Study design

A descriptive cross-sectional study was conducted between February 2021 and July 2021 to establish a comprehensive data reference regarding the prevalence of mental illness symptoms (depression, anxiety, and PTSD) and to determine the associations of these symptoms with bio-demographic and other pandemic-related factors among UAE school students. This design was selected as lit has been affirmed by literature as the best way to describe the distribution of one or more variables, devoid of causal links. Furthermore, this type of studies has been considered instrumental in measuring the prevalence of a disease or of a risk factor in a population [22].

Sampling and data collection procedure

In this cross-sectional study, data was gathered through online means between February 2021 and July 2021 in the UAE. This timeframe followed a period of lockdown, during which a majority (83.3%) of students were still engaged in complete online school learning. A total of 3,745 respondents from all seven emirates of the United Arab Emirates participated in the study. Participation was open to students from both private and government schools in the UAE, encompassing grades 2 to 12 and spanning ages 8 to 18. The study targeted individuals with the ability to competently comprehend written Arabic and/or English texts. Those enrolled in vocational, continuing education, or special education programs/schools were excluded. Furthermore, parents of surveyed students responded to a series of biodata inquiries through the same instrument.

Our study utilized convenience and snowball sampling techniques, which have been widely used in similar research conducted amidst the COVID-19 pandemic [23–25]. This approach was chosen due to the logistical challenges and restrictions posed by the pandemic, making it a practical method for data collection under the circumstances. Initially, potential participants were reached electronically through school and parental communication channels. Additionally, the study harnessed electronic communication platforms associated with the authors’ corporate affiliations. This approach involved disseminating the study invitation and link to the public through official websites, press releases, and various social media outlets such as Facebook, Instagram, and Twitter. Moreover, to ensure comprehensive outreach, the study utilized the established networks of corporate facilities, including hospitals and clinics, to circulate the invitation via SMS to the employees’ families who met the inclusion criteria. This innovative dissemination technique facilitated wider access to the study’s invitation.

The instrument

The data collection instrument used in this study was composed of three sections. Firstly, a detailed participant information sheet and an informed consent form were mandatory fields to be completed before participants had access to the anonymous questionnaire. Secondly, parents were asked to respond to 26 questions which included family sociodemographic data as well as information on the student’s general health status; the estimated time to complete this part was 15 minutes. Thirdly, students, just after they consented to their participation, were requested to answer blocks of questions that included three standardized scales tested for validity and reliability in both languages (English and Arabic).

The Mood and Feelings Questionnaire (Short Version)–MFQ is a self-reported 13-item measure that assesses the current depressive symptomatology among children. Psychometric data at an early stage have revealed a high internal consistency along with a Cronbach’s alpha of 0.90. Test-retest reliability across the clinical samples for a 1-week period is wide-ranging between 0.73 and 0.75 (intraclass correlation) [26]. The “Screen for Child Anxiety Related Emotional Disorders (SCARED)” is a youth- and parent-report measure that was established to screen children for anxiety related disorders. SCARED comprises of 41 items. In prior investigations involving outpatient psychiatric samples, the SCARED demonstrated favorable convergent and divergent validity when compared to other psychiatric assessment tools, indicating robust sensitivity (0.71) / specificity (0.67) [27, 28]. The “Children’s Revised Impact of Events Scale” (CRIES-8) realizes the principles for good screening instruments and has been utilized across a large number of cultures and countries. CRIES has exhibited strong reliability, a consistent factor structure, satisfactory face and construct validity, and has been employed to screen extensive cohorts of vulnerable children following various traumatic events [29]. The cutoff values for these scales were established based on previous research) [26–32].

Data quality assurance

To ensure the accuracy and reliability of the data collected for this study, stringent measures were implemented throughout the research process. These procedures were designed to tackle potential issues related to completeness, accuracy, and the handling of unanswered responses. A standardized data collection protocol was developed, clearly outlining the procedures for obtaining responses from participants. Although the questionnaire utilized standardized scales to ensure reliability and validity, a pilot test was conducted as an additional measure. This preliminary trial involved a select group of individuals mirroring the study’s target participants. Its purpose was to detect any potential shortcomings, enhance clarity, and optimize user experience, ultimately refining the questionnaire’s effectiveness for the larger study. Feedback from the pilot test guided adjustments to ensure the questionnaire was user-friendly and the instructions provided proper guidance. After the completion of data collection, thorough data cleaning procedures were applied. The percentage of unanswered responses for each variable was also reported for transparency purposes. These data quality assurance measures collectively aimed to enhance the reliability and inclusiveness of the dataset, ensuring the robustness of the study findings [33].

Privacy and confidentiality

Data were collected anonymously and were confidentially stored in the Emirates Health Services database system. Investigators and statisticians who helped in data analysis were the only individuals authorized to access the data and only after signing a non-disclosure agreement form. Moreover, to facilitate transparency and replication of the study’s findings, an anonymized dataset essential for reproducing the study’s results has been made accessible to fellow researchers. This dataset is publicly available on a designated repository [34], promoting collaboration and the advancement of knowledge in the field while upholding the confidentiality of participant information.

Ethical considerations

Ethical approvals were acquired from the Emirates Institutional Review Board for COVID-19 Research (Reference No. DOH/CVDC/2020/2471) and the Research Ethics Committee at the Ministry of Health and Prevention, Dubai (reference No. MOHAP/DXB-REC/ DDD/No.163 /2020). Moreover, anonymity, confidentiality, and voluntariness were preserved throughout the study. As is conventional in anonymous surveys, consent was in place before starting the survey. Parents confirmed their consent in the electronic questionnaire by answering two written mandatory questions placed just at the end of the Participant Information Sheet. Students were also requested to confirm their consent by responding to one mandatory written question just before they answered the electronic survey questions. Participants were informed they could stop completing the questionnaire or refrain from submitting their responses if they felt uncomfortable at any stage during completion. Participation in the study was voluntary. Participants had the full right to withdraw at any time without the need to justify their actions. There were no apparent risks that could result from participating in this study. However, due to the fact that some students could feel uncomfortable expressing their feelings, a mental health support hotline was made accessible to participants in case they needed relevant professional consultations.

Data analysis

Data were analyzed using IBM SPSS Statistics for Windows version 26. The number of submitted questionnaires was 3,762. However, post-data cleaning, the number was reduced to 3,745. A combination of descriptive and inferential statistical techniques were implemented to achieve the study goal. Descriptive statistics were used to present the distribution of students across different age groups, gender, and various conditions related to the current coronavirus pandemic. The inferential statistics included chi-squared tests (χ²) and p-values to assess the association between categorical variables (age groups, gender, and the presence of symptoms) and to analyze the relationship between various factors (student medical problems, method of school learning, coronavirus-related experiences of the student and their family members) and the presence of symptoms (Depression, Anxiety, PTSD). Moreover, logistic regression analysis with Odds Ratios (OR) along with 95% confidence intervals (CIs) and p-values were used to assess the association between different categorical variables and the presence of symptoms (Depression, Anxiety, PTSD). A P-value < 0.05 was considered statistically significant in all analyses. In constructing our multivariable logistic regression model, we meticulously navigated the variable selection process by considering a range of factors to ensure both statistical robustness and theoretical relevance to our research question. The prioritization of variables was grounded in a theoretical assessment of their relevance to the research objectives, with a focus on those directly linked to the investigated phenomenon. Our approach was further informed by a comprehensive literature review, incorporating insights from prior studies and established theoretical frameworks. To bolster the clinical validity of our model, we sought input from domain experts, including clinicians, to align selected variables with relevant clinical knowledge. Additionally, we employed statistical tests, such as chi-square tests or others depending on variable nature, to evaluate the significance of variables.

This comprehensive statistical approach allowed for a nuanced exploration of the factors influencing mental health symptoms among students in the UAE, providing valuable insights into the interplay between various variables and mental well-being.

Findings

The socio-demographic characteristics of participants shown in Table 1 were derived from the section answered by the parents. The majority of parents were married (94.2%), employed (81.4%), and expats (67.8%). Likewise, most respondents (93.5%) had none of their family members been previously diagnosed with a mental health-related problem or behavioral disorder. As for students, over one-third (34.3%) were pre-adolescents (<10 years), 37.5% belonged to the early adolescence age group (10–13 years), 23.7% to middle adolescence (14–17 years), and 1.8% to late adolescence (22 years). It is to be noted that these age groups were defined based on the UAE stages of school education [35] and a published article on stages of adolescence [36]. For gender, a little over half (50.6%) of the participants were male. Most of the students (81.6%) studied in private schools and attended school completely online (82.3%).

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Table 1. Socio-demographic characteristics of the sample (N = 3745).

https://doi.org/10.1371/journal.pone.0296479.t001

In Table 2, data were also collected from parents’ questions. It showed that 14% had a close family member at the time tested positive for coronavirus, followed by 14% who indicated that a close family member was before or at the time sick/hospitalized because of the current coronavirus infection. However, only 5.8% reported that a close family member had died because of the coronavirus. A smaller percentage of students (3%) tested positive for coronavirus at the time while 5.4% were either unwell or hospitalized.

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Table 2. COVID-19 information pertaining to the sample (N = 3,745).

https://doi.org/10.1371/journal.pone.0296479.t002

A comprehensive examination of the outcome variables, which encompassed mental health symptoms as self-reported by the students, revealed substantial variability. Among the 3,745 students, 642 (17.1%) reported depression symptoms on the MFQ-Child Self-report scale, which utilized a total score range of 0–26 with a suggested cutoff of ≥12. On SCARED-Child version scale, among the 3,745 students, 871 (23.3%) exceeded the scale’s cutoff (>30), signifying the potential presence of an anxiety disorder. Similarly, symptoms indicative of a risk for PTSD were observed in 1519 (40.6%) students who met or surpassed the defined cutoff score of ≥ 17 on CRIES-8 scale (Fig 1.).

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Fig 1. Prevalence of common mental health disorders.

https://doi.org/10.1371/journal.pone.0296479.g001

Further inferential analysis looked into trends and associations among the outcome variables and predictive variables, age and gender. The data in Table 3 underscores intriguing patterns and disparities. Significant age and gender differences were found to be associated with mental health symptoms. A significantly higher proportion of participants who were late adolescents reported symptoms of two conditions (depression and anxiety) compared to participants in the younger age group (p<0.05). Additionally, a significantly higher proportion of female students reported symptoms of one condition-depression (p<0.05), anxiety (p<0.01), or risk for PTSD only (p<0.05) or two conditions (p<0.05).

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Table 3. Distribution of symptoms of depression, anxiety, and risk for PTSD by age and gender.

https://doi.org/10.1371/journal.pone.0296479.t003

A more detailed examination of the relationship between pandemic-related factors and mental health symptoms is shown in Table 4. Students who were reported to have medical problems were more likely to have mental health symptoms as compared to those with nil history (p<0.01). Those who reported a close family member was sick or hospitalized because of the coronavirus infection were more likely to report mental health symptoms as compared to those who reported the statement was false (p<0.05). In terms of the death of a close family member due to coronavirus infection, respondents who reported a close family member had died because of the coronavirus infection were more likely to show mental health symptoms as compared to those who did not (p<0.01).

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Table 4. Prevalence of symptoms of depression, anxiety, and PTSD stratified by pandemic-related factors.

https://doi.org/10.1371/journal.pone.0296479.t004

Following a thorough regression analysis, the study substantiates the factors associated with depression, anxiety, and risk for PTSD as shown in Table 5. Notably, students who had any medical problems demonstrated a 2.0-fold increased likelihood (95% CI 1.5–2.6) of manifesting anxiety symptoms and a 1.3-fold increased likelihood (95% CI 1.0–1.8) of being at risk for PTSD. Likewise, participants who had experienced the death of a close family member due to coronavirus infection exhibited a 1.7-fold increased likelihood (95% CI 1.2–2.4) of reporting depression symptoms. Moreover, they were 1.7 times more likely (95% CI 1.2–2.4) to experience elevated anxiety levels and 1.7 times more likely (95% CI 1.2–2.3) to be at risk for PTSD, even after adjusting for variables such as age, gender, and pre-existing mental health-related problems.

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Table 5. Predictive factors of common mental health symptoms using regression analysis.

https://doi.org/10.1371/journal.pone.0296479.t005

Prevalence of anxiety, depression, and risk for PTSD

This study has adequate evidence that students in the UAE are exhibiting symptoms of mental health disorders in the post COVID-19 pandemic period and this is consistent with that of recent studies across the globe. In a comprehensive review of evidence, the WHO concluded that the world has experienced a 25% increase in the prevalence of anxiety and depression in the first year of the COVID-19 crisis. More precisely, the report revealed that the pandemic has particularly affected the mental health of young people who, more seriously, were found disproportionally at risk of suicidal and self-harming behaviors [37]. Accordingly, the organization considered the COVID-19 pandemic a wake-up call to the world to set up mental health services [38]. Another study examined the mental health challenges among Bangladeshi healthcare professionals during COVID-19, urging comprehensive mental health support. This study may offer valuable context and a comparative viewpoint to better comprehend the mental health symptoms observed in school students in the UAE following the lockdown. It highlighted the significance of comprehensive mental health support and interventions, emphasizing the need for such measures not only during but also after the pandemic [39]. More support can be derived from a study that explored workplace stressors for nurses during the COVID-19 pandemic, emphasizing the need for comprehensive mental health interventions. Understanding these dynamics is critical for contextualizing and comparing the mental health experiences of school student’s post-lockdown in the UAE, emphasizing the need for planned interventions across various affected populations [40]. Several other studies indicated that adolescents experienced more adverse mental health effects during the pandemic in comparison to adults. These comparative findings underscored that adolescents were more prone to reporting symptoms of depression, anxiety, and post-traumatic stress disorder (PTSD) [41, 42].

Gender and age differences

The results from this study highlight that female and older adolescents showed a significantly higher proportion of anxiety, depression, and risk for PTSD symptoms. These differences are supported by a number of recent studies that showed female high school students at an increased risk of psychological stress [43] and at higher levels of anxiety and depressive symptoms during the pandemic [44]. Interestingly, a number of researchers have argued that a possible explanation for female high school students’ higher levels of anxiety, depression, and stress symptoms during the COVID-19 pandemic could be due to physiologic hormonal and bodily changes or a lack of coping mechanisms [45, 46].

Past medical history and family/social support

This study explored more associations between mental symptoms and existing medical conditions. Findings showed that students who had any medical problem were 2.0 (95% CI 1.5–2.6) times more likely to have anxiety, 1.3 (95% CI 1.0–1.8) times more likely to have PTSD. These results are supported by a recent post-lockdown study conducted in Germany which showed that children with complex chronic diseases were more likely to have mental health problems [47]. In another supportive study, researchers concluded that COVID-19-associated mental health risks were more likely to appear in children and adolescents with special needs [48]. Conventionally, social ties and family relationships are understood to have a significant impact on the maintenance of psychological well-being and reduce the risk for depression among adolescents [49–53]. The relevant findings from our study are supportive of this conviction; participants who had experienced the death of a close family member due to coronavirus infection were 1.7 (95% CI 1.2–2.4) times more likely to have depression, 1.7 (95% CI 1.2–2.3) times more likely to have anxiety, and 1.7 (95% CI 1.2–2.3) times more likely to have PTSD.

In a nutshell, symptoms of anxiety, depression, and risk for PTSD were found in the UAE school students. Mental health services are needed to help those children cope and recover as the Covid-19 pandemic is receding. Special attention must be regarded to disadvantaged children and proactive plans should be put in place for potentially forthcoming threats.

Strengths and limitations

The study holds several strengths that underscore its significance and contribution to the field of children mental health research in the UAE. Interestingly, healthcare entities in the country have proactively prioritized mental health even before the pandemic, and the study takes advantage of this groundwork. The collaboration of a multi-disciplinary team consisting of government health regulators, disaster management experts, healthcare providers, and academia further enhances the robustness of the research. Notably, the involvement of parents and students from across the seven emirates strengthens the representativeness of the findings. The generation of robust datasets serves as a valuable resource for multiple disciplines, including physical and mental health, education, social studies, and economics, amplifying the study’s utility. An additional strength lies in the novelty of the study, as the literature review highlights its pioneering nature in the UAE context. However, the study is not without limitations. The wealth of data variables presents a challenge in comprehensive incorporation within a single study. This constraint, while inevitable, offers an avenue for subsequent research to extract relevant studies from the data bank, thus serving the broader community of mental health professionals and policymakers. Like many similar research efforts conducted during the ongoing pandemic, the challenge of relying on convenience and snowball sampling methods was inevitable [54]. Chosen for their practicality given the circumstances, it is important to acknowledge that this approach can have implications for the generalizability of our findings to the broader population.

Implications

The implications of our findings are substantial in shaping psychological support strategies for children. Specific attention must be given to vulnerable groups, such as late adolescents, female students, and those grappling with complex chronic illnesses or challenging family dynamics. Individuals who underwent pandemic-related traumas, like severe illness or bereavement, require targeted interventions. Continuous mental wellness evaluations, tailored coping mechanisms for evolving learning contexts, prompt identification of individual psychological needs, and accessible interventions for distressed students are essential. Educators need training to discern school students’ verbal and non-verbal cues indicating potential mental distress, fostering effective school-family communication. These insights underscore the importance of developing a comprehensive school mental health program that promotes the well-being of youth and enhances their resilience against future uncertainties.