Introduction

Coronavirus Disease in 2019 (COVID-19) is a public health emergency which has led to over 1.7 million death cases and 76 million infection cases across the world by the end of December 2020 (Johns Hopkins University, 2020). The pandemic with a staggeringly high number of cases and death toll has become a traumatic event for people around the world (González-Sanguino et al., 2020). Assessed at two weeks after the outbreak of COVID-19 in China, 14.4% of 584 children suffered from post-traumatic stress symptoms (PTSS, Liang et al., 2020; Ramirez, Arriaga, Hernandez-Gonzalez, & De la Roca-Chiapas, 2020). Mental health issues in childhood can predict the development of later psychological disorders in adults (Nishida et al., 2016). Therefore, more research should be conducted on the relationship between fear of Covid-19 and PTSS in children.

Fear of COVID-19

Fear of COVID-19 is defined as how much fearful a child feels in the face of the COVID-19 pandemic. It includes fear of infection by the COVID-19 virus, and worries about health conditions, the safety of living environments as well as preventive measures, such as quarrantine and social distancing. Fear might also be the result of worries that daily life would be negatively influenced by the COVID-19 pandemic,. Moreover, fear of COVID-19 in children also reflects children’s fear that important people around them such as their friends or family members would be infected by the virus. Previous research has suggested that gender and age show significant moderating effect on fear of COVID-19. A study on fear of COVID-19 infection with 1,743 Brazilians found that women and younger participants had higher fear of COVID-19 (Andrade et al., 2022). A meta-analysis on gender and fear of COVID-19 suggested that females were more likely to show fear of COVID-19 than males (Metin et al., 2022). Also, females’ flourishing was more likely to be negatively affected by fear of COVID-19 than males (Metin et al., 2022).

Existing literature shows that fear has been associated with elevated stress responses. In a group of neck cancer patients, fear about recurrence of neck cancer was positively associated with post-traumatic stress symptoms (Moschopoulou et al., 2018). For both adult and child earthquake survivors, exacerbated fearful experience was a significant predictor of higher post-traumatic stress in response to the earthquake (Tang et al., 2017; Wang, Wu, & Lan, 2020). Likewise, higher fear of COVID-19 has been found to be related to more negative mental health outcomes in adults and adolescents (Fitzpatrick et al., 2020a, b; Seçer & Ulaş, 2020). However, the relationship of fear of COVID-19 to PTSS in children has not been well investigated. For example, a study found that caregiving is a moderator of the relationship in adults; the impact of fear of COVID-19 on PTSS was stronger for caregivers (Arteseros-Bañón & Pérez-Jover, 2021). Based on the importance of selective attention in the development of emotional disorders (Beck, 1976; Daleiden, Vasey, & Daleiden, 1997), a critical factor that may modulate the relationship is individual difference in tendencies to focus on positive and negative information. However, it is surprising that no studies have investigated if tendencies to focus on negative and positive information moderate the relationship of fear of COVID-19 to PTSS.

Cognitive Tendencies to Focus on Positive and Negative Information

Attention to positive and negative information is an important factor in the development and maintenance of emotional disorders (Beck, 1976). Using psychological inventories, a study found that attention to positive information and attention to negative information predicted the development of anxiety and depression symptoms one-year later in Chinese adolescents (Ho et al., 2018). Attention to negative information measured by the self-report scale was associated with negative affectivity and decreased optimism (Noguchi et al., 2006) The relationship between post-traumatic stress and selective attention has also been demonstrated in various studies (Lazarov et al., 2018). A systematic review of 11 articles using eye-tracking technology suggested that people with PTSS tended to sustainably focus on threatening information (Lazarov et al., 2018). A longitudinal study illustrated that strong attentional bias about negative information predicted more PTSS in young children (Briggs-Gowan et al., 2016). This evidence implies that cognitive tendency to attend to negative information is associated with PTSS during the COVID-19 pandemic.

As for cognitive tendency to focus on positive information, research by Joyal et al. (2019) suggested that people with PTSS might be more alert to positive information than healthy individuals. Another study on women with breast cancer found that attentional bias about positive information was not related to PTSS (Chan et al., 2011b). Therefore, evidence on the relationship of attention to positive information and PTSS is inconclusive. However, positive cognition has been previously reported as a factor that promotes mental health in children. Attention to positive information measured by self-report questionnaire was correlated to positive affectivity and optimism (Noguchi et al., 2006). Attention to positive information measured by a self-report scale was also a mediator of the relationship of hope to psychosocial wellbeing in adolescents (Yeung et al., 2015). A study on children with psychosocial deprivation found that attention towards positive stimuli measured by a behavioral task was associated with better coping mechanism, and fewer internalizing symptoms (Troller-Renfree et al., 2017). Thus, it is important to explore the association of cognitive tendency to focus on positive information with PTSS in the context of COVID-19 pandemic.

The Moderating Effect of Cognitive Tendencies to Focus on Positive and Negative Information

Children’s cognitive tendencies to focus on negative and positive information may be an important individual factor that moderates the association between fear of COVID-19 and PTSS. Fear is a common emotional response to the COVID-19 pandemic in children (Stavridou et al., 2020). Based on the information processing perspective, selective attention is at the early stage of information processing that allocates cognitive resources to different information in the environment; thus, selective attention has substantial influence over cognitive functions at later stage including interpretation, goal setting and response access (Daleiden et al., 1997). Children who tend to focus on negative information may have enhanced information processing of the frightening stimuli. Consequently, the later stage of information processing is largely affected by the focus on frightening stimuli, which leads to attentional biases. Attentional biases are important characteristics of PTSS in children (Mueller et al., 2020; Remmerswaal, Huijding, Bouwmeester, Brouwer, & Muris, 2014). Thus, at the same level of fear of COVID-19, children with strong tendency to focus on negative information may be more likely to show PTSS than those with weak tendency to focus on negative information.

On the other hand, children who have a stronger tendency to focus on positive information may process more positive information during the COVID pandemic, which contributes to more positive psychological outcomes (Yeung et al., 2015). Positive cognition may buffer the negative effect of fear on mental health as it serves as a protective factor against psychopathology (Macleod & Moore, 2000). However, there isn’t enough evidence on the relationship between a strong tendency to focus on positive information and PTSS. Therefore, it is unknown whether at the same level of fear of COVID-19, children with stronger tendency to focus on positive information may be less likely to develop PTSS.

The current study investigated the association between fear of COVID-19 and PTSS in children, and the moderating role of children’s cognitive tendencies to focus on positive and negative information in the association. Based on the above review, it was hypothesized that children who were exposed to greater fear of COVID-19 would report higher level of PTSS. Moreover, it was hypothesized that strong cognitive tendency to focus on negative information was associated with increased PTSS. It was also hypothesized that the relationship of fear of COVID-19 to PTSS was moderated by children’s cognitive tendencies to focus on negative information.

The data collection was conducted in a primary school between May and June 2020 in Shenzhen, China. By May the 1st 2020, there were 82,874 infection cases and 4633 death cases in China. Primary schools in Shenzhen had been closed from to January 19th to May 18th, 2020. Because of COVID-19 preventive measures, students were not allowed to conduct behavioral tasks in the laboratory. Thus, 122 students conducted the self-report measures of cognitive tendencies to focus on negative and positive information, PTSS and fear of COVID-19 in the classrooms as monitored by teachers.

Methods

Participants

One hundred and twenty two native Chinese children from the sixth grade of a primary school in Shenzhen of China were recruited in 2020. Approximately 127 children were approached and 5 children refused to participate in the study. Children in the primary school were from families of the middle class. The exclusion criterion was birthplace outside of China. 3 students’ questionnaires were excluded as a result of the birthplace outside of China. The final sample consisted of 59 (49.6%) girls and 60 (50.4%) boys. All participants were born in China and had been living in Shenzhen for at least 12 months during the data collection period. The average age is 11.91 (SD = 0.49 years, range = 11 years to 13 years). The age of the students from the same grade varies because primary schools in China don’t have a specific cut-off age for admission. Statistical power analysis showed that the sample size could give a power of 0.91 for a medium effect size (Cohen’s f2 = 0.15), an alpha value of 0.5, and a regression analysis of 4 predictors (gender, fear of COVID-19, attention to negative information and attention to positive information) (Faul et al., 2007).

Materials

Cognitive Tendencies to Focus on Positive and Negative Information

The Chinese version of Attention to Positive and Negative Information Scale (APNIS; Chan, Ho, Tedeschi, & Leung, 2011a) was used in the study. APNIS is a 40-item self-report scale that measures people’s tendency to attend to positive or negative information (e.g., “I pay attention to the positive things others will do”). The scale adopted a five-point Likert scale (1= “strongly disagree” and 4=“strongly agree”). The Chinese version of APNIS scale for Chinese adolescents can be divided into Attention to Negative Information scale (ANI scale; 19 items) and Attention to Positive Information scale (API scale; 11 items) (Lv et al., 2016). Scores on each item were summed up to obtain the ANI scores and API scores. The higher the score, the stronger the cognitive tendency to focus on positive or negative information. In the current study, the ANI subscale had a good internal consistency with Cronbach’s α = 0.877, and the API subscale had a good internal consistency with Cronbach’s α = 0.801.

Fear of COVID-19

The COVID-19 Fear Scale (CFS) was adapted from the 18-item SARS Fear Scale developed for healthcare workers during the SARS pandemic in 2003 (Ho et al., 2005). With three items deleted from the original scale, because these items are only relevant to healthcare workers, the rest of the 15 items measure how fearful a person feels in the face of COVID-19 pandemic. On a 4-point Likert scale, participants indicated how much the statement is true (0=“definitely false” and 3=“definitely true”). Scores were summed up from each item to obtain a CFS score. The higher the CFS scale scores, the higher the fear of COVID-19. The scale demonstrated very good internal consistency of Cronbach’s α = 0.868.

Post-traumatic Stress Symptoms

The Chinese version of PTSD Checklist for DSM-5 (PCL-5; Cheng et al., 2020) was used to measure post-traumatic stress symptoms in children. The scale has been commonly used in the COVID-19 pandemic (Salehi et al., 2021). The PCL-5 consists of 20 items that measure PTSS based on DSM-5 criteria. Participants rated items such as “Feeling jumpy or easily startled?” and “Having difficulty concentrating?” on a five-point Likert scale from not-at-all (0) to extremely (4). A total PCL-5 score was obtained by adding scores from each item. PCL-5 scores above 31 to 33 indicated possible PTSD diagnosis in the samples (Bovin et al., 2016). A cut-off point of 33 was recommended (Franklin et al., 2018; Krüger-Gottschalk et al., 2017). Hence, 33 was used as the cut-off point to categorize participants into high versus low PTSS groups. Previous studies have validated the use of the Chinese version of PCL-5 for Chinese children and adolescents aged from 8 to 18 years old; the scale showed good internal consistency in the previous studies involving children or adolescents (Li et al., 2019; Liu, Wang, & Qing, 2015). An excellent internal consistency with Cronbach’s α = 0.943 was found in the present study.

Procedure

Ethics Approval was obtained from the Human Subjects Ethics Sub-Committee of the City University of Hong Kong (2019-20-CIR6-B5). Parents’ informed consent forms were sent to parents several days before data collection. Children who submitted both the signed assent forms and the signed parents’ informed consent forms participated in the study. Students and parents were informed that they could withdraw from the study at any time without any negative consequence. During the study, students were instructed to complete the questionnaires in the classrooms as monitored by teachers and researchers. The questionnaires took approximately 40 min to complete. A researcher debriefed the children who reported that they experienced high stress at the end of the study. Also, mental health counselling services were recommended to these children if they needed it.

Results

Descriptive Statistics

Compared to boys, girls had significantly higher post-traumatic stress level, t (117) = -2.116, p < .05, and stronger attention to negative information, t (116) = -1.987, p < .05. Girls did not significantly differ in attention to positive information, t (115) = 0.495, p = .621, and fear of COVID-19, t (117) =-0.793, p = .429, from boys (refer to Table 1).The two-tailed Pearson’s correlation revealed that age was not significantly related to CFS, r=-.049, p = .593, ANI, r=-.132, p = .155, API, r=-.056, p = .545, and PCL-5 scores, r=-.108, p = .244. Using a cut-off point of 33 in PTSD checklist for DSM-5, approximately 15.1% of the sample was classified in the high PTSS group. Among the high PTSS group, 66.7% were girls, and 33.3% were boys. Chi-square analysis suggested that gender was not significantly associated with PTSS groups, χ2 (1) = 2.477, p = .116.

Table 1 Mean (Standard Deviation) of Psychological Variables by Gender (n = 119)
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The Associations Among fear of COVID-19, Cognitive Tendencies to Focus on Positive and Negative Information, and PTSS in Children

A series of independent t-tests were conducted to testify the difference in fear of COVID-19 as well as attention to negative and positive information between students in the high and low PTSS groups. The tests showed that children in the high PTSS group had significantly stronger fear of COVID-19, t (117)= -4.832, p < .001, and stronger attention to negative information, t (116)= -7.003, p < .001. However, the difference in attention to positive information was not significant, t (115) = 1.455, p = .148.

A partial Pearson’s correlation was subsequently conducted to assess the association among fear of COVID-19, attention to positive and negative information and PTSS, after controlling for gender (refer to Table 2). Fear of COVID-19 was significantly associated with PTSS, r = .573, p < .001. Fear of COVID-19 was also significantly associated with attention to negative information, r = .608, p < .001. Attention to negative information was significantly related to PTSS, r = .713, p < .001. However, attention to positive information was not significantly related to PTSS, r=-.124, p = .183.

Table 2 Partial correlation matrix among psychological variables, controlling for gender (n = 119)
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The Moderating role of Cognitive Tendencies to Focus on Positive and Negative Information

Then, PROCESS macro model 2 with a bootstrap of 5000 and confidence interval of 95% was conducted to examine the moderation effect of attention to negative and positive information (ANI and API) on the association between fear of COVID-19 (CFS) and post-traumatic stress symptom (PTSS) in children, after controlling for gender (Hayes, 2013). ANI and API scores were entered as the moderators, and gender was entered as the covariate (refer to Fig. 1). The interaction term of ANI scores and CFS scores was highly significant, b = 0.048, 95% CI [0.028, 0.067], t = 4.897, p < .001 The results showed that CFS scores were not significantly related to PTSS scores when ANI scores were low, b = -0.360, 95% CI [-0.866, 0.145], t = -1.413, p = .161; when ANI scores were high, there was a significant relationship of CFS scores to PTSS scores, b = 0.792, 95% CI [0.399, 1.185], t = 3.998, p < .001. However, the interaction term of API scores and CFS scores was not significant, b = -0.007, 95% CI [-0.021, 0.008], t = -0.874, p = .384. The moderation analysis showed that cognitive tendency to focus on negative information was a significant moderator of the relationship of fear of COVID-19 to PTSS, while the tendency to focus on positive information was not (Table 3).

Fig. 1
figure 1

Moderation model with unstandardized coefficients: including gender in the model, a1 = interaction effect of fear of COVID-19 and attention to negative information on post-traumatic stress symptoms, a2 = interaction effect of fear of COVID-19 and attention to positive information on post-traumatic stress symptoms, b1 = the effect of attention to negative information on post-traumatic stress symptoms, b2 = the effect of attention to positive information on post-traumatic stress symptoms, c = the effect of fear of COVID-19 on post-traumatic stress symptoms once the moderators and the interaction terms were included in the model. c’ = total effect of fear of COVID-19 on post-traumatic stress symptoms in children, without accounting for the moderators, d = the effect of gender on post-traumatic stress symptoms in children ** p < .001 *p < .005

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Table 3 Attention to positive and negative information as moderators of the relationship between fear of COVID-19 and PTSS, controlling for gender
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Discussion

The Association Among Fear of COVID-19, Cognitive Tendencies to Focus on Positive and Negative Information, and PTSS

The present study examined PTSS in children who were exposed to COVID-19 pandemic. Girls had stronger cognitive tendency to focus on negative information and higher level of PTSS than boys. This was consistent with the findings that the prevalence of PTSS was higher in girls than in boys (Farhood et al., 2018). The study found that 15.1% of children were at high risk of being diagnosed with post-traumatic stress disorder. The percentage of high PTSS (15.1%) was close to the percentage (14.4%) found in a previous study conducted in Mainland China with a larger sample size of children and adolescents (Liang et al., 2020).

Children categorized into the high PTSS group showed higher level of fear of COVID-19 and stronger cognitive tendency to focus on negative information than children who were in the low PTSS group. The subsequent partial correlation showed that higher fear of COVID-19, and stronger attention to negative information were significantly associated with higher PTSS in children exposed to COVID-19, after gender was controlled. The findings were consistent with results from previous studies, which suggested that experiencing strong fear of COVID-19 was a risk factor of PTSS (Moschopoulou et al., 2018; Tang et al., 2017; Wang et al., 2020). In addition, cognitive tendency to focus on negative information was a significant correlate of PTSS in children. This lent further empirical evidence to the cognitive theories of emotional disorders that highlight the role of negative cognition in the development of emotional disorders (Beck, 1976; Mogg & Bradley, 2016). Children who attend more to threats may engage in excessive thoughts related to negative consequences in daily life, which is related to more emotional problems (Mogg & Bradley, 2016).

Children in the high and low PTSS groups did not significantly differ in attention to positive information. Also, cognitive tendency to focus on positive information was not a significant correlate of PTSS in children. This was consistent with the finding that attention to positive information was unrelated to PTSS in Chinese women with breast cancer (Chan et al., 2011b). On the other hand, this finding was inconsistent with results that demonstrated the significant relationship of positive attentional bias measured by behavioral tasks to PTSS in other adult populations (Clausen et al., 2016; Joyal et al., 2019; Schäfer et al., 2016).

The Moderating Effect of Cognitive Tendencies to Focus on Positive and Negative Information

The study found that fear of COVID-19 was only significantly associated with PTSS for children who had strong tendency to attend to negative information. This moderating effect highlighted the importance of cognitive tendency in influencing how fear was related to PTSS during the COVID-19. According to the information processing perspective, attention is the mechanism deciding which information will be registered, influencing cognitive functions at later stage (Daleiden et al., 1997). Cognitive tendency to attend to negative information is likely to be a significant factor related to maladaptive cognitive deficits that contribute to emotional disorders (Daleiden et al., 1997). Therefore, fear of COVID-19 is not significantly associated with PTSS in children without a strong tendency to focus on negative information. Moreover, according to our findings, the tendency to focus on positive information was not significantly associated with PTSS. Therefore, reduced attention to positive information may not be as important as increased attention to negative information in the development of PTSS.

The results highlight the importance of cognitive interventions in treating children with strong fear of COVID-19. Only fearful children who had cognitive tendency to negative stimuli during the COVID-19 pandemic showed high PTSS. This showed that interventions that target cognitive biases may be important in preventing children with strong fear of the pandemic from developing PTSS. Also, children at high risk of showing PTSS are those who do not only have strong fear of COVID-19 but also have strong tendency to focus on negative information. Therefore, early prevention should reduce children’s cognitive tendency to negative information.

Strength and Limitations

A strength of the study is that it is the first study to investigate the moderation effect of cognitive tendencies on the relationship between fear of COVID-19 and PTSS in children during the COVID-19 pandemic. It provides support for the cognitive model of emotional disorders and the need for interventions to reduce post-traumatic stress symptoms in children during the COVID-19 pandemic. However, the results should be interpreted with caution. First, the study used only self-report measures to assess cognitive tendencies, fear of COVID-19, and PTSS in children. Thus, the results were subjective to memory biases. Future studies should use behavioral tasks to assess cognitive tendency to attend to negative information in children. Secondly, participants had a relatively restricted age range. Thus, the results might not be generalized to adults or adolescents. Future studies which recruit a larger sample of people from different cultures or age groups are needed to see if cultural or age influences the results. Thirdly the study design was cross-sectional, thus the results so not imply causality. It was unclear whether fear of COVID-19 led to PTSS in children during the COVID-19 pandemic. Also, the cognitive tendency to focus on negative and positive information was not assessed multiple times to understand how the cognitive tendency changed during COVID-19 pandemic. Future longitudinal studies may be interested in measuring the variable at multiple time points over a period to understand the change of attention to negative and positive information over time and its association with PTSS. Moreover, future studies should be conducted to provide robust empirical evidence for the rationale underlying the moderation effect of cognitive tendency to focus on negative information.

To sum up, the study found that fear of COVID-19 was associated with PTSS, after gender was controlled for. The association was only significant for children with strong tendency to focus on negative information. This highlighted the importance of cognitive tendency to focus on negative information in interventions of PTSS for children with strong fear of COVID-19.