Observational Study of the Impact of COVID-19 on Sleep in Children With and Without Special Educational Needs

Article information

J Sleep Med. 2022;19(2):46-54

Publication date (electronic) : 2022 August 30

doi : https://doi.org/10.13078/jsm.220004

Heather Elphick^,¹^,²

, Philippa Howsley ²

, Nathaniel Mills ¹

, Vicki Beevers ³

, Lisa Artis ³

¹National Institute of Health Research Children and Young People MedTech Co-operative, Sheffield, UK

²Department of Sleep Medicine, Sheffield Children’s NHS Foundation Trust, Sheffield, UK

³The Sleep Charity, Doncaster, UK

Address for correspondence Heather Elphick, MD, MB, ChB, MRCP Department of Sleep Medicine, Sheffield Children’s NHS Foundation Trust, Western Bank, Sheffield, S10 2TH, UK Tel: +44-7982809467 Fax: +44-114-2717400 E-mail: h.elphick@nhs.net

Received 2022 March 29; Revised 2022 June 30; Accepted 2022 August 8.

Abstract

Objectives

Children and young people (CYP) with special educational needs (SEN) are more likely to experience disturbed sleep and poor mental wellbeing. This study explored the differential impact of the coronavirus disease 2019 (COVID-19) pandemic on the sleep and mental wellbeing of CYP with and without SEN.

Methods

The National Institute of Health Research Children and Young People MedTech Cooperative, Sheffield Children’s National Health Service (NHS) Foundation Trust, and The Sleep Charity carried out an online survey between June 23, 2020, and August 17, 2020. The 77-item survey was shared on social media platforms.

Results

A total of 559 participants were included in the analyses, and 15.74% of them reported having CYP with SEN. While sleep changes due to the pandemic were largely similar for both groups, CYP with SEN were more likely to get up or wake up during the night than those without SEN (40.91% vs. 27.18%). CYP with SEN were significantly more likely than those without SEN to be demotivated (61.44% vs. 31.57%), sad and tearful (36.15% vs. 19.35%), or anxious and stressed (41.67% vs. 18.54%) during the pandemic, and the increased anxiety was more likely to contribute to poorer sleep (43.48% vs. 14.82%).

Conclusions

While the majority of CYP in both groups reported sleep changes due to the pandemic, CYP with SEN experienced more sleep disturbance. The findings provide initial evidence to suggest that the pandemic may have had a greater impact on the sleep and mental wellbeing of CYP with SEN than those without SEN.

Keywords: Children; COVID-19; Mental health; Sleep; Education, special; Adolescent

INTRODUCTION

Sleep is a restorative process fundamental to physical and psychological health [1]. However, 20%–30% of children and young people (CYP) in the United Kingdom (UK) experience behavioral insomnia, a sleep disorder characterized by difficulty falling and/or staying asleep [2]. The prevalence of sleep problems rises to 40%–80% in CYP with special educational needs (SEN) [3]. With 12.2% of CYP in the UK having SEN [4], it is essential to understand and mitigate the potential impact of disrupted sleep in this population.

Disrupted sleep in CYP is associated with many deleterious short- and long-term outcomes including childhood obesity [5], behavioral problems [6], and poor school performance [7-9]. There is growing evidence to support a strong relationship between sleep and mental health in CYP [10-13]. For example, poor sleep in CYP has been associated with an increased risk of self-harm and suicidal ideation [14,15] and is predictive of anxiety disorders and depression in adulthood [16,17].

CYP with SEN are significantly more likely to be diagnosed with a mental health condition than those without SEN [18]. While the relationship between mental health and SEN is complex, disturbed sleep may be a factor contributing to the higher prevalence of mental health conditions in this population. A better understanding of the relationship between mental wellbeing and sleep in CYP with and without SEN will enable health services to deliver more effective support and intervention.

In March 2020, the World Health Organization declared coronavirus disease 2019 (COVID-19) a global pandemic. To reduce the spread of the virus, lockdown restrictions were introduced in the UK, whereby all residents were legally required to stay at home unless they were key workers (i.e., public or private sector employees considered to provide essential services).

Early work anticipated that the pandemic would have a significant impact on the mental health and wellbeing of CYP [19] and that there was a clear potential for sleep problems to emerge or worsen [20]. In support of this, there is increasing evidence that the lockdown restrictions adversely affected sleep and mental wellbeing [21-23]. Although CYP with SEN are at a greater risk of sleep problems and mental health conditions [24-26], to our knowledge, no study has yet assessed the differential impact of the pandemic on sleep and mental wellbeing in CYP with and without SEN.

The National Institute of Health Research Children and Young People MedTech Co-operative, Sheffield Children’s NHS Foundation Trust, and The Sleep Charity, therefore, carried out a survey that aimed to assess the impact of the COVID-19 pandemic on sleep and mental wellbeing of CYP with and without SEN. The research team plans to use the results from this survey to inform priorities for future research, including the development and evaluation of sleep-specific interventions for CYP with and without SEN.

METHODS

Design

This cross-sectional study was conducted using an online survey consisting of 77 questions (Supplementary Materials in the online-only Data Supplement). Parents/caregivers anonymously completed the survey using SmartSurvey (https://www.smartsurvey.co.uk/) between June 23, 2020, and August 17, 2020.

Survey

The questions for the survey were drafted based on the experiences of sleep professionals with CYP and families in their care since the beginning of the pandemic. The survey was piloted with 10 staff members with children, and the wording and order of the questions were amended following feedback. The final version of the survey was distributed to parents/caregivers via social media. The survey was posted on the Twitter accounts of two UK national organizations: @TheSleepCharity, which has 4,667 followers, and @NIHRCypMedTech, which has 1,276 followers. The followers were also asked to share the survey on their own Twitter accounts.

Analysis

To compare whether the pandemic differentially affected the sleep and wellbeing of CYP with and without SEN, survey respondents were split into two groups (CYP with SEN; CYP without SEN) based on the parent/caregiver response to Q17. Descriptive statistics were calculated for all the survey responses (Supplementary Table 1 in the online-only Data Supplement). Chi-square tests were used to statistically compare the groups. Fischer’s exact test was used when the cell count was below 5. To reduce the number of statistical tests, the analyses only focused on questions relating to sleep and mental wellbeing in CYP. Responses to questions 23a, 23b, and 26 were collapsed from seven categories to three to further reduce the number of comparisons. The responses marked “not applicable” were excluded from the analyses. The significance threshold was set at p<0.05. Cramer’s V (Φc) was calculated to assess effect size. All statistical analyses were performed using Stata/SE 15.1 (StataCorp., College Station, TX, USA; https://www.stata.com). Free-text answers were coded.

Ethics

The research was exempt from formal research ethics approval as it was categorized as a patient and public involvement and engagement exercise to gather opinions to inform future research. Informed consent was not obtained; however, consent was implied in cases where the participants completed the survey.

RESULTS

Participants

A total of 585 parents/caregivers completed the survey from 77 postcodes across the UK. Parents/caregivers who completed the survey on behalf of multiple children and one young person aged 25 years were excluded from the analyses, leaving a final sample of 559 respondents (age range 1–17 years). In total, 133 SEN diagnoses were reported across 88 children (median=1, range=1–7), with the most common being autism spectrum disorder (32.33%); attention deficit/hyperactivity disorder (15.04%); dyslexia, dyspraxia, or dyscalculia (18.80%); and learning difficulties (5.26%). The respondents’ demographics are presented in Table 1.

Table 1.

Demographic details of the survey respondents and their families

Impact of the pandemic on sleep patterns in CYP

A significant association was found between SEN and CYP getting up or waking up frequently during the night during the pandemic (χ²[1, 559]=6.75, p=0.009); 40.91% of CYP with SEN got up or woke up more frequently during the night during the pandemic compared with 27.18% of CYP without SEN (Table 2).

Table 2.

Chi-square analyses assessing relationships between SEN and CYP’s sleep

A significant association was also found between SEN and changes in going-to-bed time in CYP during the pandemic (χ²[2, 558]=11.83, p=0.006); 71.59% of CYP with SEN went to bed later, 4.55% went to bed earlier, and 23.86% reported no change, whereas 82.13% of CYP without SEN went to bed later, 0.64% went to bed earlier, and 17.23% reported no change.

No other significant differences between CYP with and without SEN were found for other questions on sleep (Table 2).

Impact of the pandemic on mental wellbeing in CYP

A significant association was found between SEN and CYP being more demotivated during the pandemic (χ²[3, 517]=31.34, p<0.001); 61.44% of CYP with SEN reported being “a lot more” or “moderately more” demotivated during the pandemic compared with 31.57% of CYP without SEN (Table 3).

Table 3.

Chi-square analyses assessing the relationships between SEN and CYP’s wellbeing

A significant association was found between SEN and CYP being more depressed, sad, or tearful during the pandemic (χ²[3, 517]=11.94, p=0.008); 36.15% of CYP with SEN reported being “a lot more” or “moderately more” depressed, sad, or tearful during the pandemic compared with 19.35% of CYP without SEN.

A significant association was found between SEN and CYP being more anxious or stressed during the pandemic (χ²[3, 521]=26.19, p<0.001); 41.67% of CYP with SEN reported being “a lot more” or “moderately more” anxious or stressed during the pandemic compared with 18.54% of CYP without SEN. The main reasons given for increased anxiety were changes to daily routines (CYP with SEN: 25.00%; CYP without SEN: 18.64%), isolation and/or missing friends/family (CYP with SEN: 19.05%; CYP without SEN: 31.19%), themselves and/or friends/family getting ill and/or dying from COVID-19 (CYP with SEN: 28.57%; CYP without SEN: 27.12%), and school and/or schoolwork (CYP with SEN: 21.43%; CYP without SEN: 14.24%).

A significant association was found between SEN and increased anxiety, making sleep worse in CYP during the pandemic (χ² [3, 393]=29.61, p<0.001); 43.48% of CYP with SEN reported that increased anxiety was making their sleep “a lot worse” or “moderately worse” during the pandemic compared with 14.82% of CYP without SEN.

A significant association was found between SEN and reduced sleep in CYP, which had an impact on their wellbeing during the pandemic (χ²[1, 334]=10.92, p=0.001); 74.60% of CYP with SEN reported that their reduced sleep had an impact on their wellbeing compared with 51.66% of CYP without SEN.

Finally, a significant association was found between SEN and CYP missing their friends during the pandemic (χ²[3, 557]=18.74, p<0.001); 76.22% of CYP without SEN reported that they were missing their friends “a lot” or “moderately” during the pandemic compared with 54.65% of CYP with SEN.

No other significant differences between CYP with and without SEN were found for the other questions on mental wellbeing (Table 3).

DISCUSSION

This study assessed the differential impact of the pandemic on sleep and wellbeing in CYP with and without SEN. The proportion of CYP with SEN in this sample (15.74%) was representative of the UK population (12.20%) [4].

Impact of the pandemic on sleep patterns

Changes in sleep patterns during the pandemic were reported in both groups, and they were largely similar (Table 2); the majority of CYP in both groups reported having more irregular bedtime and wake-up times, going to bed later, getting up later, and finding it harder to get to sleep. Almost half of the CYP also reported getting less sleep during the pandemic. These findings, therefore, agree with other studies reporting changes in sleep patterns of CYP during the pandemic [27,28]. It has been suggested that such sleep changes may have resulted from sudden changes in everyday life of CYP, including socializing with peers, extracurricular activities, schooling, and a transition to electronic-based learning [29].

While CYP with SEN were thought to be particularly vulnerable to disturbed sleep during the pandemic, only two significant differences between CYP with and without SEN were found; CYP with SEN were more likely to get up or wake up during the night and go to bed earlier during the pandemic. Taken together, these findings suggest that while the pandemic had a clear impact on sleep patterns for both CYP with and without SEN, CYP with SEN had more disturbed sleep.

Impact of the pandemic on mental wellbeing

More CYP with SEN reported experiencing a worsening of their mental wellbeing during the pandemic compared to CYP without SEN; CYP with SEN were more likely to report being a lot or moderately more demotivated, more depressed, sad, or tearful, and more anxious or stressed than CYP without SEN. The main reasons given for increased anxiety were changes to daily routines, isolation and/or missing friends/family, themselves and/or friends/family getting ill and/or dying from COVID-19, and school and/or schoolwork. CYP with SEN are considerably more likely to be diagnosed with a mental health condition than their peers [30], and recent research suggests that many CYP diagnosed with mental health conditions before the pandemic experienced a worsening of symptoms during lockdown [31]. Consistent with these reports, 28.41% of CYP with SEN in this study reported having a pre-diagnosed mental health condition, compared to 2.34% of CYP without SEN, which may partially explain these findings.

Notably, 43.48% of CYP with SEN reported that increased anxiety due to the pandemic was making their sleep a lot or moderately worse compared to only 14.82% of CYP without SEN. Moreover, 74.60% of CYP with SEN reported that less sleep during the pandemic impacted their wellbeing a lot or moderately compared to 51.66% of children without SEN. These findings suggest that despite the pandemic having a largely similar impact on the sleep patterns of CYP with and without SEN, such changes disproportionately affected the mental wellbeing of CYP with SEN. While the link between poor sleep and mental wellbeing during the pandemic has been previously reported [32-34], this is the first time to the authors’ knowledge that a link between poor sleep and mental wellbeing has been reported in CYP with SEN. Interestingly, these findings may indicate that the bidirectional relationship between sleep and mental wellbeing is stronger for CYP with SEN, although this requires further investigation.

Many CYP with SEN rely on established routines and access to specialized services to improve their wellbeing and independence, and sudden changes in routines can exacerbate mental health symptoms [18]. It is therefore plausible that the disruption caused by lockdown created highly stressful environments for CYP with SEN and their families [21] and could partially account for their worsening mental wellbeing and sleep patterns during the pandemic. Non-pharmacological sleep interventions have been shown to improve both sleep and symptoms of anxiety in CYP with and without SEN [35-37]. Making evidence-based interventions widely accessible to both CYP with and without SEN may be one way to help improve both sleep and anxiety levels in CYP. However, further work is required to understand how to best support CYP with SEN and their families as they seek to re-establish new routines and live with the uncertainty of future lockdowns and restrictions [38].

Impact of the pandemic on peer relationships

CYP without SEN missed their friends more during the pandemic than CYP with SEN, although no group differences were found for feeling lonely. There is evidence that CYP with SEN experience lower levels of peer acceptance [39,40], have fewer friendships [41,42], and are more likely to experience bullying or victimisation [43] than CYP without SEN. It is, therefore, possible that CYP without SEN may have had stronger peer relationships and experienced greater peer acceptance than CYP with SEN, resulting in them missing their friends more.

Limitations

This study used a cross-sectional design in which parents/caregivers reported their child’s sleep and mental wellbeing before and during the pandemic. However, both retrospective and parent-reported surveys have clear and well-documented limitations. In particular, although parent-report surveys provide rich and important insights, they may not have face validity, correspond to CYP self-reports, or be a proxy for more accurate behavioral or physiological assessments [44].

Second, because this survey was cross-sectional, we were unable to assess whether the sleep problems reported were short-term and resolved after the initial lockdown, or whether long-term sleep disruptions and poorer mental wellbeing persisted. Therefore, a follow-up survey is planned to capture the potential long-term impact of the pandemic on sleep and mental wellbeing in this sample of CYP. Future work should also aim to assess potentially important COVID-19-related factors, such as personal loss and family financial strain, which may predict or maintain sleep disturbances in CYP.

Finally, this study used opportunistic sampling, with parents/caregivers opting-in online, which could have resulted in a sampling bias [23]. Thus, the results of this study are likely not representative of all communities in the UK.

Conclusions

This study suggests that while the majority of CYP in both groups reported sleep changes during the pandemic, CYP with SEN experienced more sleep disturbance. The findings provide initial evidence to suggest that the pandemic may have had a greater impact on the sleep and mental wellbeing of CYP with SEN compared with those without SEN, and that the bidirectional relationship between mental health and sleep may be stronger for CYP with SEN. While further work is needed, this work demonstrates the importance of a better understanding of the impact of the pandemic on CYP with and without SEN in order to develop and deliver effective interventions to mitigate the effects of the pandemic on sleep and mental wellbeing in CYP.

Supplementary Materials

The online-only Data Supplement is available with this article at https://doi.org/10.13078/jsm.220004.

jsm-220004-jsm-supplementary1.pdf

jsm-220004-jsm-supplementary2.pdf

Notes

The authors have no potential conflicts of interest to disclose.

Author Contributions

Conceptualization: Heather Elphick, Vicki Beevers, Lisa Artis. Data curation: Philippa Howsley, Nathaniel Mills. Formal analysis: Philippa Howsley, Heather Elphick. Investigation: Philippa Howsley, Nathaniel Mills, Heather Elphick. Methodology: Philippa Howsley, Nathaniel Mills, Heather Elphick. Project administration: Philippa Howsley, Nathaniel Mills. Software: Philippa Howsley. Supervision: Heather Elphick, Vicki Beevers. Writing—original draft: Philippa Howsley. Writing—review & editing: Nathaniel Mills, Lisa Artis, Vicki Beevers, Heather Elphick.

Funding Statement

This research was supported by the Sheffield Children’s NHS Foundation Trust, National Institute of Health Research (NIHR) and Children and Young People MedTech Co-operative (CYP MedTech).

Acknowledgements

The authors are grateful to the parents/caregivers who participated in the study. The views expressed are those of the author(s) and not necessarily those of the NHS, NIHR, or Department of Health.

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Table 1.

Demographic details of the survey respondents and their families

Question^*		Total (n=559)	CYP without SEN (n=471)	CYP with SEN (n=88)
1. Parent/carer employment status
	Key worker	187 (33.45)	167/471 (35.46)	20/88 (22.73)
	Working on business premises	9 (1.61)	7/471 (1.49)	2/88 (2.27)
	Working from home	195 (34.88)	169/471 (35.88)	26/88 (29.55)
	Not working (including being made redundant or furloughed)	111 (19.86)	91/471 (19.32)	20/88 (22.73)
	Other	57 (10.20)	37/471 (7.86)	20/88 (22.73)
4. Number of children in household, median (range)		2 (1–6)	2 (1–6)	2 (1–5)
5. Parent/carer, close friend, or family member hospitalised with COVID-19
	Yes	33/557 (5.92)	28/469 (5.97)	5/88 (5.68)
	No	524/557 (94.08)	441/469 (94.03)	83/88 (94.32)
11. Child age (yr), median (range)		10 (1–17)	10 (1–17)	12 (2–16)
12. Child gender
	Male	247 (44.19)	193/471 (40.98)	54/88 (61.36)
	Female	312 (55.81)	278/471 (59.02)	34/88 (38.64)
13. Child type of school
	Private day nursery	14 (2.51)	12/470 (2.55)	2/88 (2.27)
	Childminder	2 (0.36)	2/470 (0.43)	0/88 (0.00)
	Pre-school	26 (4.66)	24/470 (5.11)	2/88 (2.27)
	State school	466 (83.51)	402/470 (85.53)	64/88 (72.73)
	Independent school	26 (4.66)	21/470 (4.47)	5/88 (5.68)
	Special school	9 (1.61)	0/470 (0.00)	9/88 (10.23)
	Home	4 (0.72)	3/470 (0.64)	1/88 (1.14)
	Other	11 (1.97)	6/470 (1.28)	5/88 (5.68)
15. Child attended school in person during lockdown (Mar–May 2020)
	Yes	58/559 (10.38)	45/471 (9.55)	13/88 (14.77)
	No	501/559 (89.62)	426/471 (90.45)	75/88 (85.23)
17. Child SEN diagnoses
	Autism spectrum disorder	43/133 (32.33)	-	43/133 (32.33)
	Attention deficit/hyperactivity disorder	20/133 (15.04)	-	20/133 (15.04)
	Learning difficulties	7/133 (5.26)	-	7/133 (5.26)
	Dyslexia/dyspraxia/dyscalculia	25/133 (18.80)	-	25/133 (18.80)
	Other	38/133 (25.57)	-	38/133 (25.57)
19. Child MHC
	Yes	36/558 (6.45)	11/470 (2.34)	25/88 (28.41)
	No	522/558 (93.55)	459/470 (97.66)	63/88 (71.59)
Child MHC diagnoses
	Anxiety disorders	27/44 (61.36)	7/13 (53.85)	20/31 (64.52)
	Post-traumatic stress disorder	7/44 (15.91)	2/13 (15.39)	1/31 (3.22)
	Depression	3/44 (6.82)	2/13 (15.39)	5/31 (16.13)
	Other	7/44 (15.91)	2/13 (15.39)	5/31 (16.13)

Values are expressed as n (%) unless otherwise specified.

item numbering refers to the question number in the survey.

CYP, children and young people; SEN, special educational needs; MHC, pre-existing mental health condition

Table 2.

Chi-square analyses assessing relationships between SEN and CYP’s sleep

Question^*	CYP without SEN (n=471)	CYP with SEN (n=88)	χ²	p	Φ_c
21a. Does your child have a regular bedtime? Before the pandemic:			0.72	0.397	0.04
Yes	449/471 (95.33)	82/88 (93.18)
No	22/471 (4.67)	6/88 (6.82)
21b. Does your child have a regular bedtime? Now:			0.40	0.528	0.03
Yes	264/467 (56.53)	46/87 (52.87)
No	203/467 (43.47)	41/87 (47.13)
22a. Does your child have a regular wake-up time? Before the pandemic:			2.71	0.100	0.07
Yes	456/471 (96.82)	82/88 (93.18)
No	15/471 (3.18)	6/88 (6.82)
22b. Does your child have a regular wake-up time? Now:			2.61	0.107	0.07
Yes	247/470 (52.55)	38/88 (43.18)
No	223/470 (47.45)	50/88 (56.82)
23a. How has your child’s sleep pattern been affected by the pandemic? Going to bed:			11.83	0.006	0.15
No change	81/470 (17.23)	21/88 (23.86)
Earlier	3/470 (0.64)	4/88 (4.55)
Later	386/470 (82.13)	63/88 (71.59)
23b. How has your child’s sleep pattern been affected by the pandemic? Getting up:			0.48	0.828	0.03
No change	120/470 (25.53)	24/88 (27.27)
Earlier	36/470 (7.66)	5/88 (5.68)
Later	314/470 (66.81)	59/88 (67.05)
26. Overall, how has the amount of sleep your child is getting changed during the pandemic?			1.04	0.595	0.04
No change	150/470 (31.91)	23/87 (26.44)
Less sleep	198/470 (42.13)	40/87 (45.98)
More sleep	122/470 (25.96)	24/87 (27.59)
28a. Has your child been going to bed after you? Before the pandemic:			2.49	0.115	0.07
Yes	23/470 (4.89)	8/88 (9.09)
No	447/470 (95.11)	80/88 (90.91)
28b. Has your child been going to bed after you? Now:			1.50	0.221	0.05
Yes	119/466 (25.54)	28/88 (31.82)
No	347/466 (74.46)	60/88 (68.18)
29. Is your child currently reporting more nightmares or vivid dreams?			0.26	0.612	0.02
Yes	111/470 (23.62)	23/88 (26.14)
No	359/470 (76.38)	65/88 (73/86)
30. Is your child currently experiencing more night terrors, sleepwalking, bedwetting?			0.59	0.442	0.03
Yes	50/469 (10.66)	7/88 (7.95)
No	419/469 (89.34)	81/88 (92.05)
31. Is your child currently getting up or waking up more during the night?			6.75	0.009	0.11
Yes	128/471 (27.18)	36/88 (40.91)
No	343/471 (72.82)	52/88 (59.09)
32. Is your child currently getting into your bed more during the night?			0.68	0.410	0.04
Yes	75/470 (15.96)	11/88 (12.50)
No	395/470 (84.04)	77/88 (87.50)
33. Is your child currently finding it harder to get to sleep?			3.72	0.054	0.08
Yes	257/469 (54.80)	58/88 (65.91)
No	212/469 (45.20)	30/88 (34.09)
34a. Does your child need a parent/carer to be with them at bedtime? Before the pandemic:			3.07	0.080	0.07
Yes	99/470 (21.06)	26/88 (29.55)
No	371/470 (78.94)	62/88 (70.45)
34b. Does your child need a parent/carer to be with them at bedtime? Now:			2.83	0.093	0.07
Yes	132/468 (28.21)	32/86 (37.21)
No	336/468 (71.79)	54/86 (62.79)

Values are expressed as n (%).

item numbering refers to the question number in the survey.

CYP, children and young people; SEN, special educational needs

Table 3.

Chi-square analyses assessing the relationships between SEN and CYP’s wellbeing

Question^*		CYP without SEN (n=471)	CYP with SEN (n=88)	χ²	p	Φ_c
47. Has your child’s reduced sleep had an impact on their own wellbeing?				10.92	0.001	0.18
	Yes	140/271 (51.66)	47/63 (74.60)
	No	131/271 (48.34)	16/63 (25.40)
48. Has your child become more hyperactive during the pandemic?				4.82	0.186	0.10
	Not a lot	289/435 (66.44)	45/82 (54.88)
	A little	99/435 (22.76)	23/82 (28.05)
	Moderately	30/435 (6.90)	8/82 (9.76)
	A lot	17/435 (3.91)	6/82 (7.32)
49. Has your child become more demotivated during the pandemic?				31.34	<0.001	0.25
	Not a lot	105/434 (24.19)	12/83 (14.46)
	A little	192/434 (44.24)	20/83 (24.10)
	Moderately	65/434 (14.98)	17/83 (20.48)
	A lot	72/434 (16.59)	34/83 (40.96)
50. Has your child become more depressed, sad, or tearful during the pandemic?				11.94	0.008	0.15
	Not a lot	209/434 (48.16)	29/83 (34.94)
	A little	141/434 (32.49)	24/83 (28.92)
	Moderately	48/434 (11.06)	18/83 (21.69)
	A lot	36/434 (8.29)	12/83 (14.46)
51. Has your child been more anxious or stressed during the pandemic?				26.19	<0.001	0.22
	Not a lot	188/437 (43.02)	20/84 (23.81)
	A little	168/437 (38.44)	29/84 (34.52)
	Moderately	45/437 (10.30)	15/84 (17.86)
	A lot	36/437 (8.24)	20/84 (23.81)
52. Has increased anxiety made your child’s sleep worse?				29.61	<0.001	0.28
	Not a lot	167/324 (51.54)	22/69 (31.88)
	A little	109/324 (33.64)	17/69 (24.64)
	Moderately	25/324 (7.72)	15/69 (21.74)
	A lot	23/324 (7.10)	15/69 (21.74)
Reasons given for increased anxiety				-	-	-
	Changes to daily routine	55/295 (18.64)	21/84 (25.00)
	Isolation and/or missing friends/family	92/295 (31.19)	16/84 (19.05)
	Themselves and/or friends/family getting ill and/or dying from COVID-19	80/295 (27.12)	24/84 (28.57)
	School and/or schoolwork	42/295 (14.24)	18/84 (21.43)
	Other	26/295 (8.81)	5/84 (5.95)
59. Has your child missed their friends during the pandemic?				18.74	<0.001	0.18
	Not a lot	13/471 (2.76)	7/86 (8.14)
	A little	99/471 (21.02)	32/86 (37.21)
	Moderately	104/471 (22.08)	15/86 (17.44)
	A lot	255/471 (54.14)	32/86 (37.21)
60. Has your child felt lonely during the pandemic?				2.47	0.480	0.07
	Not a lot	132/470 (28.09)	25/83 (30.12)
	A little	182/470 (38.72)	28/83 (33.73)
	Moderately	77/470 (16.38)	11/83 (13.25)
	A lot	79/470 (16.81)	19/83 (22.89)

Values are expressed as n (%).

item numbering refers to the question number in the survey.

SEN, special educational needs; CYP, children and young people