The 6-Item Vision-Related Quality of Life and Limitations Questionnaire: Evaluation of Psychometric Properties.

Purpose: We developed the Vision-related Quality of life and Limitations Questionnaire (VQL-6), a screening instrument to signal a need for additional care resulting from reduced vision-related quality of life in patients with chronic ophthalmic diseases. The aim of the present study was to evaluate psychometric properties. Methods: A Dutch population-based sample of 2032 participants (mean age, 55 ± 19 years) completed the VQL-6 and other questionnaires on vision-related quality of life, executive functioning, attention, mental health, and symptom validity. In addition, we recruited a sample of 208 ophthalmic patients (mean age, 72 ± 12 years) and 98 age and gender similar controls (mean age, 69 ± 11 years) who completed the VQL-6 and the National Eye Institute Visual Function Questionnaire-25. We studied the factor structure, internal consistency, convergent and divergent validity, and known-groups validity. Results: For the factor analyses, the population-based sample was split randomly in two subsamples. Exploratory factor analysis on the first subsample suggested a two-factor model (visual limitations and general health and quality of life), which was supported by confirmatory factor analyses on the second subsample, and on the patients. The VQL-6 demonstrated good internal consistency within each factor (0.78-0.89), sufficient convergent (r2= 55%) and divergent validity (r2 = 11%-24%), and good known-groups validity (Cohen's r = 0.57; P < 0.001). Conclusions: The VQL-6 has a robust two-factor structure and seems to be a valid tool to assess vision-related quality of life. Additional validation is needed in patients with chronic ophthalmic diseases. Translational Relevance: Future research is needed to determine if the VQL-6 can be used to identify patients with chronic ophthalmic diseases who are in need of additional care.

Subjective Complaints and Coping Strategies of Individuals with Reported Low-Frequency Noise Perceptions.

Background: Subjective everyday hindrances associated with low-frequency noise (LFN) can be high; however, there is still a lot unknown about experienced complaints. This study aims to investigate (1) subjective complaints and (2) coping strategies of individuals reporting everyday hindrances from LFN. Methods: Cognition, depressive symptoms, sleeping, fatigue, stress, and coping questionnaires were administered to participants sampled for their LFN complaints (LFN1 = 181), LFN complainants derived from a community sample (LFN2 = 239), and a comparison group without LFN complaints (CG = 410). Results: Individuals reporting LFN perceptions reported complaints in all domains and showed a higher proportion of above average symptom severity compared to the CG. Most complaints were reported by the LFN1 group, the least by the CG. However, on some sleeping, fatigue, and stress-related variables, a similar or even higher symptom severity was observed in the LFN2 group. Further, all groups used a similar combination of multiple coping strategies, although the LFN1 group scored higher on support seeking. Conclusions: There might be differences in the complaint severity between different LFN subgroups and future investigations of primary and secondary complaints are necessary. Also, more research about the use and success of coping strategies for LFN-related hindrances are needed for clear conclusions.

Post-COVID fatigue: Reduced quality-of-life associated with clinically relevant fatigue in mild disease courses.

Fatigue is a pervasive symptom experienced by many individuals after COVID-19. Despite its widespread occurrence, fatigue remains a poorly understood and complex phenomenon. Our aim is to evaluate the subjective experience of mental fatigue after COVID-19 and to assess its significance for daily life functioning. In this online questionnaire study (N = 220), the Fatigue Severity Scale (FSS), World Health Organization Quality-of-Life assessment (WHOQoL) and a subjective severity rating of the COVID-19 disease progression were used. For our statistical analyses we utilized independent samples t-tests, one-way ANOVA with post-hoc analyses, and a multiple regression. As expected our findings revealed the COVID group reported significantly higher levels of subjective fatigue compared to the control group. Moreover, there was a significant difference between experienced fatigue across the four severity groups. Participants who had a milder course of disease also experienced severe subjective fatigue. Subjective fatigue explained 40% variance in quality-of-life. In conclusion, severe subjective fatigue appears to be associated with increased self-reported COVID-19 symptom severity and lower quality-of-life but is already observable in milder cases. This underscores, firstly, the importance of considering also less severe cases and, secondly, the need to develop rehabilitation and psychological interventions for fatigue.

The role of executive functions in mediating the relationship between adult ADHD symptoms and hyperfocus in university students.

BACKGROUND: Hyperfocus, a state of intense, narrow and prolonged attentional focus, has been associated with symptoms of attention-deficit/hyperactivity disorder (ADHD) in both clinical and non-clinical populations. Hyperfocus may be explained by difficulties in executive control, typically observed in ADHD. AIMS: To investigate (1) whether ADHD and executive functions (EF) are associated with hyperfocus and (2) whether EF mediate the relationship between ADHD symptoms and hyperfocus. METHODS AND PROCEDURES: A non-clinical sample of 380 university students (264 females) completed self-reports of ADHD, EF, hyperfocus and hyperfocus during rewarding activities. OUTCOMES AND RESULTS: Increased difficulties in EF and severity of ADHD symptoms were significantly and positively correlated with a higher frequency of hyperfocus. Moreover, EF difficulties partially mediated the relationship between ADHD and hyperfocus (after controlling for sex and substance use), but not the relationship between ADHD and hyperfocus during rewarding activities. CONCLUSIONS AND IMPLICATIONS: Difficulties in EF partially explained the higher frequency of hyperfocus, but not of hyperfocus during rewarding activities, among university students reporting more severe ADHD symptoms. Future research should investigate whether and how specific EF and other ADHD-related neurocognitive difficulties (e.g., reward sensitivity) contribute to various types of hyperfocus experiences in ADHD. WHAT THIS PAPER ADDS?: This paper is a first attempt to explain the relationship between adult ADHD symptoms and hyperfocus experiences. Our findings suggest that, although highly correlated, existing self-reports of hyperfocus measure different aspects of this experience: hyperfocus and reward-related hyperfocus. We replicate previous findings that indicated a greater frequency of both types of hyperfocus in ADHD. Additionally, we demonstrate a connection between EF difficulties and different aspects of hyperfocus. Finally, we extend previous findings by proposing that EF difficulties partially explain the relationship between ADHD and hyperfocus, but not the relationship between ADHD and reward-related hyperfocus. We hypothesize that other neurocognitive difficulties (e.g., reward sensitivity) may contribute to explain the relationship between ADHD and different aspects of hyperfocus.

Cognitive Underperformance in a Mixed Neuropsychiatric Sample at Diagnostic Evaluation of Adult ADHD.

(1) Background: The clinical assessment of attention-deficit/hyperactivity disorder (ADHD) in adulthood is known to show non-trivial base rates of noncredible performance and requires thorough validity assessment. (2) Objectives: The present study estimated base rates of noncredible performance in clinical evaluations of adult ADHD on one or more of 17 embedded validity indicators (EVIs). This study further examines the effect of the order of test administration on EVI failure rates, the association between cognitive underperformance and symptom overreporting, and the prediction of cognitive underperformance by clinical information. (3) Methods: A mixed neuropsychiatric sample (N = 464, ADHD = 227) completed a comprehensive neuropsychological assessment battery on the Vienna Test System (VTS; CFADHD). Test performance allows the computation of 17 embedded performance validity indicators (PVTs) derived from eight different neuropsychological tests. Further, all participants completed several self- and other-report symptom rating scales assessing depressive symptoms and cognitive functioning. The Conners' Adult ADHD Rating Scale and the Beck Depression Inventory-II were administered to derive embedded symptom validity measures (SVTs). (4) Results and conclusion: Noncredible performance occurs in a sizeable proportion of about 10% up to 30% of individuals throughout the entire battery. Tests for attention and concentration appear to be the most adequate and sensitive for detecting underperformance. Cognitive underperformance represents a coherent construct and seems dissociable from symptom overreporting. These results emphasize the importance of performing multiple PVTs, at different time points, and promote more accurate calculation of the positive and negative predictive values of a given validity measure for noncredible performance during clinical assessments. Future studies should further examine whether and how the present results stand in other clinical populations, by implementing rigorous reference standards of noncredible performance, characterizing those failing PVT assessments, and differentiating between underlying motivations.

Reading Difficulties in Parkinson's Disease: A Stepped Care Model for Neurovisual Rehabilitation.

BACKGROUND: People with Parkinson's disease (PD) frequently experience reading difficulties. Little is known about what functional impairments distinguish people with PD with and without reading difficulties and how these should guide rehabilitation. OBJECTIVE: To provide concrete advice for an efficient stepped care model for reading difficulties in PD, based on extensive functional assessments. METHODS: This study included 74 people with PD in a neurovisual rehabilitation setting who underwent assessment of visual, visuoperceptual, and cognitive functions. Outcomes were compared between those with frequent (RD+; N = 55) and infrequent reading difficulties (RD-; N = 19). Aids and advice provided during rehabilitation were registered. RESULTS: Only a few functions appeared to distinguish RD+ and RD-. Visual functions (i.e., contrast sensitivity, g = 0.76; reading acuity, g = 0.66; visual acuity, g = 0.54) and visuoperceptual functions (i.e., visual attention, g = 0.58, visual motor speed, g = 0.56) showed significant worse scores in RD+ compared to RD-. Aids and advice applied consisted mainly of optimizing refraction, improving lighting, and optimizing text size and spacing. CONCLUSION: The test battery showed significant differences between RD+ and RD-on only a few tests on visual and visuoperceptual functions. The applied aids and advice matched well with these impairments. Therefore, we recommend a stepped care model, starting with a short test battery on these functions. If this battery indicates functional impairments, this can be followed by standard aids and advice to improve reading. Only in case of insufficient effect additional testing should take place.

Untreated if unrecognized: A cognitive profile of sustained subjective executive dysfunctions in COVID-19.

& STATEMENT OF IMPACTSARS-COV-2 infection can result in acute and long-lasting cognitive complaints, causing ongoing impairments in daily life which poses a challenge to society. Consequently, the evaluation and characterization of cognitive complaints, specifically in the domain of executive functions (EFs) affecting daily life, is imperative in formulating an effective neuropsychological response.In total 442 participants aged 18-65+ years from the Netherlands, Germany, Mexico, and Spain were included in an online questionnaire. Among others, the questionnaire consisted of demographics, the Behavior Rating Inventory of Executive Functioning for Adults (BRIEF-A), measures of subjective disease progression severity and experienced subjective impairment in daily activities. To assess whether daily life activities are affected by EF impairments, the main BRIEF-A composite score (GEC) was analyzed. To determine whether disease-related COVID-19 factors predict EFs complaints in daily life, a stepwise regression analysis was performed with i) experienced disease severity, ii) time since disease, and iii) health risk factor as predictors.The study revealed noteworthy differences in the occurrence of EFs problems in daily life between both groups, as indicated by the GEC, which exhibited a medium effect size even 6 months post-COVID-19 diagnosis even in mild disease progression. The scores of the BRIEF-A subscales follow a domain-specific profile, and includes clinically relevant impairments in: Working memory, Plan/Organize, Task Monitor, Shift, which are affected by the experienced severity of the disease. This cognitive profile has important implications for targeted cognitive training in rehabilitation and has the potential for an applicability to other viruses as well.

Validity assessment of early retirement claimants: Symptom overreporting on the Beck Depression Inventory - II.

OBJECTIVES: The Beck Depression Inventory-II (BDI-II) is a commonly used clinical measure; however, it contains no method to assess validity of self-report. The primary objective of this research was to examine the possibility of cut scores on the BDI-II indicating possible invalid symptom report in forensic neuropsychological evaluations. Secondary objectives were to explore the utility of education specific cut scores and the effects of the criterion for invalid symptom report. METHODS: Two hundred and seventeen early retirement claimants (age range 19-64 years) presenting for forensic neuropsychological examination were considered for this study. Invalid symptom report was determined based on two independent self-report symptom validity tests. Further, all individuals completed the BDI-II as part of their routine assessment battery. RESULTS: Individuals with invalid symptom report (30.9%) showed significantly higher BDI-II scores compared to individuals passing symptom validity assessment. ROC analysis supports the utility of the BDI-II to differentiate valid from invalid symptom report, AUC = 0.822, SE = 0.032, p < .001, 95%-CI = 0.760-0.884. A BDI-II cut score of 38 points reached a desired level of 0.90 specificity with 0.58 sensitivity. Secondary analysis indicated that the recommended cut score may vary depending on the educational level of the examinee. Further, results seem to be largely robust against the chosen criterion for invalid symptom report. CONCLUSION: The BDI-II appears to be a useful adjunct embedded validity indicator in forensic neuropsychological evaluations.

Low-Frequency Noise: Experiences from a Low-Frequency Noise Perceiving Population.

Although low-frequency noise (LFN) is associated with various complaints, there is still much unknown about this phenomenon. This research aims to provide an extensive description of (1) LFN perceptions, (2) LFN-related complaints, and (3) the characteristics of LFN complainants. In an explorative observational cross-sectional survey study, a sample of Dutch adults reporting to experience LFN (n = 190) and a group not experiencing LFN (n = 371) completed a comprehensive questionnaire. Descriptions of LFN perceptions varied individually and were dependent on different circumstances, although some common patterns were observed. Complaints were wide-ranging and individual, with a reported high impact on daily living. Common complaints included sleeping difficulties, fatigue, or annoyance. Societal consequences were described regarding housing, work, and relationships. Attempts to stop or escape the perception were manifold but often unsuccessful. The LFN sample differed regarding sex, education level, and age from the Dutch adult population, indicating more frequent inability to work, less full-time work, and less years lived in their homes. No further differences in occupational or marital status or living circumstances were found. Although this research supports some previous findings and identifies common patterns, it also highlights the individual nature of LFN-related experiences and the heterogeneity of this group. It is advised to pay attention to the complaints of affected individuals, to inform concerned authorities, and to conduct more systematic and multidisciplinary research using standardized and validated measuring instruments.

Feigning Adult ADHD on a Comprehensive Neuropsychological Test Battery: An Analogue Study.

The evaluation of performance validity is an essential part of any neuropsychological evaluation. Validity indicators embedded in routine neuropsychological tests offer a time-efficient option for sampling performance validity throughout the assessment while reducing vulnerability to coaching. By administering a comprehensive neuropsychological test battery to 57 adults with ADHD, 60 neurotypical controls, and 151 instructed simulators, we examined each test's utility in detecting noncredible performance. Cut-off scores were derived for all available outcome variables. Although all ensured at least 90% specificity in the ADHD Group, sensitivity differed significantly between tests, ranging from 0% to 64.9%. Tests of selective attention, vigilance, and inhibition were most useful in detecting the instructed simulation of adult ADHD, whereas figural fluency and task switching lacked sensitivity. Five or more test variables demonstrating results in the second to fourth percentile were rare among cases of genuine adult ADHD but identified approximately 58% of instructed simulators.

Networks of Neuropsychological Functions in the Clinical Evaluation of Adult ADHD.

This study applied network analysis to explore the relations between neuropsychological functions of individuals in the clinical evaluation of attention-deficit/hyperactivity disorder (ADHD) in adulthood. A total of 319 participants from an outpatient referral context, that is, 173 individuals with ADHD (ADHD group) and 146 individuals without ADHD (n-ADHD group), took part in this study and completed a comprehensive neuropsychological assessment. A denser network with stronger global connectivity was observed in the ADHD group compared to the n-ADHD group. The strongest connections were consistent in both networks, that is, the connections between selective attention and vigilance, and connections between processing speed, fluency, and flexibility. Further centrality estimation revealed attention-related variables to have the highest expected influence in both networks. The observed relationships between neuropsychological functions, and the high centrality of attention, may help identify neuropsychological profiles that are specific to ADHD and optimize neuropsychological assessment and treatment planning of individuals with cognitive impairment.

Distance learning during the COVID-19 pandemic for children with ADHD and/or ASD: a European multi-center study examining the role of executive function deficits and age.

BACKGROUND: One of the COVID-19 pandemic consequences that has affected families the most is school lockdowns. Some studies have shown that distance learning has been especially challenging for families with a child with neurodevelopmental disorders such as ADHD or ASD. However, previous studies have not taken the heterogeneity of these disorders into account. The aim of the present study was therefore to investigate differences between families with a child with ADHD, ASD, or both conditions, and to examine the role of underlying deficits in executive functioning (EF) in both children and parents in relation to negative and positive effects of distance learning. METHODS: Survey data assessing both negative and positive experiences of distance learning were collected from parents with a child aged 5-19 years in seven Western European countries: the UK, Germany, Spain, Sweden, the Netherlands, Italy, and Belgium. Altogether, the study included 1010 families with a child with ADHD and/or ASD and an equally large comparison group of families with a child without mental health problems. We included measures of three different types of negative effects (i.e., effects on the child, effects on the parent, and lack of support from school) and positive effects on the family. RESULTS: Results confirmed that families with a child with ADHD, ASD or a combination of ADHD and ASD showed higher levels of both negative and positive effects of distance learning than the comparison group. However, few differences were found between the clinical groups. Group differences were more pronounced for older compared to younger children. Regarding the role of both ADHD/ASD diagnosis and EF deficits, primarily children's EF deficits contributed to high levels of negative effects. Parent EF deficits did not contribute significantly beyond the influence of child EF deficits. Families of children with ADHD/ASD without EF deficits experienced the highest levels of positive effects. CONCLUSIONS: School closings during COVID-19 have a major impact on children with EF problems, including children with neurodevelopmental disorders. The present study emphasizes that schools should not focus primarily on whether a student has a neurodevelopmental disorder, but rather provide support based on the student's individual profile of underlying neuropsychological deficits.

Stability of Attention Performance of Adults with ADHD over Time: Evidence from Repeated Neuropsychological Assessments in One-Month Intervals.

Neuropsychological assessments of attention are valuable sources of information in the clinical evaluation of adults with attention-deficit/hyperactivity disorder (ADHD). However, it is unclear whether the attention performance of adults with ADHD is stable or fluctuates over time, which is of great importance in the interpretation of clinical assessments. This study aimed to explore the stability of attention performance of adults with ADHD in repeated assessments at one-month intervals. Twenty-one adults diagnosed with ADHD took part in this study by completing selective attention and vigilance tests three times, each one month apart. Test scores of participants were compared with and interpreted based on test norms. A considerable proportion of 'below average' performance scores were observed in most of the variables of selective attention and vigilance in all three assessments. Further, selective attention and vigilance performance scores did not differ significantly between the three repeated assessments. Finally, the majority of participants received consistent test score interpretations across the three repeated assessments. This study confirms previous research and highlights abnormal selective attention and vigilance performance in adults with ADHD. Further, this study preliminarily demonstrates relatively stable attention performance across repeated assessments, which has the potential to support clinical assessment, treatment planning, and evaluation.

Correction: The Screening Visual Complaints questionnaire (SVCq) in people with Parkinson's disease-Confirmatory factor analysis and advice for its use in clinical practice.

[This corrects the article DOI: 10.1371/journal.pone.0272559.].

The Screening Visual Complaints questionnaire (SVCq) in people with Parkinson's disease-Confirmatory factor analysis and advice for its use in clinical practice.

BACKGROUND: The Screening Visual Complaints questionnaire (SVCq) is a short questionnaire to screen for visual complaints in people with Parkinson's disease (PD). OBJECTIVE: The current study aims to investigate the factor structure of the SVCq to increase the usability of this measure in clinical practice and facilitate the interpretation of visual complaints in people with PD. METHODS: We performed a confirmatory factor analysis using the 19 items of the SVCq of 581 people with PD, investigating the fit of three models previously found in a community sample: a one-factor model including all items, and models where items are distributed across either three or five factors. The clinical value of derived subscales was explored by comparing scores with age-matched controls (N = 583), and by investigating relationships to demographic and disease related characteristics. RESULTS: All three models showed a good fit in people with PD, with the five-factor model outperforming the three-factor and one-factor model. Five factors were distinguished: 'Diminished visual perception-Function related' (5 items), 'Diminished visual perception-Luminance related' (3 items), 'Diminished visual perception-Task related' (3 items), 'Altered visual perception' (6 items), and 'Ocular discomfort' (2 items). On each subscale, people with PD reported more complaints than controls, even when there was no ophthalmological condition present. Furthermore, subscales were sensitive to relevant clinical characteristics, like age, disease duration, severity, and medication use. CONCLUSIONS: The five-factor model showed a good fit in people with PD and has clinical relevance. Each subscale provides a solid basis for individualized visual care.

Symptom and performance validity in samples of adults at clinical evaluation of ADHD: a replication study using machine learning algorithms.

INTRODUCTION: Research has shown non-trivial base rates of noncredible symptom report and performance in the clinical evaluation of attention-deficit/hyperactivity disorder (ADHD) in adulthood. The goal of this study is to estimate and replicate base rates of symptom and performance validity test failure in the clinical evaluation of adult ADHD and derive prediction models based on routine clinical measures. METHODS: This study reuses data of a previous publication of 196 adults seeking ADHD assessment and replicates the findings on an independent sample of 700 adults recruited in the same referral context. Measures of symptom and performance validity (one SVT, two PVTs) were applied to estimate base rates. Prediction models were developed using machine learning. RESULTS: Both samples showed substantial rates of noncredible symptom report (one SVT failure: 35.7% - 36.6%), noncredible test performance (one PVT failure: 32.1% - 49.3%; two PVT failures: 18.9% - 27.3%), or both (each one SVT and PVT failure: 13.3% - 22.4%; one SVT and two PVT failures: 9.7% - 13.7%). Machine learning algorithms resulted in generally moderate to weak prediction models, with advantages of the reused sample compared to the independent replication sample. Associations between measures of symptom and performance validity were negligible to small. CONCLUSIONS: This study highlights the necessity to include measures of symptom and performance validity in the clinical evaluation of adult ADHD. Further, this study demonstrates the difficulty to characterize the group failing symptom or performance validity assessment.

It Takes Time: Vigilance and Sustained Attention Assessment in Adults with ADHD.

Objectives: The present study compares the utility of eight different tests of vigilance and sustained attention in the neuropsychological examination of adults with Attention-deficit/hyperactivity disorder (ADHD). Methods: Thirty-one adults diagnosed with ADHD performed eight tests for vigilance and sustained attention, spread over three assessment days. Results: Adults with ADHD showed cognitive impairments in most tests and test variables, even though their sensitivity differed greatly. No specific type of test variable stands out to be the most sensitive, and no evidence for a differential deterioration of performance over time was observed. Conclusion: This study underscores the role of vigilance and sustained attention tests in the assessment of adult ADHD. It is further concluded that summary scores over the entire test duration are sufficient, but that all variables of a test should be considered. Finally, we hypothesize that reassessment on a different day may benefit a more accurate clinical assessment of adults with ADHD, in order to adequately take intraindividual fluctuations and limitations regarding test reliability into account.

Confirmatory factor analysis of the Dutch Screening Visual Complaints questionnaire in people with multiple sclerosis.

BACKGROUND: Visual complaints among people with multiple sclerosis (pwMS) are common, but often difficult to recognize. The Screening Visual Complaints questionnaire (SVCq) has been developed to screen for visual complaints in people with a neurodegenerative disease, including multiple sclerosis (MS). A previous study performed a factor analysis in a normal population which revealed an acceptable one-factor model, a three-factor model and a five-factor model within the SVCq. To increase the usability of the SVCq in people with MS, the purpose of the current study was to investigate the fit of the three models in a cohort of pwMS. RESULTS: The confirmatory factor analysis on the SVCq in 493 people with MS showed good fit for all the models. The three-factor model (diminished visual perception, altered visual perception and ocular discomfort) outperformed the one-factor model. The five-factor model outperformed both models, which showed that dividing the first factor (diminished visual perception) into three more factors (function-related, luminance-related and task-related) has merit. CONCLUSIONS: All models may be useful in clinical care for pwMS. The one-factor model may give a quick overview of the presence and severity of visual complaints in general. The individual factors, of either the three- or the five factor models, may contribute to a better recognition of the nature of visual complaints in pwMS and may guide further steps in rehabilitation for pwMS with visual complaints.

Parental experiences of homeschooling during the COVID-19 pandemic: differences between seven European countries and between children with and without mental health conditions.

The aim of the present study was to examine parental experiences of homeschooling during the COVID-19 pandemic in families with or without a child with a mental health condition across Europe. The study included 6720 parents recruited through schools, patient organizations and social media platforms (2002 parents with a child with a mental health condition and 4718 without) from seven European countries: the UK (n = 508), Sweden (n = 1436), Spain (n = 1491), Belgium (n = 508), the Netherlands (n = 324), Germany (n = 1662) and Italy (n = 794). Many parents reported negative effects of homeschooling for themselves and their child, and many found homeschooling to be of poor quality, with insufficient support from schools. In most countries, contact with teachers was limited, leaving parents with primary responsibility for managing homeschooling. Parents also reported increased levels of stress, worry, social isolation, and domestic conflict. A small number of parents reported increased parental alcohol/drug use. Some differences were found between countries and some negative experiences were more common in families with a child with a mental health condition. However, differences between countries and between families with and without a mental health condition were generally small, indicating that many parents across countries reported negative experiences. Some parents also reported positive experiences of homeschooling. The adverse effects of homeschooling will likely have a long-term impact and contribute to increased inequalities. Given that school closures may be less effective than other interventions, policymakers need to carefully consider the negative consequences of homeschooling during additional waves of the COVID-19 pandemic and future pandemics.