RR:C19 Evidence Scale rating by reviewer:
Potentially informative. The main claims made are not strongly justified by the methods and data, but may yield some insight. The results and conclusions of the study may resemble those from the hypothetical ideal study, but there is substantial room for doubt. Decision-makers should consider this evidence only with a thorough understanding of its weaknesses, alongside other evidence and theory. Decision-makers should not consider this actionable, unless the weaknesses are clearly understood and there is other theory and evidence to further support it.
This is an interesting study that uses strong methods and generally appropriate analyses. I have essentially one substantive suggestion for the authors to consider. This has to do with the central take-home message, in terms of both cause-effect links that are implied and based on these, what is suggested for preventive interventions during COVID.
The authors do recognize, in noting limitations, that this is a cross-sectional study and that some links may be bidirectional. An additional issue that they might consider, however, is that the various constructs that they assessed – sleep, physical activity, depression, anxiety – are all arguably components, or symptoms, of the same overarching problem (serious distress), rather than any of them being “levers” that if altered, would mitigate serious distress. Thus it is not clear why sleep and physical activity are conceptualized as potential drivers of overall well-being, as seen in their recommendation that, “Government funded mental health programs to implement evidence-based sleep interventions for children and their parents, along with targeted messaging around physical activity should be considered to promote mental health within the family context during lockdown restriction.”
The aforementioned recommendations are by no means unreasonable, but the question is, why would preventive interventions not directly target mental health of parents, which in turn could help improve (a) their own sleep patterns and physical activity, and also (b) their functioning as parents, thus, would benefit their children? The value of taking this “upstream” approach to prevention is now explicitly recognized in accumulated research from leading researchers studying diverse childhood adversities, as summarized in a 2017 Special Section of the journal, Child Development, on resilience. It is also clearly stated in the 2019 National Academies Science, Engineering, and Medicine consensus study report on Vibrant and Healthy Kids. In both cases, there are these central messages: (a) if we are to maximize the well-being of children at risk, the first, most important task is to ensure the well-being of the primary caregiver(s), and (2) any interventions recommended should be practical and feasible for use at large scale in the real world, with prior evidence that central processes targeted have robust effect sizes in improving the outcomes of concern.
In sum, I would encourage the authors to give a little more thought to their central conclusions and recommendations. The authors call for “… more structured behavioral sleep strategies to improve sleep, (e.g.,) …to provide more consistency in implementing sleep routines and managing oppositional behavior at bedtime. Progressive muscle relaxation and cognitive behavioral strategies can also assist children to manage anxiety that may be interfering with sleep onset.” As the pandemic continues, parents across the world are under enormous strain given concerns about health and employment, in addition to disruptions in childcare and school openings. Thus, it would be helpful if the authors considered ways in which parents themselves can be directly supported as they juggle multiple responsibilities through COVID, and realistically appraise what they can expect to change from large-scale, government-funded interventions that ultimately, are intended to improve mental health outcomes.