Coping Strategies and Meta-Worry in Adolescents’ Adjustment during COVID-19 Pandemic

1. Introduction

The world population has begun to hear about COVID-19 (Coronavirus Disease-2019) in December 2019, when a severe form of viral infection (SARS-CoV-2) was identified in Wuhan District, China. A few months later (March, 2020) the virus had spread to 114 countries with more than 118.000 cases and 4.291 deaths: On March 11th, 2020, pandemic status was declared [1]. Currently, as we are writing (December 15, 2021), the weekly epidemiological update of the virus shows 268 934 575 people infected and 5 297 850 persons lost their lives [2]. The pandemic strongly impacts the quality of life and mental health of populations worldwide, with psychological distress and increased anxiety symptoms both in adults [3] and adolescents [4, 5, 6].

First, studies on the consequences of COVID-19 in children have been conducted in China. Leilei et al. [7] observed that nearly 40% of adolescents had experienced a condition of psychological distress. Jiao et al. [8] found that children and adolescents (aged between 3–18 y.o.) showed anxious manifestations and looked for the proximity of others, were distracted, irritable, and afraid to ask about the pandemic.

Similar consequences in the child population were tracked in other parts of the world. A review [9] of studies from the United States, China, Europe, Australia, India, Malaysia, Korea, Thailand, Israel, Iran, and Russia shows that conditions of social distancing and loneliness—particularly when total lockdown was imposed— strongly impact adolescents’ mental health. Data globally confirm an increase in symptoms of anxiety and depression during the quarantine period [9].

From the beginning of the COVID-19 pandemic, parents to have observed internalizing and externalizing symptoms in their children. A Spanish/Italian study [10] indicates that nearly 85% of parents perceived changes in the emotional and behavioral state of their children (aged between 3–18 y.o.). The most frequent symptoms were difficulty concentrating (76,6%), boredom (52%), irritability (39%), restlessness (38,8%), nervousness (38%), feelings of loneliness (31,3%), unquietness (30,4%), and worry (30,1%). Spanish parents declared more symptoms than Italians (differences probably due to stricter restrictive measures). Necessarily having to remain in the (limited) space of one’s home and the prohibition to go out seemed to increase anxiety levels and other related problems, such as sleep disorders and worry. Moreover, children’s symptoms resulted positively related to parental well-being, particularly with the level of parents’ distress for imposed modifications in daily life. In Italy—where the “stay at home” period lasted from early March to May 2020—parents reported increased distress for fears of contagion, working difficulties, and the need to schedule daily routine for children, including school homework and “distance learning” [11, 12]. This increased distress, in turn, escalated the children’s problems with a bidirectional influence on the parent’s and children’s psychological adjustment [13]. Data from Hawes et al. [14] show also a link between worry about contracting the virus, school-related problems, and symptoms, such as depression, generalized anxiety, and panic/somatic symptoms in adolescents and young adults (12–22 y.o.).

Developmental and clinical literature show that children and adolescents with anxiety symptoms suffer more intense worries and have repetitive thoughts and “thinking about worry” (“meta-worry” [15, 16]). Worry is a chain of repetitive and verbal thoughts about potentially dangerous consequences of events. According to Wells’ model [17], it is not the content of the thoughts or the intensity of the worries to characterize people with emotional disorders, but meta-cognitive beliefs about worries. Meta-beliefs are intrusive and disturbing thoughts where the focus is worry itself and the functioning of one’s mind. The positive beliefs are based on the advantages or benefits of worrying as a coping strategy (e.g., “Worrying helps me to avoid problems in the future”). The negative beliefs include the thoughts of uncontrollability and the dangerousness of worry (e.g., “If I worry a lot, I could make myself sick”). Positive beliefs lead to increased worry, and when levels of worry get excessive, people become to be worried about the negative consequences of thinking, monitor their thinking, or active attempts to suppress dangerous thoughts. These cognitive experiences are associated with negative emotions and distress [17].

As with adults [17, 18], worry intensity and negative meta-beliefs about worry (dangerousness and uncontrollability) resulted positively linked with anxiety symptoms in children [19, 20] and adolescents [21]. Particularly, negative meta-cognitive beliefs are more frequent in children with clinical anxiety disorders compared to nonclinical groups [22, 23, 24]. Similarly, Natalucci et al. [25] found an association between cognitive monitoring (i.e., the tendency to be aware of one’s own thoughts), negative meta-cognitive beliefs, and internalizing disorders. These data globally support the link between frequent worry, meta-worry, and increased anxiety symptoms in children. Therefore, we can suppose that, in the context of the COVID-19 pandemic and related worries, in children with a tendency to worry and to monitor their internal states (meta-worry) the risk of developing anxious symptoms may increase. In agreement with Wells’s model [17, 18], meta-beliefs about worry could play an additional role in feeding and maintaining children’s anxiety symptoms.

Orgilés et al. [10] noted that more than 30% of parents observed an increase in worry in their children, especially when one of the parents left the home. Zhou et al. [26] report that approximately 40% of adolescents (aged 12–18 y.o.) declared they worried about a variety of things and were unable to control their worries. A survey [27] with an extensive sample (age range 18–70 y.o.) shows that worries about the possibility of contracting COVID-19 is present primarily in individuals with state anxiety. Among respondents with state anxiety, 33.3% were “very worried” about being infected with COVID-19, whereas only 2.2% were “not worried at all.”

When facing stressful situations, people active intentional responses to demands and emotions, also known as coping strategies [28]. Studies on coping in children and adolescents for a long time have been based on the theoretical model developed by Lazarus and Folkman [29] with adults. Authors define coping as “constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person” ([29], p. 141). The most common strategies in children and adolescents are family support seeking, problem-solving, escape, and distraction. Younger children seem to prefer escape, support-seeking, and distraction, whereas adolescents adopt internal dialogue and problem-solving thanks to the development of logical-formal thinking, the ability to control their behavior, and emotion regulation [30]. Recent studies have been conducted with the aim to establish the ways adolescents cope with pandemic-related psychological distress. Studies with adolescents (e.g., [31]) highlight that adolescents’ active coping— based on doing something to reduce stress, such as thinking positively, distancing oneself from sources of stress, problem-solving, and asking for help is a protective factor to depression, anxiety, and stress development. Conversely, dysfunctional coping, such as avoidance behaviors, keeping feelings to oneself, and not seeking support resulted in a risk factor for distress and internalizing disorders [30]. Similar results emerge from the research by Türk et al. [32]. During the pandemic crisis, children who used dysfunctional coping strategies (e.g., avoidance coping) had higher anxiety levels; contrarily, children who adopted positive strategies, such as trying to lead a healthy lifestyle, experienced lower levels of anxiety. Furthermore, dysfunctional coping results are also associated with adolescent’s risk behaviors, such as internet addiction, alcohol, and other substance abuse [33].

2. Method

3. Results

4. Discussion

The aim of the present study was to explore the psychological impact of COVID-19 on Italian adolescents, a population of young people among the most affected by the pandemic, and the restrictions on daily life due to the long lockdown among western countries. Fear of contagion and death, home confinement, the lack of direct contact with peers, and the interruption of recreational and school activities abruptly changed the daily life of teenagers, with immediate effects on perceived stress and psychopathological symptoms whose long-term maintenance is currently unknown [41]. Particularly, this study investigated the relative contribution of meta-cognitive beliefs about worries and coping styles in predicting adolescents’ anxiety symptoms. In fact, while there are several studies on the role of coping in reacting to COVID-19-related distress [6, 31, 32], no research as far as we know has explored how meta-worry beliefs contribute to anxiety. According to Wells’s [17] meta-cognitive model, people who are aware of their worries and who try to control them experience higher levels of anxiety, which tend to be maintained over time.

First, the participants were subdivided into two subsamples with/without clinical anxiety symptoms, according to RCMAS-2 (Revised Children’s Manifest Anxiety Scale-2) measures [35]. Data indicate that 37% of participants fall within the clinical range. This estimated incidence is higher than the worldwide prevalence of clinically elevated anxiety among adolescents prior to the COVID-19 pandemic (11.6% as reported by Racine et al. [42]). Moreover, this 37% rate of Italian adolescents with clinically elevated anxiety is markedly higher than the percentage (10.32%) reported by Benedetto et al. [19] with the same anxiety measures (RCMAS-2) in a community sample of adolescents before the outbreak of the pandemic.

Data from the present study also agree with gender differences observed in studies prior to COVID-19 [23, 43] and during the pandemic [14, 26, 44], with girls reporting more anxiety symptoms than boys.

In line with the hypotheses, participants with elevated anxiety report higher scores in meta-cognitive processes, with the only exception of positive meta-worry. In other words, in this study, anxious adolescents perceived their worries as most dangerous and uncontrollable (e.g., “I can’t control my worries”), they spent more time to monitor their thoughts (“I must stop worrying”), or they seemed more superstitious about the influence of their thoughts on reality (“If I keep worrying something bad will happen”). Otherwise, the positive beliefs—thinking about worry’s usefulness—seem to have a subordinate role in participants’ anxiety. Unlike adults [17], the role of positive meta-worry in the genesis and maintenance of children’s internalizing disorders has not always been confirmed [e.g., 45, 46]. Instead, data from the present study are to be added to the more consistent ones about the link between negative meta-beliefs (dangerousness/uncontrollability of worry) and the intensity of children’s worry (e.g., [16, 47]).

The present study aimed also to explore the association between adolescents’ anxiety and coping strategies to mitigate stress during the period of total lockdown. Supporting the starting hypothesis, we found that adolescents with low anxiety levels use more often active coping (e.g., use problem-solving skills) compared with anxious adolescents. Conversely, participants with clinical levels of anxiety declared a more intense use of emotion-focused coping (e.g., altering one’s feelings and thoughts about events) in trying to reduce the emotional reactivity derived from the stressful experience. In addition, emotion-oriented coping was engaged more frequently in girls than boys. Avoidance coping (e.g., withdrawing or distracting oneself from the awareness of the problem) result positively related with cognitive monitoring, that is, the tendency to engage in meta-cognitive self-reflection and active control of one’s feelings and thoughts. However, this task-irrelevant thinking maintained by cognitive monitoring may increase opportunities for negative appraisals of intrusive thoughts, increasing anxiety symptoms [48]. Therefore, avoidance and emotion-focused coping, together with maladaptive cognitive processes, intensify rather than attenuate anxiety. In addition, maladaptive coping strategies, as a preferred coping strategy, distract attention from the external environment and from the search for more effective solutions (such as changing the situation through active action; cf. [48]). In confirmation of this, in the present study, adolescent’s anxiety symptoms resulted linked with increased use of maladaptive coping strategies for managing emotions and/or avoiding stressful events, but decreased activation of task-oriented coping.

A stepwise regression was conducted to assess which factors among meta-worry beliefs and coping strategies predicted adolescents’ anxiety. It was found that emotion-focused coping is the strongest predictor of anxiety, followed by task-oriented coping with a reverse negative direction. Cognitive monitoring, with a positive direction, added a small but significant amount of variance in anxiety levels. Therefore, it would seem that emotion-based coping is a risk factor for elevated anxiety symptoms, while task-oriented coping seems to act as a protective factor. Cognitive monitoring influences anxious expression, but to a lesser extent if compared to coping strategies.

In sum, our data, together with findings by Zhang et al. [31] and Türk et al. [32], suggest that an emphasis on emotion-focused coping and avoidance coping may have accentuated anxiety symptoms in teenagers. Our findings are also consistent with Hussong et al. [49], who underline cumulative stress associated with teenagers’ experience with the COVID-19 pandemic: In fact, while initially, the restrictions due to the pandemic might seem short-lived (such as a temporary closure of schools and distancing from friends), uncertainty has increased over the weeks. In their longitudinal study (May–July 2020), authors found that increased symptoms (both internalizing/ externalizing) were mitigated in teenagers with problem-focused coping and greater self-efficacy (a greater sense of agency and positive affect), but were exacerbated in teenagers with an emotion-focused coping style.

This study has certainly some limitations to be addressed. First, the cross-sectional research design cannot provide a causal relationship between the health and social crisis due to COVID-19 and the increased anxiety symptoms in adolescents. Only for descriptive purposes, we compare the results of the present study with those of our quite similar study for design (community sample) and anxiety measures [23]. Although this previous study is not strictly comparable to a pre-COVID-19 baseline—as there are no within-subject repeated measures— some considerations are plausible. We note that in the current sample the adolescents with clinical symptoms resulted more than triple (37%) of those observed in the previous study (11.6%). Future studies could examine with longitudinal design the changes not only in anxiety symptoms but also in the strategies with which children and adolescents can cope with COVID-19 worries and restrictions on daily life. A longitudinal approach will be needed in future research as the health and social crisis due to COVID-19 is persisting around the world and the long-term psychological impact on the population is unknown [50].

A second limit is the sample composition, predominantly female and numerically small. The research was conducted in Italy, the first of the European countries to be involved in the acute phases of the COVID-19 outbreak and to experience a long total lockdown (10 weeks, March–May 2020; [34, 51]. Home confinement, social distancing from family and peers, fears, and worries experienced by the Italian youths have affected their psychological distress [11, 12, 13], but these conditions cannot be generalized to other groups for different detrimental impacts across countries. Other studies evidence that poverty and socioeconomic disadvantage, living in rural rather than urban areas, high local prevalence of COVID-19 infection, loss of a loved person for COVID-19, and exposure to social media disseminating fears are all contextual factors associated with higher distress and internalizing disorders [52]. Finally, the study measures are self-reported and the questionnaires were disseminated through the web. This online sampling strategy was necessary as the research was conducted during the period of the total lockdown, but self-selection among the participants cannot be excluded. Similarly, preexisting physical or psychopathological conditions that may have increased participants’ vulnerability to anxiety have not been evaluated (cf. [50]).

Despite these limitations, the findings of present study evidence maladaptive coping and cognitive factors associated with adolescents’ anxiety. Particularly, emotion-focused seem to affect anxiety symptoms to a greater extent than meta-cognitive beliefs, whereas task-oriented coping predicted lower anxiety. Findings highlight the need for active interventions aimed to enhance adolescents’ psychological resources to cope with daily pandemic-related stress.

5. Conclusions

The development of interventions aimed to increase adolescents’ resilience to COVID-19 related stress is a priority for both researchers and health professionals, particularly in the perspective that the crisis due to COVID-19 disease may persist for a long time negatively affecting daily life and well-being of young populations. Anxiety symptoms exhibit some continuity over time, leading to the need for early intervention. Cognitive-behavioral therapies, together with the most recent procedures that include meta-cognitive components, are the recommended approaches for adolescents [53, 54]. Particularly, addressing meta-cognitive beliefs about worry is an effective and promising approach for children’s anxiety treatment [55].

Intervention programs that enhance effective coping strategies should be promoted by services and health professionals to ensure adequate psychological support to youths. The effectiveness of coping-centered programs is well known: For example, Essau et al. [56] have demonstrated that 10 weeks of training on coping skills (e.g., problem solving, self-reward for trying, and achieving goals), identifying and modifying anxiety-related thoughts, reduced anxiety and depression symptoms in children and adolescents. More recently, Orgilés et al. [57] have developed a program aimed to enhance coping skills and resilience to deal with the COVID-19 pandemic. Results show that children in the intervention group reported less symptoms of anxiety, unstable mood, sleep problems, and cognitive impairments during home confinement than children who did not receive the intervention. In this control group, children continued to use more likely emotionally oriented strategies. which were associated with greater psychological distress. Having more family/social support and having the opportunity to engage in physical activity are also protective factors associated with reduced anxiety [58]. Since the emergency for COVID-19 is far from over, the challenge for scholars and professionals will be to disseminate effective programs also use innovative strategies (such as school-based or app-based support; cf. [59]) in order to reach a larger population of young people.