Impact of Covid 19 Amid Multilayered Crisis on Social and Emotional Behaviors of Preterm Children and Parental Practices: Cross-Sectional Study from Lebanon

Abstract

Background: Early childhood development is highly sensitive to the quality of nurturing care, with parental mental health and caregiving practices playing a crucial role. In Lebanon, the COVID-19 pandemic overlapped with severe national crises—economic collapse, political instability, and the 2020 Beirut port explosion—intensifying risks for young children and their families. Preterm infants, already at elevated developmental risk, remain an understudied group in terms of how these compounded adversities have affected their socio-emotional development and caregiving environments.

Objective: This study aimed to compare the social-emotional outcomes, parenting behaviors, and parental stress levels between families of preterm and term-born children within the context of the COVID-19 pandemic and the August Beirut blast.

Methods: This cross-sectional study conducted between 2022 and 2024 targeted 224 participants, including 114 parents of term children and 110 parents of preterm children (mean gestation 32.21 weeks) recruited from private and governmental hospitals. Validated instruments included the Ages and Stages Questionnaires: Social-Emotional (ASQ-SE-2) for social-emotional behavior, UNICEF MICS 6 for parenting activities, the Parenting Stress Index-Short Form (PSI-SF), and a Parent-Child Relationship (PCR) scale. Inferential statistical analyses used SPSS version 31.

Results: Preterm children exhibited significantly higher social-emotional developmental delay (23.6%) compared to term children (7.0%, p<0.001). Preterm children were also more likely to be affected physically or emotionally by the Beirut blast (12.7% vs. 3.5%). Interestingly, parents of preterm children engaged in more frequent developmental activities (64.5% vs. 39.5%, p<0.001), yet reported significantly lower quality in the parent-child relationship regarding closeness and affection: the PCR score for parents of preterm children was significantly lower (26.06/30 vs. 27.41/30, p-value 0.004). Furthermore, parents of preterm children reported significantly higher stress levels (79.62 vs. 69.93, p<0.001), with 32.7% scoring in the clinical referral range. Stepwise linear regression explained 40.9% of the variance in social-emotional outcomes, identifying preterm status (β =12.66, p =0.001), elevated parental stress (β =1.05, p<0.000), and the child’s acquisition of new skills (β =-5.588, p=0.009) as the primary predictors of behavioral scores.

Conclusion: Prematurity is associated with higher risk of social-emotional vulnerabilities, which are exacerbated by clinical levels of parental stress despite high levels of parental engagement. These findings highlight the critical need for multi-dimensional screening and family-centered interventions that address both child development and parental mental health in high-risk populations.