 2023 (N = 2015) | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| n | % (95% CI) | n | % (95% CI) | n | % (95% CI) | n | % (95% CI) | n | % (95% CI) | n | % (95% CI) | |
| Poor caregiver mental health (K6) | 264 | 17.4 (14.7–20.4) | 247 | 19.5 (16.5–22.9) | 541 | 18.9 (16.9–21.2) | 265 | 13.9 (12.3–15.6) | 250 | 11.7 (9.8–14.0) | 253 | 13.1 (11.1–15.4) |
| Perceived negative impact on caregiver mental health since March 2020 | 949 | 47.4 (44.0–50.7) | 708 | 50.3 (46.7–53.9) | 1490 | 60.0 (56.5–63.4) | 1173 | 57.6 (55.2–59.9) | — | — | 1080 | 54.5 (51.3–57.7) |
| Perceived negative impact on caregiver mental health in the last 30 d | — | — | 595 | 42.9 (39.3–46.6) | 1354 | 54.1 (50.7–57.4) | 770 | 37.7 (35.5–40.0) | 862 | 38.1 (33.0–43.5) | 459 | 22.6 (19.9–25.4) |
| Poor/fair child mental health (SRMH) | 271 | 6.2 (4.9–7.7) | — | 528 | 13.4 (11.6–15.5) | 326 | 8.5 (7.1–10.1) | — | — | 297 | 6.3 (4.9–8.2) | |
| Perceived negative impact on child mental health since March 2020 | 1055 | 25.6 (23.0–28.3) | 884 | 33.1 (29.9–36.5) | 1807 | 44.0 (40.9–47.2) | 1438 | 41.7 (38.7–44.8) | — | — | 1203 | 34.3 (30.3–38.4) |
| Perceived negative impact on child mental health in the last 30 d | — | — | 717 | 27.4 (24.3–30.7) | 1618 | 39.8 (36.9–42.9) | 928 | 26.6 (23.9–29.6) | — | — | 436 | 12.6 (10.3–15.4) |
Proportions and 95% CIs for the caregiver were weighted using national population distributions for caregiver age, gender, family structure (sole caregiving, number of children and any under 5 years), regionality, state/territory and SEIFA Index of Relative Disadvantage. Dash (—) denotes that measure was not collected in that survey wave.
Mental Health Measures by Survey and by State (as a Proxy for Total Length of Lockdown), Described With Number of Respondents and Adjusted Estimated Probabilities (95% Confidence Intervals [CIs])
| State | June 2020 (N = 2020) | September 2020 (N = 1434) | July 2021 (N = 2508) | April 2022 (N = 2035) | September 2022 (N = 2036) | April 2023 (N = 2015) | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Caregiver Measure | n | % (95% CI) | n | % (95% CI) | n | % (95% CI) | n | % (95% CI) | n | % (95% CI) | n | % (95% CI) | |
| Poor caregiver mental health (K6) | Vic | 85 | 17.0 (12.7–21.4) | 93 | 24.9 (19.3–30.4) | 200 | 25.0 (20.8–29.1) | 77 | 13.2 (10.3–16.1) | 90 | 14.9 (11.8–18.0) | 73 | 13.2 (9.7–16.6) |
| NSW | 96 | 20.0 (15.1–24.8) | 78 | 17.5 (12.8–22.1) | 188 | 22.6 (18.9–26.4) | 87 | 15.3 (12.1–18.4) | 74 | 13.4 (10.4–16.4) | 89 | 13.4 (9.9–17.0) | |
| Other | 83 | 12.1 (8.6–15.6) | 76 | 17.4 (11.9–22.9) | 153 | 12.7 (10.1–15.4) | 101 | 12.5 (10.0–14.9) | 86 | 10.4 (8.1–12.7) | 91 | 12.2 (8.5–15.9) | |
| Perceived negative impact on caregiver mental health since March 2020 | Vic | 284 | 50.2 (44.4–55.9) | 266 | 56.7 (50.8–62.7) | 483 | 66.9 (62.5–71.2) | 344 | 63.6 (59.3–67.8) | — | — | 323 | 57.0 (51.4–62.5) |
| NSW | 307 | 50.3 (44.7–55.9) | 213 | 49.4 (43.4–55.3) | 477 | 60.3 (55.7–64.8) | 347 | 59.9 (55.8–64.0) | — | — | 303 | 54.5 (49.1–60.0) | |
| Other | 358 | 44.0 (38.5–49.5) | 229 | 43.2 (36.7–49.6) | 530 | 56.4 (52.0–60.8) | 482 | 56.1 (52.5–59.7) | — | — | 454 | 52.8 (47.9–57.8) | |
| Perceived negative impact on caregiver mental health in the last 30 d | Vic | — | — | 268 | 56.9 (50.9–62.8) | 447 | 62.0 (57.5–66.4) | 221 | 40.8 (36.4–45.3) | 258 | 47.4 (42.8–52.0) | 148 | 25.7 (20.4–31.0) |
| NSW | — | — | 170 | 40.8 (34.8–46.9) | 483 | 61.5 (57.0–66.0) | 223 | 39.3 (34.9–43.7) | 243 | 42.2 (37.6–46.9) | 133 | 23.4 (18.7–28.1) | |
| Other | — | — | 157 | 29.8 (24.0–35.6) | 424 | 42.7 (38.3–47.2) | 326 | 39.6 (35.9–43.3) | 361 | 41.3 (37.6–45.0) | 178 | 20.4 (20.4–31.0) | |
| Child measure | State | June 2020 (N = 3411) | September 2020 (N = 2553) | July 2021 (N = 4327) | April 2022 (N = 3371) | September 2022 (N = 3352) | April 2023 (N = 3325) | ||||||
| Poor/fair child mental health (SRMH) | Vic | 85 | 7.3 (4.5–10.1) | — | — | 194 | 14.1 (11.2–17.1) | 111 | 9.6 (7.0–12.3) | — | — | 89 | 6.8 (4.2–9.4) |
| NSW | 76 | 5.7 (3.5–8.0) | — | — | 168 | 13.2 (10.0–16.4) | 74 | 7.4 (4.9–9.9) | — | — | 68 | 5.7 (3.9–7.6) | |
| Other | 110 | 8.3 (5.5–11.2) | — | — | 166 | 9.5 (7.4–11.6) | 141 | 8.8 (6.2–11.3) | — | — | 140 | 8.1 (6.1–10.1) | |
| Perceived negative impact on child mental health since March 2020 | Vic | 321 | 27.6 (23.3–32.0) | 389 | 43.8 (37.9–49.7) | 626 | 49.1 (44.9–53.4) | 459 | 43.3 (38.0–48.5) | — | — | 371 | 36.8 (32.6–41.1) |
| NSW | 306 | 28.1 (23.1–33.1) | 267 | 35.6 (30.0–41.1) | 603 | 44.4 (40.2–48.6) | 412 | 46.0 (40.4–51.7) | — | — | 350 | 34.2 (29.9–38.4) | |
| Other | 428 | 29.3 (24.5–34.1) | 228 | 20.0 (15.9–24.2) | 578 | 32.8 (29.0–36.5) | 567 | 35.3 (31.0–39.7) | — | — | 482 | 33.6 (27.7–39.5) | |
| Perceived negative impact on child mental health in the last 30 d | Vic | — | — | 375 | 42.5 (36.6–48.5) | 596 | 47.1 (42.7–51.5) | 284 | 27.2 (22.3–32.0) | — | — | 145 | 15.3 (12.0–18.5) |
| NSW | — | — | 184 | 24.0 (18.8–29.1) | 594 | 44.6 (40.1–49.1) | 254 | 29.8 (24.0–35.6) | — | — | 121 | 13.1 (9.8–16.4) | |
| Other | — | — | 158 | 16.3 (11.8–20.8) | 428 | 25.4 (21.9–28.9) | 390 | 24.1 (20.1–28.0) | — | — | 170 | 13.1 (9.2–17.0) | |
| State | June 2020 (N = 2020) | September 2020 (N = 1434) | July 2021 (N = 2508) | April 2022 (N = 2035) | September 2022 (N = 2036) | April 2023 (N = 2015) | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Caregiver Measure | n | % (95% CI) | n | % (95% CI) | n | % (95% CI) | n | % (95% CI) | n | % (95% CI) | n | % (95% CI) | |
| Poor caregiver mental health (K6) | Vic | 85 | 17.0 (12.7–21.4) | 93 | 24.9 (19.3–30.4) | 200 | 25.0 (20.8–29.1) | 77 | 13.2 (10.3–16.1) | 90 | 14.9 (11.8–18.0) | 73 | 13.2 (9.7–16.6) |
| NSW | 96 | 20.0 (15.1–24.8) | 78 | 17.5 (12.8–22.1) | 188 | 22.6 (18.9–26.4) | 87 | 15.3 (12.1–18.4) | 74 | 13.4 (10.4–16.4) | 89 | 13.4 (9.9–17.0) | |
| Other | 83 | 12.1 (8.6–15.6) | 76 | 17.4 (11.9–22.9) | 153 | 12.7 (10.1–15.4) | 101 | 12.5 (10.0–14.9) | 86 | 10.4 (8.1–12.7) | 91 | 12.2 (8.5–15.9) | |
| Perceived negative impact on caregiver mental health since March 2020 | Vic | 284 | 50.2 (44.4–55.9) | 266 | 56.7 (50.8–62.7) | 483 | 66.9 (62.5–71.2) | 344 | 63.6 (59.3–67.8) | — | — | 323 | 57.0 (51.4–62.5) |
| NSW | 307 | 50.3 (44.7–55.9) | 213 | 49.4 (43.4–55.3) | 477 | 60.3 (55.7–64.8) | 347 | 59.9 (55.8–64.0) | — | — | 303 | 54.5 (49.1–60.0) | |
| Other | 358 | 44.0 (38.5–49.5) | 229 | 43.2 (36.7–49.6) | 530 | 56.4 (52.0–60.8) | 482 | 56.1 (52.5–59.7) | — | — | 454 | 52.8 (47.9–57.8) | |
| Perceived negative impact on caregiver mental health in the last 30 d | Vic | — | — | 268 | 56.9 (50.9–62.8) | 447 | 62.0 (57.5–66.4) | 221 | 40.8 (36.4–45.3) | 258 | 47.4 (42.8–52.0) | 148 | 25.7 (20.4–31.0) |
| NSW | — | — | 170 | 40.8 (34.8–46.9) | 483 | 61.5 (57.0–66.0) | 223 | 39.3 (34.9–43.7) | 243 | 42.2 (37.6–46.9) | 133 | 23.4 (18.7–28.1) | |
| Other | — | — | 157 | 29.8 (24.0–35.6) | 424 | 42.7 (38.3–47.2) | 326 | 39.6 (35.9–43.3) | 361 | 41.3 (37.6–45.0) | 178 | 20.4 (20.4–31.0) | |
| Child measure | State | June 2020 (N = 3411) | September 2020 (N = 2553) | July 2021 (N = 4327) | April 2022 (N = 3371) | September 2022 (N = 3352) | April 2023 (N = 3325) | ||||||
| Poor/fair child mental health (SRMH) | Vic | 85 | 7.3 (4.5–10.1) | — | — | 194 | 14.1 (11.2–17.1) | 111 | 9.6 (7.0–12.3) | — | — | 89 | 6.8 (4.2–9.4) |
| NSW | 76 | 5.7 (3.5–8.0) | — | — | 168 | 13.2 (10.0–16.4) | 74 | 7.4 (4.9–9.9) | — | — | 68 | 5.7 (3.9–7.6) | |
| Other | 110 | 8.3 (5.5–11.2) | — | — | 166 | 9.5 (7.4–11.6) | 141 | 8.8 (6.2–11.3) | — | — | 140 | 8.1 (6.1–10.1) | |
| Perceived negative impact on child mental health since March 2020 | Vic | 321 | 27.6 (23.3–32.0) | 389 | 43.8 (37.9–49.7) | 626 | 49.1 (44.9–53.4) | 459 | 43.3 (38.0–48.5) | — | — | 371 | 36.8 (32.6–41.1) |
| NSW | 306 | 28.1 (23.1–33.1) | 267 | 35.6 (30.0–41.1) | 603 | 44.4 (40.2–48.6) | 412 | 46.0 (40.4–51.7) | — | — | 350 | 34.2 (29.9–38.4) | |
| Other | 428 | 29.3 (24.5–34.1) | 228 | 20.0 (15.9–24.2) | 578 | 32.8 (29.0–36.5) | 567 | 35.3 (31.0–39.7) | — | — | 482 | 33.6 (27.7–39.5) | |
| Perceived negative impact on child mental health in the last 30 d | Vic | — | — | 375 | 42.5 (36.6–48.5) | 596 | 47.1 (42.7–51.5) | 284 | 27.2 (22.3–32.0) | — | — | 145 | 15.3 (12.0–18.5) |
| NSW | — | — | 184 | 24.0 (18.8–29.1) | 594 | 44.6 (40.1–49.1) | 254 | 29.8 (24.0–35.6) | — | — | 121 | 13.1 (9.8–16.4) | |
| Other | — | — | 158 | 16.3 (11.8–20.8) | 428 | 25.4 (21.9–28.9) | 390 | 24.1 (20.1–28.0) | — | — | 170 | 13.1 (9.2–17.0) | |
All models were adjusted for caregiver gender, sole caregiver status, education, home language other than English, regionality, and SEIFA. Child models were additionally adjusted for child age, gender, poor caregiver mental health (K6), and clustering at the level of family. Dash (—) denotes that measure was not collected in that survey wave. By the end of COVID-19 lockdowns in October 2021, the total length was greatest for the state of Victoria (total 37 weeks), followed by the state of NSW (total 25 weeks) and then all other states and territories (total range 8–15 weeks). The following geographical categories were used as a proxy for total length of lockdown: (1) Victorian (most), (2) NSW, and (3) other (least). Vic, Victoria.
Analysis
Descriptive statistics (frequencies, weighted proportions and 95% confidence intervals [CIs]) were used to describe the mental health measures overall and by demographic characteristics. To reduce effects of nonresponse and noncoverage, and therefore approximate population distributions, caregiver mental health measures were weighted using national population distributions for caregiver age, gender, family structure (sole-caregiving, number of children, and proportions of families with children aged <5 years), regionality, state/territory, and SEIFA. Child measures were weighted using the national population distributions of children aged <18 years for children’s age, gender, and state/territory.
We used binary logistic regression models to investigate whether increasing length of lockdown (using state as proxy) was associated with mental health measures over time, after adjusting for caregiver gender, sole caregiver status, education, home language other than English, regionality, and SEIFA (Table 1). The child models were additionally adjusted for child age, gender, poor caregiver mental health (K6), and clustering at the level of family. The regression models were used to estimate marginal probabilities of each mental health outcome, by state/territory category, at the 6 survey time points. The Results describe the overall patterns of the sample estimates and evidence for group differences according to the 95% CIs. P values are not presented because they provide no information about an association over and above the CIs.52 Data were analyzed using Stata/IC v18 (Stata, College Station, Texas, United States).
Results
Participant Characteristics
Across the 6 survey waves, a total of 17 099 caregivers were approached, and 12 408 (72.5%) provided data for themselves and 20 339 children. Supplemental Table 4 describes the sample sizes and characteristics for each survey. Overall, caregiver mean age was 42.5 years (SD 9.8 years), ranging 18 to 92 years, and 51.4% (n = 6191 of 12 048) were female. Respondents cared for a median of 2 children, range 1 to 6. Just under a quarter (n = 2922) were sole caregivers and 22.0% (n = 2648) spoke a language other than English at home. Seventeen percent (n = 2082) lived in regional/remote areas. No data were available to compare respondents and nonrespondents. However, the socioeconomic characteristics suggested a strong response bias toward more advantaged groups with 32.3% (n = 3890) in the highest SEIFA quintile compared with 11.6% (n = 1402) in the lowest. Overall, children’s mean age was 9.6 years (SD 5.1 years) and 47.8% (n = 9721 of 20 339) were female. The proportions of respondents in lockdown at the time of survey completion were 33.0% (n = 473 of 1434) in Wave 2 (September 2020) and 56.5% (n = 1416 of 2508) in Wave 3 (July 2021), and 0 for Waves 1, and 4 to 6 (note, not tabulated). Supplemental Table 4 shows that there were differences between surveys in demographic characteristics, supporting the use of sample weights in analyses to adjust for these differences between surveys and the Australian population.
Mental Health Overall and by Demographic Characteristics
Table 2 shows that the negative caregiver and child mental health experiences peaked in July 2021, the survey that mostly closely corresponded with the peak of Australia’s lockdown length, eg, the weighted proportions and 95% CIs of caregivers reporting poor K6 were higher in the lockdown periods of 2020–2021 (weighted proportions ranging 17%–20%) than postlockdown in 2022–2023 (weighted proportions ranging 12%–14%). Child poor/fair SRMH doubled from June 2020 to July 2021 (6%–13%) before reducing to 6% in April 2023.
Supplemental Tables 5 and 6 describe the mental health measures by demographic characteristics for caregivers and children, respectively. Across time points, poor caregiver mental health (K6) was similar between genders, but perceived negative mental health impacts were more commonly reported by female than male caregivers. Sole caregivers reported double the levels of poor K6 compared with multicaregiver households, whereas the latter were more likely to perceive negative impacts of the pandemic on their mental health. This pattern was similar for education status; more caregivers with lower education (high school only) experienced poor K6, whereas more caregivers with higher education (university training) perceived negative impacts.
Poor K6 was more common in 2020 to 2022 for caregivers who spoke a home language other than English, and for caregivers living in metropolitan areas compared with their regional counterparts (except for April 2022, Supplemental Table 5), but the small sample numbers meant the estimates were imprecise. Perceived negative impacts since March 2020 were more common for English-speaking homes in June 2020 and April 2023. Weighted proportions of perceived negative impacts were higher for metropolitan families during the lockdown periods of September 2020 and July 2021, but otherwise higher for regional/remote families, again noting that distributions overlapped.
Supplemental Table 6 shows that the weighted proportions of poor/fair child SRMH were similar between child genders in 2020 to 2021, but had reduced more for males by April 2023 (95% CI 4%–7%) than females (95% CI 6%–11%). Weighted proportions of poor/fair SRMH and perceived negative impacts increased with child age. SRMH and negative impacts were similar by regionality.
Mental Health in the Lockdown and Postlockdown Periods
Table 3 and Fig 1 present the marginal probabilities of each mental health measure by lockdown length and survey wave. Across the measures, there was a relationship between lockdown and negative mental health experiences. In July 2021, for caregivers in Victoria and New South Wales (NSW) (who experienced a total of 37 and 25 weeks of lockdown during the pandemic, respectively), the estimated probabilities of poor K6 were approximately double that of caregivers in other jurisdictions (who experienced a total lockdown ranging 8–15 weeks). The estimated probabilities were also approximately doubled within jurisdictions in July 2021 compared with April 2023. Poor/fair SRMH also halved for Victorian and NSW children from July 2021 to April 2023. Although the distributions for child SRMH probabilities overlapped for the jurisdictions at all waves, the Victorian range was more distinct from other jurisdictions at the peak of lockdown in July 2021.
Adjusted* estimated probabilities over time, by survey and by jurisdiction (as a proxy for total length of lockdown), for caregivers (at left, panels 1–3) and children (at right, panels 4–6).
Adjusted* estimated probabilities over time, by survey and by jurisdiction (as a proxy for total length of lockdown), for caregivers (at left, panels 1–3) and children (at right, panels 4–6).
For perceived negative impacts since March 2020, the estimated probabilities of Victorian caregivers and children were higher than other jurisdictions in September 2020 and July 2021. Estimated probabilities for Victorian and NSW families reduced to similar levels reported by families in other jurisdictions by April 2023. Perceived negative impacts in the last 30 days increased for caregivers and children relative to lockdown. Compared with other jurisdictions, proportions of Victorian families reporting negative impacts was higher during the state’s September 2020 and July 2021 lockdowns, and for NSW caregivers during the state’s July 2021 lockdown. Proportions reduced for all families regardless of jurisdiction in 2022 and 2023.
Discussion
This study investigated the mental health experiences of Australian families during 3 years of the COVID-19 pandemic, captured with the only nationally representative, repeated, cross-sectional survey of families conducted during this period. After poor mental health and perceived negative impacts peaked as the length of Australia’s strict lockdowns increased during 2020 to 2021, they decreased in the postlockdown phase in 2022 to 2023. Across the 3 years of the pandemic, there were socioeconomic gradients. Consistent with the global literature, poor child mental health (SRMH) increased with child age, and poor caregiver mental health (K6) was more common for sole caregivers, caregivers with a home language other than English, and lower education. In contrast, and consistent with our earlier article,47 perceived negative impacts of the pandemic since March 2020 were more common for caregivers who were female, partnered, spoke English at home, or had university education.
At a population level, the decreasing frequency of negative mental health experiences in the postlockdown period is reassuring and shows signs of resilience and recovery. Although caregiver and child mental health are typically correlated,53 our findings also likely reflect the direct consequence of lessening restrictions. Although the study did not have comparative prepandemic data, poor caregiver K6 was higher in April 2023 (13%) than representative Australian adult data collected prepandemic (8% in 2017) or during the first national lockdown (11%),54 which suggests that child rearing was associated with poorer mental health during the pandemic.
Our findings align with data from Australia and other high-income countries showing that social and structural inequities persisted from prepandemic through to the lockdown46 ,47 ,55 ,56 and postlockdown periods.40 ,42 ,43 Analysis of 6 Australian cohorts by O’Connor et al46 showed that families of children with greater prepandemic adversity, such as lower household income and greater neighborhood-level disadvantage, more commonly reported pandemic-related worries, negative emotional states, more economic difficulties, and fewer positive life changes during the lockdown period studied (May 2020–April 2021).46 There were different social gradients for the K6 compared with the perceived negative impact (on self) items. This may represent the greater relative increase in adversity experienced by socially advantaged families as a result of the pandemic, compared with those who were already experiencing adversity prepandemic.47 Although the available postlockdown data tell a mixed story about whether caregiver and child mental health is improving or worsening,40 –43 studies consistently find that caregivers experiencing greater socioeconomic adversity (eg, financial hardship, sole parenting) have poorer mental health than their more socially advantaged counterparts.
To our knowledge, this is the first study to examine caregiver and child mental health across 3 years of the pandemic. Strengths included the large cross-sectional and nationally representative surveys, which employed a robust methodology (surveys piloted and included the validated K6), collected data on caregiver and child mental health, surveyed female and male caregivers, and achieved good response proportions. The study also had limitations. There may be response bias given that those with poor mental health are less inclined than those with better mental health to participate in online surveys, biasing reporting toward the null.57 The reliance on caregiver report, from only 1 caregiver per household, means the child rating may be biased by caregiver perception. In the German COVID-19 and PSYchological Health study, for example, adolescents aged 14 to 17 had lower self-reported risk of mental health problems compared with parent-reported outcomes for 7- to 10-year-olds,40 which contrasts with our finding of more poor mental health and perceived negative impacts reported by caregivers for older compared with younger children. The RCH poll eligibility criteria and sampling approach mean the findings are unlikely to generalize to caregivers without final-year primary/elementary school English, Internet access, or who are younger than 18. However, given the similarities in mental health experiences across high-income countries during lockdown periods, it is likely that our findings of recovery are also generalizable. Finally, prepandemic and longitudinal data are necessary to confirm whether negative mental health experiences were greater for specific subgroups over time.
Conclusions
The increase in poor mental health and stress in parents and children during COVID-19 lockdowns is now well documented internationally. This study is 1 of the first to investigate mental health during the postlockdown period, and shows significant recovery for Australian families. Despite this level of resilience, there remain inequities, not unlike the prepandemic distribution of mental health disorders. In Australia, families face ongoing burdens such as difficulty accessing primary care and related services,58 and increasing financial stress because of recent inflation and cost-of-living pressures; experiences that are shared by other high-income countries.59 –61 The pandemic has shone a light on mental health and provided policy opportunities for treatment; however, the increased demand for limited resources suggests that the need for prevention with a focus on upstream determinants is vital. This is particularly relevant given that half of mental health disorders begin before the age of 14 years.62 An ongoing lesson is the importance of data to understand patterns of problems and resilience.4 ,44 Given the increasing policy interest, the need to know what works and for whom is more important than ever.
Acknowledgments
We thank all families who took part in the RCH National Child Health Polls.
Dr Price conceptualized and designed the study, designed the data collection instruments, conducted the analysis, curated the data, and drafted the initial manuscript; Drs Measey, Rhodes, and Goldfeld conceptualized and designed the study, designed the data collection instruments, and coordinated and supervised data collection; Dr Hoq conceptualized and designed the study, conducted the analysis, and curated the data; and all authors critically reviewed and revised the manuscript for important intellectual content, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.
FUNDING: The National Child Health Polls are funded by The Royal Children’s Hospital Foundation. Research at the Murdoch Children’s Research Institute is supported by the Victorian Government's Operational Infrastructure Support Program. Dr Price was supported by The Erdi Foundation Child Health Equity (coronavirus disease 2019) Scholarship. Dr Goldfeld was supported by a National Health and Medical Research Council Practitioner Fellowship (1155290). The other authors received no additional funding. The Murdoch Children’s Research Institute administered research grants for the work and provided infrastructural support (as study sponsor) to its staff, but played no role in the conduct or analysis of the research.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest relevant to this article to disclose.
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