Beyond the Pandemic Prism: Influence of COVID-19 Priming on Assessments of Child Mental Health

Beyond the Pandemic Prism: Influence of COVID-19 Priming on Assessments of Child Mental Health | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Beyond the Pandemic Prism: Influence of COVID-19 Priming on Assessments of Child Mental Health Hekmat Alrouh, Hannah Dorsman, Michiel Luijten, Hedy van Oers, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8523481/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 11 You are reading this latest preprint version Abstract The influence of survey framing and priming on reported outcomes is a critical yet underexplored issue in mental health research, particularly during the COVID-19 pandemic. This study compared routinely assessed reports of child wellbeing and behavioural problems with reports framed around the pandemic using identical instruments. We analysed data from two large Dutch cohorts—the general-population Netherlands Twin Register (N = 6,593) and the clinical DREAMS cohort (N = 4,180)—collected between March 2020 and March 2023. Linear mixed model analyses revealed when surveys explicitly referenced COVID-19, parents reported significantly lower wellbeing (mean difference: −0.60) and higher internalizing (mean difference: +0.41) and externalizing problems (+0.25), compared to regular surveys. These framing effects were larger than differences between early- and post-pandemic periods and were strongest for internalizing symptoms. The findings suggest that crisis-oriented survey framing can prime respondents to report more negative outcomes, even with neutral item content. This has important implications for the design and interpretation of mental health assessments during public health emergencies. Accurate monitoring of child mental health trends requires attention to methodological biases such as framing effects, especially when comparing data across contexts or over time. Child mental health Survey framing COVID-19 pandemic Priming effects Parental reports Measurement bias Figures Figure 1 Figure 2 Introduction The assessment of mental health is a critical component of developmental psychology and epidemiology. Research methods frequently rely on self or proxy reported measures obtained through surveys. Cognitive psychology shows that the order and framing of survey questions can substantially influence how respondents interpret and answer questions, a phenomenon known as priming ( 1 ). For instance, the contextual placement of political questions can alter perceptions of wellbeing, more than the effect of a financial crisis ( 2 ). Similar effects have been observed in other contexts, such as menstrual attitudes, physical capability assessments, social media use and self-rated health ( 3 – 6 ). Despite extensive documentation of priming and survey framing effects in various psychological research domains, the literature on this topic within child mental health studies is deficient. Our previous research on child and adolescent mental health during and after the COVID-19 pandemic utilized baseline data from a twin cohort and subsequent COVID-19 specific surveys to assess changes in mental health outcomes ( 7 – 9 ). In addition, data were collected through regular longitudinal surveys in the twin cohort and through standard intake questionnaires in a clinical cohort. By comparing data from concurrent regular and COVID-19 specific surveys, we aim to examine whether mental health symptoms are reported differently when assessed through identical instruments, but one framed within the context of a COVID-19 study and the other as a regular health survey. Given the negative associations with the pandemic, we hypothesize that mental health assessments conducted under the COVID-19 framing yield more negative results than those conducted under a neutral survey framing. Taking such effects into account helps obtain a more accurate picture of the levels of mental health problems and their course throughout the pandemic. Materials and methods Sample: The general population sample was drawn from the Netherlands Twin Register (NTR)(10), which began in 1986, recruiting parents of newborn twins and multiples. After obtaining informed consent, the family is registered with the NTR, and the parents receive regular periodical surveys of their children on a wide range of topics including mental and physical health, developmental milestones, as well as psychological and behavioural traits. The NTR has registered about 52% of all Dutch twin-pairs born between 1987 and 2017 (10). The clinical sample was drawn from the DREAMS (Dutch Research in Child and Adolescent Mental Health) population, a collaboration between four academic child and adolescent psychiatry centres in the Netherlands. As part of the regular intake procedure, parents are asked to fill out questionnaires about the child’s behaviour and mental health. For the regular measurements, data from one centre (Karakter) were available. For the COVID-19 specific survey, DREAMS invited children receiving psychiatric care and their parents via e-mail through their respective psychiatric centres. During the COVID-19 pandemic, both cohorts conducted multiple survey waves from March 2020 to March 2023 that focused on the COVID-19 pandemic and its effects on child behaviour and wellbeing (8). In both cohorts, the COVID-19 specific surveys included an introduction text about the COVID-19 pandemic, as well as questions related to parental employment changes, infections, quarantines, and familial deaths due to COVID-19. These questions preceded the instruments for child mental health and wellbeing. For the present study, we included all NTR and DREAMS participants who filled out a regular or COVID-19 survey in the period between March 2020 and March 2023. Supplemental Figure S1 shows a timeline of the data collection for both cohorts. Measures Wellbeing: Parental reports assessed wellbeing using a Dutch version of Cantril's Self-Anchoring Striving Scale (11). This instrument asks respondents to rate their child's life on a zero to ten Likert scale, from "the worst life" to "the best life." This instrument was available in the NTR cohort only. Internalizing and externalizing problems: The Brief Problem Monitor of the Achenbach System of Empirical Based Assessment (ASEBA-BPM) (12) was employed. The BPM is a shortened version of the Child Behavior Checklist (CBCL/6-18 years) (13). It assesses behavioural and emotional problems in children as reported by their parents. Items are rated on a three-point Likert-scale, where parents rate if a statement applies to their child (0 = ‘not true’, 1 = ‘somewhat true’, 2 = ‘very true’). If more than 20% of items were missing, we excluded the participant from the BPM analysis, otherwise we coded missing items on the BPM as zero. The BPM yields an internalizing score calculated from six items. The externalizing score usually is calculated from seven items, but because one item pertains to behaviour at school and data were also collected during pandemic related school closure, this item was excluded from the survey. The six remaining items were weighted so that the sum score has the same range as the normal scoring to allow comparison to other studies. Periods: The lockdown measures in the Netherlands lasted two years, from March 2020 to February 2022. We divided this time into two periods, early-pandemic (March 2020 – February 2021) and late-pandemic (March 2021 – February 2022). Data collection continued until March 2023, one year after lifting all lockdown measures. We designated this period as post-pandemic (March 2022 – March 2023). Statistical Analysis Linear mixed model (LMM) analyses were performed using the nlme package (version 3.1.164) in R (version 4.3.3). The model was fit using maximum likelihood estimation. The following equation was used to describe the model: Y = (β1 + b1 i ) + β2 * survey + β2 * period + β4 * sex + β5 * age + β6 * rater + β7 * survey * period +e i Where Y is the outcome of interest (internalizing/externalizing/wellbeing), survey is the survey type (regular/COVID-19), period is early/late/post-pandemic, rater is mother or father (only for NTR, which has ratings from both parents), e i is the error term, β1 is the population average intercept, β2-β7 are the fixed effects (population averages), and b1 i is the random intercept for individuals (nested within families in the NTR sample to account for clustering within twin pairs). In the main analysis, we included all measurements obtained between March 2020 and March 2023. To ensure that observed differences are not due to differences in the populations that responded to the regular surveys compared to the COVID-19 specific surveys, we conducted a sensitivity analysis that only included families that filled out both surveys. Results The NTR cohort consisted of 6,593 children with a mean age of 11.1 years (SD = 2.0). For this cohort more COVID-19 surveys than regular surveys were available as the former was sent to all children aged 8–18 years in the registry, while the regular surveys were sent only when a child reached a milestone age of 7, 10, or 12 that year. The DREAMS cohort consisted of 4,180 children with a mean age of 11.8 (SD = 3.0) years. For this cohort, more regular than COVID-19 surveys were available as the former is part of the regular intake procedure for all children receiving psychiatric care, while the COVID-19 survey was on a volunteer basis. Table 1 shows the sample characteristics for the two cohorts per period and survey type. In the NTR cohort, survey type was associated with differences in parental ratings of all three outcomes. Internalizing and externalizing scores were higher in COVID-19 surveys by 0.41 points (95% CI: 0.31 to 0.50, P < 0.0001) and 0.25 points (95% CI: 0.15 to 0.35, P < 0.0001) respectively compared to regular surveys, and wellbeing scores were lower by 0.60 points (95% CI: -0.65 to -0.54, P < 0.0001; see Table 2 ). Comparatively, the differences between early and post pandemic scores were 0.22 for internalizing, 0.17 for externalizing, and − 0.04 for wellbeing. Furthermore, an interaction between survey type and period was observed for externalizing (interaction estimate: -0.22, 95% CI: -0.38 to -0.07, P = 0.0056) and wellbeing scores (interaction estimate: 0.36, 95% CI: 0.28 to 0.45, P < 0.0001), indicating that the differences between survey types decreased over time. In other words, the differences between the two surveys became less pronounced in late and post pandemic compared to early pandemic periods. In the DREAMS cohort, internalizing scores were higher by 0.50 points (95% CI: 0.19 to 0.82, P = 0.002) in COVID-19 surveys compared to regular surveys. Comparatively, the difference between early and post-pandemic internalizing scores was 0.07. No difference related to survey type was observed for externalizing scores (mean difference: -0.08, 95% CI: -0.38 to 0.22, = 0.606), and there was no notable interaction between survey type and period. Figure 1 illustrates the results for internalizing and externalizing scores through graphs of the estimated marginal means by period for each cohort and outcome, Fig. 2 illustrates the results for the wellbeing score (available only for the NTR cohort). The sensitivity analysis yielded comparable results in terms of significance and effect size of survey type. Results of the sensitivity analysis can be found in Table S1 and Figure S2-3 in the supplementary material. This figure presents estimated marginal means for internalizing (panel A) and externalizing (panel B) problems reported by parents in the Netherlands Twin Register (NTR) and Dutch Research in Child and Adolescent Mental Health (DREAMS) cohorts. Scores from surveys framed around COVID-19 (COVID surveys) are compared with those from regular surveys conducted during three distinct pandemic phases: early-pandemic (March 2020–February 2021), late-pandemic (March 2021–February 2022), and post-pandemic (March 2022–March 2023). Error bars indicate 95% confidence intervals. Alt text: Two-panel line graphs showing parent-reported internalizing (Panel A) and externalizing (Panel B) problem scores across three pandemic periods (early, late, post-pandemic). Each panel compares regular and COVID-19-specific surveys separately for the Netherlands Twin Register (NTR) and the clinical DREAMS cohort. Scores were higher (indicating more problems) in COVID-19 surveys, particularly during the early-pandemic period, and decreased gradually in subsequent periods. Error bars show 95% confidence intervals. The figure shows estimated marginal means for child wellbeing scores reported by parents from the Netherlands Twin Register (NTR) cohort, comparing COVID-19-specific surveys with regular surveys. Data are grouped by three pandemic periods: early-pandemic (March 2020–February 2021), late-pandemic (March 2021–February 2022), and post-pandemic (March 2022–March 2023). Wellbeing was measured using Cantril’s Self-Anchoring Striving Scale. Error bars indicate 95% confidence intervals. Alt Text: Line graph displaying mean child wellbeing scores reported by parents in the Netherlands Twin Register (NTR), comparing regular surveys with COVID-19-specific surveys across three pandemic periods (early, late, post-pandemic). Scores are consistently lower (indicating worse wellbeing) in COVID-19 surveys, particularly in the early-pandemic period, with differences reducing slightly in later periods. Error bars represent 95% confidence intervals. Discussion Our study demonstrates clear survey framing effects on parent-reported wellbeing and internalizing and externalizing problems of children and adolescents during the COVID-19 pandemic. These findings are consistent with prior research on priming effects, where the context and framing of questions influence respondents' perceptions and answers ( 1 – 4 ). The pandemic-related priming, which included preliminary questions about parental employment changes, infections, quarantines, and familial deaths, likely heightened parents' sensitivity to their children's distress, resulting in lower wellbeing and more severe internalizing and externalizing problems. The effects of survey type were larger than the differences between any two periods in this data. This finding is particularly relevant considering the increased mental health problems that have been widely documented during the pandemic ( 8 , 9 , 14 , 15 ). Based on our results, the interpretations of previous studies on the magnitude of effects of COVID-19 pandemic on mental health should be reconsidered. While the findings of this study focused on the pandemic as an example of priming, it is likely that similar effects would also be observed in the context of other crises or extreme events. Our results revealed that the framing effect diminished over time for externalizing and wellbeing scores but persisted for internalizing scores. This suggests that the framing effect can vary with respect to time for different reported outcomes. The difference in effects of survey framing on reported internalizing and externalizing problems can be better understood when examining the component questions for each scale. Items on the internalizing scale primarily ask the parents to rate their child’s feelings (i.e. feels worthless, fearful, guilty, self-conscious, unhappy, worries), which are more open to interpretation. In contrast, items on the externalizing scale involve more concrete observations of a child’s actions (i.e. argues, destroys things, disobedient, stubborn, temper tantrums, and threatens). This insight suggests that survey questions focusing on observable behaviours might be less susceptible to priming effects, providing a more robust measure of child behaviour. Furthermore, the survey framing effect was observed for both negatively oriented questions and neutrally phrased items, such as the Cantril ladder. This indicates that even neutral questions can be influenced by the preceding content, highlighting the pervasive nature of framing effects in survey research. Our findings underscore the need for careful consideration in survey design, particularly in contexts likely to evoke strong emotional responses or stress, such as a global pandemic. Researchers should aim to minimize framing effects by using neutral introduction and balanced contexts that do not emphasize one aspect over others. Additionally, the order of questions should be designed to prioritize outcome-related questions before those concerning stressors or emotionally charged topics. The study also emphasizes the importance of prospective longitudinal data collection in obtaining accurate assessment of study outcomes. “Reactive” studies, which are conducted in response to emerging events, may result in biased responses due to priming or framing effects. To fully realize the benefits of longitudinal data, it is crucial to maintain consistency in questionnaire content and to place any new items that could cause priming effects at the end of the survey. While our study provides compelling evidence of the influence of survey framing on mental health, there are limitations that need to be addressed. Since our study relied on parental reports, incorporating children's self-reports could provide a more comprehensive view of the psychological impacts of the pandemic, and provide insight into whether framing effects extend to self-rated outcomes. Additionally, this observational study did not allow for random assignment of survey types. However, our sensitivity analysis, which included families that filled out both types of surveys, supports the robustness of our findings. The fluctuating lockdown measures within the defined periods might have influenced responses in ways we could not entirely account for, despite our efforts to control for time. In conclusion, our study highlights the critical influence of survey framing on reported outcomes in child and adolescent mental health research. Understanding and mitigating these biases are essential for advancing our knowledge and effectively addressing the mental health needs of youth, particularly in crisis situations like the COVID-19 pandemic. Future surveys should be designed with these considerations in mind to ensure accurate and reliable data collection, ultimately contributing to the development of effective mental health interventions. Declarations Competing interests: Authors declare that they have no competing interests. Data and materials availability The data necessary to reproduce the analyses presented here are not publicly accessible, but are available from the corresponding author upon reasonable request. Funding: This research was funded by ZonMw project number 50-56300-98-973. Data collection in the NTR was supported by: NWO large investment (480-15-001/674; Netherlands Twin Registry Repository: researching the interplay between genome and environment). Author Contribution Conceptualization: HAMethodology: HA, JZInvestigation: HA, HD, ML, HO, JT, RG, HK, MB, JZFunding acquisition: AP, MBProject administration: AP, TP, MBSupervision: TP, MBWriting – original draft: HA, HDWriting – review & editing: HA, ML, HO, JT, EB, RG, HK, AP,WS, TP, MB, JZ Acknowledgement We thank all participating families. We also thank the COVID-19 Wellbeing and Mental Health Consortium for their valuable contribution to this study. Data Availability The data necessary to reproduce the analyses presented here are not publicly accessible, but are available from the corresponding author upon reasonable request. References Schwarz N (1999) Self-reports: How the questions shape the answers. Am Psychol 54:93–105 Deaton A (2012) The financial crisis and the well-being of Americans. Oxf Econ Pap 64:1–26 Aubeeluck A, Maguire M (2002) The Menstrual Joy Questionnaire Items Alone Can Positively Prime Reporting of Menstrual Attitudes and Symptoms. Psychol Women Q 26:160–162 Claessen FMAP et al (2016) Influence of Priming on Patient-Reported Outcome Measures: A Randomized Controlled Trial. Psychosomatics 57:47–56 Mieczkowski H, Lee AY, Hancock JT (2020) Priming Effects of Social Media Use Scales on Well-Being Outcomes: The Influence of Intensity and Addiction Scales on Self-Reported Depression. Social Media + Soc 6:2056305120961784 Garbarski D, Schaeffer NC, Dykema J (2015) The effects of response option order and question order on self-rated health. Qual Life Res 24:1443–1453 Fischer K et al (2022) Internalizing problems before and during the COVID-19 pandemic in independent samples of Dutch children and adolescents with and without pre-existing mental health problems. Eur Child Adolesc Psychiatry. 10.1007/s00787-022-01991-y van Oers HA et al (2023) Changes in child and adolescent mental health across the COVID-19 pandemic (2018–2023): Insights from general population and clinical samples in the Netherlands. JCPP Advances e12213 10.1002/jcv2.12213 Zijlmans J et al (2023) The effects of COVID-19 on child mental health: Biannual assessments up to April 2022 in a clinical and two general population samples. JCPP Adv 3:e12150 Levante A et al (2023) Internalizing and externalizing symptoms in children during the COVID-19 pandemic: a systematic mixed studies review. Front Psychol 14:1182309 Ng CSM, Ng SSL (2022) Impact of the COVID-19 pandemic on children’s mental health: A systematic review. Front Psychiatry 13 Ligthart L et al (2019) The Netherlands Twin Register: Longitudinal Research Based on Twin and Twin-Family Designs. Twin Res Hum Genet 22:623–636 Cantril H (1965) The pattern of human concerns. Rutgers University Press Achenbach T, McConaughy S, Ivanova M, Rescorla L (2017) Manual for the ASEBA Brief problem monitor for ages 6–18 (BPM/6–18). University of Vermont Research Center for Children, Youth, and Families, Burlington Achenbach TM (2001) Manual for ASEBA school-age forms & profiles. University of Vermont, Research Center for Children, Youth & Families Additional Declarations No competing interests reported. Supplementary Files Supplementarymaterial.docx Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 03 May, 2026 Reviews received at journal 23 Mar, 2026 Reviews received at journal 13 Mar, 2026 Reviews received at journal 07 Mar, 2026 Reviewers agreed at journal 18 Feb, 2026 Reviewers agreed at journal 03 Feb, 2026 Reviewers agreed at journal 27 Jan, 2026 Reviewers invited by journal 27 Jan, 2026 Editor assigned by journal 07 Jan, 2026 Submission checks completed at journal 07 Jan, 2026 First submitted to journal 05 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8523481","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":581316442,"identity":"b6dfc35d-da8b-4060-aed1-841b33815a72","order_by":0,"name":"Hekmat Alrouh","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwklEQVRIiWNgGAWjYDACdiBmbLABkjxIIngBM1hLGpIWZuK0HCZBC38z78PHvDvOy8n3nz3A8LHtHoM5IS0Sh9mNjXnP3DY2uJGXwDizrZjBspmQww6zsUnztt1O3CDBY8DM25bAYHCYgA55iJZz9fP7zxgw/yVGiwFEy4EEhgM5BsyMxGgxPMzGbDi3LdlwA9AvB3vOJfAQ1CJ3vI3xwds2O3lgiB188KMsQc7geAMBPcjgAAMidkbBKBgFo2AUUAIA0YU7DuBaPscAAAAASUVORK5CYII=","orcid":"","institution":"Vrije Universiteit Amsterdam","correspondingAuthor":true,"prefix":"","firstName":"Hekmat","middleName":"","lastName":"Alrouh","suffix":""},{"id":581316443,"identity":"12396cc3-7ad9-47c9-81c5-f2aae0170601","order_by":1,"name":"Hannah Dorsman","email":"","orcid":"","institution":"Amsterdam University Medical Centers","correspondingAuthor":false,"prefix":"","firstName":"Hannah","middleName":"","lastName":"Dorsman","suffix":""},{"id":581316444,"identity":"ef208070-849c-4130-84cd-eb6153ea220c","order_by":2,"name":"Michiel Luijten","email":"","orcid":"","institution":"Emma Kinderziekenhuis","correspondingAuthor":false,"prefix":"","firstName":"Michiel","middleName":"","lastName":"Luijten","suffix":""},{"id":581316445,"identity":"a6ebb297-7b55-4593-ae5b-89183de4f3ac","order_by":3,"name":"Hedy van Oers","email":"","orcid":"","institution":"Emma Kinderziekenhuis","correspondingAuthor":false,"prefix":"","firstName":"Hedy","middleName":"van","lastName":"Oers","suffix":""},{"id":581316446,"identity":"c19760da-0a7c-4280-b57a-26a03831f2d5","order_by":4,"name":"Jacintha M. Tieskens","email":"","orcid":"","institution":"Leiden University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Jacintha","middleName":"M.","lastName":"Tieskens","suffix":""},{"id":581316447,"identity":"0dd79d89-f856-4934-a71d-45ba00334d44","order_by":5,"name":"Emma Broek","email":"","orcid":"","institution":"Leiden University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Emma","middleName":"","lastName":"Broek","suffix":""},{"id":581316448,"identity":"b495c165-19c2-4a77-a5b3-0d4d0d1e0233","order_by":6,"name":"Rowdy de Groot","email":"","orcid":"","institution":"Amsterdam Publice Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Rowdy","middleName":"","lastName":"de Groot","suffix":""},{"id":581316451,"identity":"6e8c784c-348c-4806-8016-1a91e25104dd","order_by":7,"name":"Helen Klip","email":"","orcid":"","institution":"Karakter Child and Adolescent Psychiatry University Centre","correspondingAuthor":false,"prefix":"","firstName":"Helen","middleName":"","lastName":"Klip","suffix":""},{"id":581316453,"identity":"f8ffe9e7-9618-43e1-a143-c7e98b91f936","order_by":8,"name":"Arne Popma","email":"","orcid":"","institution":"Amsterdam Publice Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Arne","middleName":"","lastName":"Popma","suffix":""},{"id":581316455,"identity":"086d6481-1f20-4154-ace5-722eee675795","order_by":9,"name":"Wouter Staal","email":"","orcid":"","institution":"Karakter Child and Adolescent Psychiatry University Centre","correspondingAuthor":false,"prefix":"","firstName":"Wouter","middleName":"","lastName":"Staal","suffix":""},{"id":581316456,"identity":"a47e52d9-3161-4a4c-908e-e7f8ba23710c","order_by":10,"name":"Tinca J.C. Polderman","email":"","orcid":"","institution":"Amsterdam University Medical Centers","correspondingAuthor":false,"prefix":"","firstName":"Tinca","middleName":"J.C.","lastName":"Polderman","suffix":""},{"id":581316457,"identity":"5cd9ef67-ceb1-4f8c-b138-e8b50401d8a7","order_by":11,"name":"Meike Bartels","email":"","orcid":"","institution":"Vrije Universiteit Amsterdam","correspondingAuthor":false,"prefix":"","firstName":"Meike","middleName":"","lastName":"Bartels","suffix":""},{"id":581316458,"identity":"bb6aa4db-af5c-4a18-a72f-6f5521ce6504","order_by":12,"name":"Josjan Zijlmans","email":"","orcid":"","institution":"Amsterdam Publice Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Josjan","middleName":"","lastName":"Zijlmans","suffix":""}],"badges":[],"createdAt":"2026-01-05 16:38:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8523481/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8523481/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101751866,"identity":"1b481830-f468-43b0-b085-a616d5b5d269","added_by":"auto","created_at":"2026-02-03 10:24:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":70948,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMean parent-reported internalizing and externalizing problem scores in regular and COVID-19-specific surveys across pandemic periods\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8523481/v1/a559f0c2eb6ef92f8aa709e2.png"},{"id":101459791,"identity":"6ba0bb77-8b77-4b73-97aa-527d27ae46b2","added_by":"auto","created_at":"2026-01-30 01:32:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":32799,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMean parent-reported child wellbeing scores by survey type and pandemic period\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8523481/v1/52cdf1f609f216061d5c43f2.png"},{"id":101755225,"identity":"2d075b6a-1118-4c46-a5c3-6935bf2fdaf6","added_by":"auto","created_at":"2026-02-03 10:49:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":588042,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8523481/v1/da5852ed-9982-49a0-8073-b0974138cdbc.pdf"},{"id":101459793,"identity":"075d56bb-3109-4981-a6e5-c20ed77f776b","added_by":"auto","created_at":"2026-01-30 01:32:47","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":593863,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-8523481/v1/66042f2ec931d9e46cc765f1.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Beyond the Pandemic Prism: Influence of COVID-19 Priming on Assessments of Child Mental Health","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe assessment of mental health is a critical component of developmental psychology and epidemiology. Research methods frequently rely on self or proxy reported measures obtained through surveys. Cognitive psychology shows that the order and framing of survey questions can substantially influence how respondents interpret and answer questions, a phenomenon known as priming (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). For instance, the contextual placement of political questions can alter perceptions of wellbeing, more than the effect of a financial crisis (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Similar effects have been observed in other contexts, such as menstrual attitudes, physical capability assessments, social media use and self-rated health (\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Despite extensive documentation of priming and survey framing effects in various psychological research domains, the literature on this topic within child mental health studies is deficient.\u003c/p\u003e \u003cp\u003eOur previous research on child and adolescent mental health during and after the COVID-19 pandemic utilized baseline data from a twin cohort and subsequent COVID-19 specific surveys to assess changes in mental health outcomes (\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In addition, data were collected through regular longitudinal surveys in the twin cohort and through standard intake questionnaires in a clinical cohort. By comparing data from concurrent regular and COVID-19 specific surveys, we aim to examine whether mental health symptoms are reported differently when assessed through identical instruments, but one framed within the context of a COVID-19 study and the other as a regular health survey. Given the negative associations with the pandemic, we hypothesize that mental health assessments conducted under the COVID-19 framing yield more negative results than those conducted under a neutral survey framing. Taking such effects into account helps obtain a more accurate picture of the levels of mental health problems and their course throughout the pandemic.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eSample:\u003c/p\u003e\n\u003cp\u003eThe general population sample was drawn from the Netherlands Twin Register (NTR)(10), which began in 1986, recruiting parents of newborn twins and multiples. After obtaining informed consent, the family is registered with the NTR, and the parents receive regular periodical surveys of their children on a wide range of topics including mental and physical health, developmental milestones, as well as psychological and behavioural traits. The NTR has registered about 52% of all Dutch twin-pairs born between 1987 and 2017 (10).\u003c/p\u003e\n\u003cp\u003eThe clinical sample was drawn from the DREAMS (Dutch Research in Child and Adolescent Mental Health) population, a collaboration between four academic child and adolescent psychiatry centres in the Netherlands. As part of the regular intake procedure, parents are asked to fill out questionnaires about the child\u0026rsquo;s behaviour and mental health. For the regular measurements, data from one centre (Karakter) were available. For the COVID-19 specific survey, DREAMS invited children receiving psychiatric care and their parents via e-mail through their respective psychiatric centres.\u003c/p\u003e\n\u003cp\u003eDuring the COVID-19 pandemic, both cohorts conducted multiple survey waves from March 2020 to March 2023 that focused on the COVID-19 pandemic and its effects on child behaviour and wellbeing \u0026nbsp;(8). In both cohorts, the COVID-19 specific surveys included an introduction text about the COVID-19 pandemic, as well as questions related to parental employment changes, infections, quarantines, and familial deaths due to COVID-19. These questions preceded the instruments for child mental health and wellbeing.\u003c/p\u003e\n\u003cp\u003eFor the present study, we included all NTR and DREAMS participants who filled out a regular or COVID-19 survey in the period between March 2020 and March 2023. Supplemental Figure S1 shows a timeline of the data collection for both cohorts.\u003c/p\u003e\n\u003cp\u003eMeasures\u003c/p\u003e\n\u003cp\u003eWellbeing: Parental reports assessed wellbeing using a Dutch version of Cantril\u0026apos;s Self-Anchoring Striving Scale\u0026nbsp;(11). This instrument asks respondents to rate their child\u0026apos;s life on a zero to ten Likert scale, from \u0026quot;the worst life\u0026quot; to \u0026quot;the best life.\u0026quot; This instrument was available in the NTR cohort only.\u003c/p\u003e\n\u003cp\u003eInternalizing and externalizing problems: The Brief Problem Monitor of the Achenbach System of Empirical Based Assessment (ASEBA-BPM)\u0026nbsp;(12)\u0026nbsp;was employed. The BPM is a shortened version of the Child Behavior Checklist (CBCL/6-18 years)\u0026nbsp;(13). It assesses behavioural and emotional problems in children as reported by their parents. Items are rated on a three-point Likert-scale, where parents rate if a statement applies to their child (0 = \u0026lsquo;not true\u0026rsquo;, 1 = \u0026lsquo;somewhat true\u0026rsquo;, 2 = \u0026lsquo;very true\u0026rsquo;). If more than 20% of items were missing, we excluded the participant from the BPM analysis, otherwise we coded missing items on the BPM as zero. The BPM yields an internalizing score calculated from six items. The externalizing score usually is calculated from seven items, but because one item pertains to behaviour at school and data were also collected during pandemic related school closure, this item was excluded from the survey. The six remaining items were weighted so that the sum score has the same range as the normal scoring to allow comparison to other studies.\u003c/p\u003e\n\u003cp\u003ePeriods: The lockdown measures in the Netherlands lasted two years, from March 2020 to February 2022. We divided this time into two periods, early-pandemic (March 2020 \u0026ndash; February 2021) and late-pandemic (March 2021 \u0026ndash; February 2022). Data collection continued until March 2023, one year after lifting all lockdown measures. We designated this period as post-pandemic (March 2022 \u0026ndash; March 2023).\u003c/p\u003e\n\u003cp\u003eStatistical Analysis\u003c/p\u003e\n\u003cp\u003eLinear mixed model (LMM) analyses were performed using the nlme package (version 3.1.164) in R (version 4.3.3). The model was fit using maximum likelihood estimation. The following equation was used to describe the model:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Y = (\u0026beta;1 + b1\u003csub\u003ei\u003c/sub\u003e ) + \u0026beta;2 * survey + \u0026beta;2 * period + \u0026beta;4 * sex + \u0026beta;5 * age + \u0026beta;6 * rater + \u0026beta;7 * survey * period +e\u003csub\u003ei\u003c/sub\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhere Y is the outcome of interest (internalizing/externalizing/wellbeing), survey is the survey type (regular/COVID-19), period is early/late/post-pandemic, rater is mother or father (only for NTR, which has ratings from both parents), e\u003csub\u003ei\u003c/sub\u003e is the error term, \u0026beta;1 is the population average intercept, \u0026beta;2-\u0026beta;7 are the fixed effects (population averages), and b1\u003csub\u003ei\u003c/sub\u003e is the random intercept for individuals (nested within families in the NTR sample to account for clustering within twin pairs).\u003c/p\u003e\n\u003cp\u003eIn the main analysis, we included all measurements obtained between March 2020 and March 2023. To ensure that observed differences are not due to differences in the populations that responded to the regular surveys compared to the COVID-19 specific surveys, we conducted a sensitivity analysis that only included families that filled out both surveys.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe NTR cohort consisted of 6,593 children with a mean age of 11.1 years (SD\u0026thinsp;=\u0026thinsp;2.0). For this cohort more COVID-19 surveys than regular surveys were available as the former was sent to all children aged 8\u0026ndash;18 years in the registry, while the regular surveys were sent only when a child reached a milestone age of 7, 10, or 12 that year. The DREAMS cohort consisted of 4,180 children with a mean age of 11.8 (SD\u0026thinsp;=\u0026thinsp;3.0) years. For this cohort, more regular than COVID-19 surveys were available as the former is part of the regular intake procedure for all children receiving psychiatric care, while the COVID-19 survey was on a volunteer basis. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the sample characteristics for the two cohorts per period and survey type.\u003c/p\u003e \u003cp\u003eIn the NTR cohort, survey type was associated with differences in parental ratings of all three outcomes. Internalizing and externalizing scores were higher in COVID-19 surveys by 0.41 points (95% CI: 0.31 to 0.50, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) and 0.25 points (95% CI: 0.15 to 0.35, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) respectively compared to regular surveys, and wellbeing scores were lower by 0.60 points (95% CI: -0.65 to -0.54, P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001; see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Comparatively, the differences between early and post pandemic scores were 0.22 for internalizing, 0.17 for externalizing, and \u0026minus;\u0026thinsp;0.04 for wellbeing. Furthermore, an interaction between survey type and period was observed for externalizing (interaction estimate: -0.22, 95% CI: -0.38 to -0.07, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0056) and wellbeing scores (interaction estimate: 0.36, 95% CI: 0.28 to 0.45, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), indicating that the differences between survey types decreased over time. In other words, the differences between the two surveys became less pronounced in late and post pandemic compared to early pandemic periods.\u003c/p\u003e \u003cp\u003eIn the DREAMS cohort, internalizing scores were higher by 0.50 points (95% CI: 0.19 to 0.82, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002) in COVID-19 surveys compared to regular surveys. Comparatively, the difference between early and post-pandemic internalizing scores was 0.07. No difference related to survey type was observed for externalizing scores (mean difference: -0.08, 95% CI: -0.38 to 0.22, = 0.606), and there was no notable interaction between survey type and period. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the results for internalizing and externalizing scores through graphs of the estimated marginal means by period for each cohort and outcome, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e illustrates the results for the wellbeing score (available only for the NTR cohort). The sensitivity analysis yielded comparable results in terms of significance and effect size of survey type. Results of the sensitivity analysis can be found in Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e and Figure S2-3 in the supplementary material.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThis figure presents estimated marginal means for internalizing (panel A) and externalizing (panel B) problems reported by parents in the Netherlands Twin Register (NTR) and Dutch Research in Child and Adolescent Mental Health (DREAMS) cohorts. Scores from surveys framed around COVID-19 (COVID surveys) are compared with those from regular surveys conducted during three distinct pandemic phases: early-pandemic (March 2020\u0026ndash;February 2021), late-pandemic (March 2021\u0026ndash;February 2022), and post-pandemic (March 2022\u0026ndash;March 2023). Error bars indicate 95% confidence intervals.\u003c/p\u003e \u003cp\u003eAlt text: Two-panel line graphs showing parent-reported internalizing (Panel A) and externalizing (Panel B) problem scores across three pandemic periods (early, late, post-pandemic). Each panel compares regular and COVID-19-specific surveys separately for the Netherlands Twin Register (NTR) and the clinical DREAMS cohort. Scores were higher (indicating more problems) in COVID-19 surveys, particularly during the early-pandemic period, and decreased gradually in subsequent periods. Error bars show 95% confidence intervals.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe figure shows estimated marginal means for child wellbeing scores reported by parents from the Netherlands Twin Register (NTR) cohort, comparing COVID-19-specific surveys with regular surveys. Data are grouped by three pandemic periods: early-pandemic (March 2020\u0026ndash;February 2021), late-pandemic (March 2021\u0026ndash;February 2022), and post-pandemic (March 2022\u0026ndash;March 2023). Wellbeing was measured using Cantril\u0026rsquo;s Self-Anchoring Striving Scale. Error bars indicate 95% confidence intervals.\u003c/p\u003e \u003cp\u003eAlt Text: Line graph displaying mean child wellbeing scores reported by parents in the Netherlands Twin Register (NTR), comparing regular surveys with COVID-19-specific surveys across three pandemic periods (early, late, post-pandemic). Scores are consistently lower (indicating worse wellbeing) in COVID-19 surveys, particularly in the early-pandemic period, with differences reducing slightly in later periods. Error bars represent 95% confidence intervals.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study demonstrates clear survey framing effects on parent-reported wellbeing and internalizing and externalizing problems of children and adolescents during the COVID-19 pandemic. These findings are consistent with prior research on priming effects, where the context and framing of questions influence respondents' perceptions and answers (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The pandemic-related priming, which included preliminary questions about parental employment changes, infections, quarantines, and familial deaths, likely heightened parents' sensitivity to their children's distress, resulting in lower wellbeing and more severe internalizing and externalizing problems. The effects of survey type were larger than the differences between any two periods in this data. This finding is particularly relevant considering the increased mental health problems that have been widely documented during the pandemic (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Based on our results, the interpretations of previous studies on the magnitude of effects of COVID-19 pandemic on mental health should be reconsidered. While the findings of this study focused on the pandemic as an example of priming, it is likely that similar effects would also be observed in the context of other crises or extreme events.\u003c/p\u003e \u003cp\u003eOur results revealed that the framing effect diminished over time for externalizing and wellbeing scores but persisted for internalizing scores. This suggests that the framing effect can vary with respect to time for different reported outcomes. The difference in effects of survey framing on reported internalizing and externalizing problems can be better understood when examining the component questions for each scale. Items on the internalizing scale primarily ask the parents to rate their child\u0026rsquo;s feelings (i.e. feels worthless, fearful, guilty, self-conscious, unhappy, worries), which are more open to interpretation. In contrast, items on the externalizing scale involve more concrete observations of a child\u0026rsquo;s actions (i.e. argues, destroys things, disobedient, stubborn, temper tantrums, and threatens). This insight suggests that survey questions focusing on observable behaviours might be less susceptible to priming effects, providing a more robust measure of child behaviour.\u003c/p\u003e \u003cp\u003eFurthermore, the survey framing effect was observed for both negatively oriented questions and neutrally phrased items, such as the Cantril ladder. This indicates that even neutral questions can be influenced by the preceding content, highlighting the pervasive nature of framing effects in survey research.\u003c/p\u003e \u003cp\u003eOur findings underscore the need for careful consideration in survey design, particularly in contexts likely to evoke strong emotional responses or stress, such as a global pandemic. Researchers should aim to minimize framing effects by using neutral introduction and balanced contexts that do not emphasize one aspect over others. Additionally, the order of questions should be designed to prioritize outcome-related questions before those concerning stressors or emotionally charged topics.\u003c/p\u003e \u003cp\u003eThe study also emphasizes the importance of prospective longitudinal data collection in obtaining accurate assessment of study outcomes. \u0026ldquo;Reactive\u0026rdquo; studies, which are conducted in response to emerging events, may result in biased responses due to priming or framing effects. To fully realize the benefits of longitudinal data, it is crucial to maintain consistency in questionnaire content and to place any new items that could cause priming effects at the end of the survey.\u003c/p\u003e \u003cp\u003eWhile our study provides compelling evidence of the influence of survey framing on mental health, there are limitations that need to be addressed. Since our study relied on parental reports, incorporating children's self-reports could provide a more comprehensive view of the psychological impacts of the pandemic, and provide insight into whether framing effects extend to self-rated outcomes.\u003c/p\u003e \u003cp\u003eAdditionally, this observational study did not allow for random assignment of survey types. However, our sensitivity analysis, which included families that filled out both types of surveys, supports the robustness of our findings. The fluctuating lockdown measures within the defined periods might have influenced responses in ways we could not entirely account for, despite our efforts to control for time.\u003c/p\u003e \u003cp\u003eIn conclusion, our study highlights the critical influence of survey framing on reported outcomes in child and adolescent mental health research. Understanding and mitigating these biases are essential for advancing our knowledge and effectively addressing the mental health needs of youth, particularly in crisis situations like the COVID-19 pandemic. Future surveys should be designed with these considerations in mind to ensure accurate and reliable data collection, ultimately contributing to the development of effective mental health interventions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eCompeting interests:\u003c/h2\u003e\n\u003cp\u003eAuthors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData and materials availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data necessary to reproduce the analyses presented here are not publicly accessible, but are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003ch2\u003eFunding:\u003c/h2\u003e\n\u003cp\u003eThis research was funded by ZonMw project number 50-56300-98-973. Data collection in the NTR was supported by: NWO large investment (480-15-001/674; Netherlands Twin Registry Repository: researching the interplay between genome and environment).\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eConceptualization: HAMethodology: HA, JZInvestigation: HA, HD, ML, HO, JT, RG, HK, MB, JZFunding acquisition: AP, MBProject administration: AP, TP, MBSupervision: TP, MBWriting \u0026ndash; original draft: HA, HDWriting \u0026ndash; review \u0026amp; editing: HA, ML, HO, JT, EB, RG, HK, AP,WS, TP, MB, JZ\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eWe thank all participating families. We also thank the COVID-19 Wellbeing and Mental Health Consortium for their valuable contribution to this study.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe data necessary to reproduce the analyses presented here are not publicly accessible, but are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSchwarz N (1999) Self-reports: How the questions shape the answers. Am Psychol 54:93\u0026ndash;105\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeaton A (2012) The financial crisis and the well-being of Americans. Oxf Econ Pap 64:1\u0026ndash;26\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAubeeluck A, Maguire M (2002) The Menstrual Joy Questionnaire Items Alone Can Positively Prime Reporting of Menstrual Attitudes and Symptoms. Psychol Women Q 26:160\u0026ndash;162\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClaessen FMAP et al (2016) Influence of Priming on Patient-Reported Outcome Measures: A Randomized Controlled Trial. Psychosomatics 57:47\u0026ndash;56\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMieczkowski H, Lee AY, Hancock JT (2020) Priming Effects of Social Media Use Scales on Well-Being Outcomes: The Influence of Intensity and Addiction Scales on Self-Reported Depression. Social Media + Soc 6:2056305120961784\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarbarski D, Schaeffer NC, Dykema J (2015) The effects of response option order and question order on self-rated health. Qual Life Res 24:1443\u0026ndash;1453\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFischer K et al (2022) Internalizing problems before and during the COVID-19 pandemic in independent samples of Dutch children and adolescents with and without pre-existing mental health problems. Eur Child Adolesc Psychiatry. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00787-022-01991-y\u003c/span\u003e\u003cspan address=\"10.1007/s00787-022-01991-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Oers HA et al (2023) Changes in child and adolescent mental health across the COVID-19 pandemic (2018\u0026ndash;2023): Insights from general population and clinical samples in the Netherlands. JCPP Advances e12213 \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/jcv2.12213\u003c/span\u003e\u003cspan address=\"10.1002/jcv2.12213\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZijlmans J et al (2023) The effects of COVID-19 on child mental health: Biannual assessments up to April 2022 in a clinical and two general population samples. JCPP Adv 3:e12150\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevante A et al (2023) Internalizing and externalizing symptoms in children during the COVID-19 pandemic: a systematic mixed studies review. Front Psychol 14:1182309\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNg CSM, Ng SSL (2022) Impact of the COVID-19 pandemic on children\u0026rsquo;s mental health: A systematic review. Front Psychiatry 13\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLigthart L et al (2019) The Netherlands Twin Register: Longitudinal Research Based on Twin and Twin-Family Designs. Twin Res Hum Genet 22:623\u0026ndash;636\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCantril H (1965) The pattern of human concerns. Rutgers University Press\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAchenbach T, McConaughy S, Ivanova M, Rescorla L (2017) Manual for the ASEBA Brief problem monitor for ages 6\u0026ndash;18 (BPM/6\u0026ndash;18). University of Vermont Research Center for Children, Youth, and Families, Burlington\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAchenbach TM (2001) Manual for ASEBA school-age forms \u0026amp; profiles. University of Vermont, Research Center for Children, Youth \u0026amp; Families\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-child-and-adolescent-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ecap","sideBox":"Learn more about [European Child \u0026 Adolescent Psychiatry](http://link.springer.com/journal/787)","snPcode":"787","submissionUrl":"https://submission.nature.com/new-submission/787/3","title":"European Child \u0026 Adolescent Psychiatry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Child mental health, Survey framing, COVID-19 pandemic, Priming effects, Parental reports, Measurement bias","lastPublishedDoi":"10.21203/rs.3.rs-8523481/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8523481/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe influence of survey framing and priming on reported outcomes is a critical yet underexplored issue in mental health research, particularly during the COVID-19 pandemic. This study compared routinely assessed reports of child wellbeing and behavioural problems with reports framed around the pandemic using identical instruments. We analysed data from two large Dutch cohorts—the general-population Netherlands Twin Register (N = 6,593) and the clinical DREAMS cohort (N = 4,180)—collected between March 2020 and March 2023. Linear mixed model analyses revealed when surveys explicitly referenced COVID-19, parents reported significantly lower wellbeing (mean difference: −0.60) and higher internalizing (mean difference: +0.41) and externalizing problems (+0.25), compared to regular surveys. These framing effects were larger than differences between early- and post-pandemic periods and were strongest for internalizing symptoms. The findings suggest that crisis-oriented survey framing can prime respondents to report more negative outcomes, even with neutral item content. This has important implications for the design and interpretation of mental health assessments during public health emergencies. Accurate monitoring of child mental health trends requires attention to methodological biases such as framing effects, especially when comparing data across contexts or over time.\u003c/p\u003e","manuscriptTitle":"Beyond the Pandemic Prism: Influence of COVID-19 Priming on Assessments of Child Mental Health","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-30 01:32:42","doi":"10.21203/rs.3.rs-8523481/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-03T09:20:19+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-23T13:24:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-13T16:52:07+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-07T17:15:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"131338622359502986231584981926951302779","date":"2026-02-18T16:21:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"137996108260683775541783294283145242026","date":"2026-02-03T16:27:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"267273835606156382712166828811844701826","date":"2026-01-27T17:17:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-27T12:29:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-07T14:37:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-07T14:37:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Child \u0026 Adolescent Psychiatry","date":"2026-01-05T16:20:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-child-and-adolescent-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ecap","sideBox":"Learn more about [European Child \u0026 Adolescent Psychiatry](http://link.springer.com/journal/787)","snPcode":"787","submissionUrl":"https://submission.nature.com/new-submission/787/3","title":"European Child \u0026 Adolescent Psychiatry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"809d2cff-557f-4397-b8b8-1467ebe62d1a","owner":[],"postedDate":"January 30th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-03T09:20:19+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-03T09:23:57+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-30 01:32:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8523481","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8523481","identity":"rs-8523481","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}