COVID-19 related posttraumatic stress disorder in children and adolescents in Saudi Arabia.

INTRODUCTION: The COVID-19 pandemic resulted in quarantine/lockdown measures in most countries. Quarantine may create intense psychological problems including post-traumatic stress disorder (PTSD) especially for the vulnerable critically developing children/adolescents. Few studies evaluated PTSD associated with infectious disasters but no Saudi study investigated PTSD associated with COVID-19 in children/adolescents. This study was undertaken to screen for PTSD in children/adolescent in Saudi Arabia to identify its prevalence/risk factors during COVID-19 pandemic and its quarantine.
METHODS: A cross-sectional survey was conducted after 2 months form start of quarantine for COVID-19 pandemic utilizing the original English version and an Arabic translated version for the University of California at Los Angeles Brief COVID-19 Screen for Child/Adolescent PTSD that can be parent-reported or self-completed by older children/adolescents. Participants (Saudi citizens/non-Saudi residents) were approached online via social media.
RESULTS: Five hundred and thirty seven participants were enrolled. The participants were 262 boys and 275 girls with a mean age of 12.25±3.77 years. Symptoms of no, minimal, mild and potential PTSD were identified in 15.5%, 44.1%, 27.4% and 13.0% of children/adolescents, respectively. The age, gender, school grade, and residence were not predictive of PTSD symptoms. Univariate analysis of risk factors for PTSD revealed that work of a close relative around people who might be infected was significantly different between groups of PTSD symptoms, but this difference disappeared during multivariate analysis. Children/adolescents of Saudi citizens had significantly lower median total PTSD score than children/adolescents of expatriate families (p = 0.002).
CONCLUSION: PTSD associated with the COVID-19 and its resultant quarantine shouldn't be overlooked in different populations as it is expected in a considerable proportion of children/adolescents with variable prevalence, risk factors and severity. Parents/healthcare providers must be aware of PTSD associated with COVID-19 or similar disasters, so, they can provide children/adolescent with effective coping mechanisms.

Introduction

The COVID-19 that appeared in China in December, 2019, was officially recognized by the World Health Organization as a pandemic on January 30, 2020. This virus has, since then, spread to all countries with variable burden, severity, psychological and socioeconomic impacts [1].

In response to SARS-CoV-2 spread, lockdown measures have been implemented in most of the affected countries to stop/slow down further transmission of the deadly virus [2, 3]. Such disease containment measures may suppress the outbreak, but they can also adversely affect family values, rituals and norms, which otherwise protect and regulate family functioning in times of disasters [4].

Quarantine is a preventive measure to safeguard public health and is characterized by isolation of persons who have been exposed to an infection, restriction of their movements separating them from others, for a specified time period [5]. Quarantine is beneficial for the general public to contain and limit the spread of an infectious agent, but it may create intense emotional, psychological and financial problems for some individuals [6, 7]. Global pandemics, in fact, are known to have intensively affected the mental well-being of individuals and masses [8].

Quarantine is often a troublesome upsetting experience with dramatic effects for those who suffer it. It is usually associated with multiple stressors such as its long duration, fright of infection, frustration, monotony, separation from loved ones, loss of freedom, financial loss, inadequate basic supplies (water, food, etc..), stigmatization and rejection by other people in the neighborhood, inadequate information with uncertainty over disease status and inadequate clear guidelines for necessary actions [6].

The critically developing children/adolescents are among the most vulnerable groups for community-based attenuation measures to fight COVID-19. This can disturb the usual lifestyle of children with closure of schools, parks, and playgrounds that may cause confusion and florid mental distress. Children/adolescents have to face these changes and may manifest signs of hostility, impatience, and intolerance. This may result in provoking the already over stressed parents to cause physical and mental violence to such children [9]. Thus, children needing quarantine due to confirmed or suspected COVID-19 infection might need extra efforts to pacify their fear, anxiety, and other psychological problems [10, 11].

Massive fear of COVID-19 has created plenty of psychiatric problems across several categories of the community [12]. Posttraumatic stress disorder (PTSD) has emerged as an important psychiatric problem. Its severity has been found to be directly proportionate to the duration of quarantine [7, 13].

PTSD is an anxiety disorder that can occur in persons who have been exposed to a traumatic, violent or catastrophic event such as earthquakes, hurricanes or pandemics like COVID-19, or who witnessed such experience happening to some close relatives [14]. PTSD is characterized by ignoring stimuli associated with a traumatic experience, restoring the trauma event, and hyperarousal, such as increased attentiveness that can extend for more than a month following exposure to trauma. This usually leads to significant interference with individual’s normal working and social life, including school performance in case of children. Children can suffer dramatic changes in their cognition and mood, presenting with problems of behavior, attention and ability to concentrate in the school environment [14, 15].

Few studies [7, 16] have evaluated PTSD associated with infectious disasters but no study from Saudi Arabia has investigated the effects of COVID-19 and its resultant long duration of quarantine on children/adolescents. Therefore, this study was undertaken to screen for symptoms associated with PTSD in children/adolescents in Saudi Arabia to identify the prevalence/magnitude and risk factors of PTSD as a consequence of COVID-19 pandemic and its long period of quarantine.

Materials and methods

Study design and selection of participants

A cross-sectional survey was designed utilizing Brief COVID-19 Screen for Child/Adolescent (BCSCA) PTSD developed by University of California at Los Angeles (UCLA) [17]. This survey was conducted in the Kingdom of Saudi Arabia (KSA) from 12th of March to 12th of June 2020, two months after start of quarantine for COVID-19 pandemic. Participants were randomly selected and approached by an electronic online form of BCSCA. Parents and children/adolescents with age range of 6–18 years were invited to answer this questionnaire if they were Saudi citizens or residents and experienced the COVID-9 quarantine. Participants living outside KSA or having children outside the specified age range of 6–18 years as well as incomplete questionnaires were excluded from this study.

Ethical considerations

Ethical approval was obtained from the biomedical ethics unit of Faculty of Medicine of King Abdulaziz University. A written informed consent was not obtained from parents or participants under 18 years old as filling the required online questionnaire by participants was considered their consent for participation in this survey. Participants’ identity and confidentiality of their responses were protected.

Measuring tool

The UCLA-BCSCA for PTSD questionnaire was used which is a newly developed tool to specifically help in screening for COVID-19-related PTSD in children/adolescents. The UCLA-BCSCA is derived from the validated UCLA PTSD reaction index for the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) and it is one of the most commonly used instruments for the evaluation of traumatized children/adolescents. The UCLA-BCSCA for PTSD includes an initial set of questions (e.g., Have you or someone close to you become very sick or been in the hospital because of this illness? Has anyone close to you died because of this illness? Does someone close to you work around people who might have this illness?), to briefly review the traumatic event and set the stage for the subsequent related questions. Thus, it assists the child in recalling details of the traumatic event. These initial questions are followed by an 11-item set of validated questions about the frequency of PTSD symptoms in the past month (rated from 0 = none of the time to 4 = most of the time), including 4 symptom categories (Category B: Intrusion symptoms; questions 4, 7, 10, Category C: Avoidance symptoms; questions 1, 6, Category D: Negative conditions/mood symptoms; questions 5,8,9 and Category E: Arousal/Reactivity symptoms; questions 2,3,11) [18, 19].

The UCLA BCSCA assessment tool includes reaction index total scale score based on (DSM-5) PTSD diagnostic screener, with screener rating from 1–10 denoting minimal PTSD symptoms, from 11–20 denoting mild PTSD symptoms whereas rating of 21 or higher denotes potential PTSD and warrants further evaluation by full PTSD-reaction index assessment and triage.

Questionnaire implementation and distribution

The UCLA-BCSCA is originally available in English and it was translated into Arabic, checked by two bilingual experts and used in a pilot study for Arabic speaking participants to detect if any amendments are required.

Both English and Arabic questionnaires were converted to Google forms, so participants can select to fill the most convenient questionnaire for them. Then, the links of both questionnaires were sent via social media, including WhatsApp’s, Facebook and Twitter, to participants. Participants were allowed to send the questionnaire’s link to their relatives and friends as a mean to increase the sample size.

The parental-reported/completed questionnaire was directed to parents of children who can fill the whole questionnaire including response to questions directed for their children after taking opinions and answers first from their eldest child. Furthermore, the parent could also enter the questionnaire link again to fill further questionnaire(s) for other children between 6–18 years. The whole questionnaire was self-completed by children/adolescents who could understand the questions without the help of their parents. However, if children/adolescents ask for the help of their parents to explain any question, parents were present beside them as interviewers to explain any raised question or issue.

Sample size and study power

The sample size was calculated on the basis of the published data on the prevalence of PTSD in 30% of isolated or quarantined children according to parental reports associated with pandemic disasters and short quarantine periods during pandemic influenza H1N1 and utilizing a closely similar measuring tool (UCLA-PTSD-Reaction Index-Parent Version) [16]. An estimated sample size of 233 from the population of children/adolescents (6–18 years) in KSA, achieved 90% power to detect a difference of 10% between the hypothesized proportion of 30% and the alternative hypothesis that the maximum expected proportion is 40% with longer quarantine period using a two-sided, binomial hypothesis test with a target significance level <0.05. However, 537 complete responses could be collected which exceeded the required estimated sample size and extremely increased the power of the study to more than 99%. The sample size and study power were calculated by PASS software (Pass output in S1 Fig).

Statistical analysis

Data were analyzed by SPSS version 25.0 (IBM corporation, Armonk, NY) after checking for completeness and inconsistencies. Data were scrutinized and double-checked before and after entry into SPSS program. Frequencies and percentages were used to represent categorical variables, whereas continuous variables were presented as mean, standard deviation (SD) and range. Kolmogorov Smirnov (KS) test was used to test data normality. The associations between qualitative data were compared by chi-square test. Kruskal Wallis test was used to test the differences between medians of the total UCLA-BCSCA PTSD score of the studied variables. Significance was considered at P value <0.05.

Results

Five hundred and thirty-seven participants including 494 Saudi citizens and 43 non-Saudi residents from 5 main regions of KSA completely filled the questionnaire. The participants were 262 (48.8%) boys and 275 (51.2%) girls with a mean and SD of 12.25 ± 3.77 years and a range from 7–18 years. Three hundred and twenty-eight parents (61.1%) had 3 or more children. The sociodemographic data of participants are presented in Table 1.

Table 1

Sociodemographic characteristics of participants (n = 537).

Character		n	(%)
Nationality	Saudi citizen	494	(92.0)
	Non-Saudi resident	43	(8.0)
Region	Central	48	8.9
	Western	433	80.6
	Eastern	19	3.5
	North	23	4.3
	South	14	2.6
Number of children in family	1	76	14.1
	2	133	24.8
	3	103	19.2
	4	103	19.2
	5	64	11.9
	>5	58	10.8
Children/adolescent gender	Male	262	48.8
	Female	275	51.2
School grade of child/adolescent	Primary (grades1-6)	259	48.2
	Intermediate (grades 7–9)	120	22.3
	Secondary (grades 10–12)	158	29.4

In the initial set of questions to explore for traumatic experience with COVID-19 (Table 2), the most frequently reported traumatic effects/events of COVID-19 on Saudi children/adolescents and their families/close relatives were the fears from work of close relative around people who might have COVID-19, followed by upsetting issues that happened to children/adolescents or their families because of COVID-19 in 29.8% and 9.5% of children/adolescents respectively (Table 2).

Table 2

Traumatic effects/events of COVID-19 in Saudi children/adolescents and their families/close relatives.

Effect/Event		n	(%)
Illness of child/close relative because of COVID-19	No	517	96.3
	Yes	20	3.7
Quarantine of child/close relative because of COVID-19	No	512	95.3
	Yes	25	4.7
Positive SARS-CoV-2 of child/close relative	No	501	93.3
	Yes	36	6.7
Work of close relative around people who might have COVID-19	No	377	70.2
	Yes	160	29.8
Moving of a family member away from home because of COVID-19	No	509	94.8
	Yes	28	5.2
Death of any close relative/friend because of COVID-19	No	516	96.1
	Yes	21	3.9
Anything else happened to you or your family because of SARS-CoV-2	No	486	90.5
	Yes	51	9.5

The most frequent upsetting issues were being away from some family members (because of isolation or lockdown in other country), home stay/isolation from outside world for long period and work/isolation of mother/father in health care center reported by 23.5%, 21.6%, and 9.8% of participants respectively (S1 Table). The death of any close relative/friend because of COVID-19 was only recorded by 21 participants (3.9%) with death of 15 close relatives (one sister, 2 brothers, 3 grandmothers, 3 cousins, 2 father’s aunts, 2 father’s cousins, and 2 uncle’s wives) and 6 friends/neighbors.

A median score of 1 was recorded for question number 1 ‘I try to stay away from people, places or things that remind me about what happened or what is still happening’ and question number 4 ‘When something reminds me of what happened or is still happening, I get very upset, afraid or sad’ as well as for question number 6 ‘I try not to think about or have feelings about what happened or is still happening’ (Table 3).

Table 3

Values of individual symptoms and category symptoms of UCLA-BCSCA for PTSD.

Individual/Category symptoms	Median	IQR (Q25-Q75)	Min	Max
Q1: I try to stay away from people, places or things that remind me about what happened or what is still happening	1.0	0.0–3.0	0	4
Q2: I get upset easily, or get into arguments, or physical fights	0.0	0.0–1.0	0	4
Q3: I have trouble concentrating or paying attention	0.0	0.0–1.0	0	4
Q4: When something reminds me of what happened or is still happening, I get very upset, afraid or sad	1.0	0.0–2.0	0	4
Q5: I have trouble feeling happiness or love	0.0	0.0–1.0	0	4
Q6: I try not to think about or have feelings about what happened or is still happening	1.0	0.0–2.0	0	4
Q7: When something reminds me of what happened, I have strong feelings in my body like heart rate beats fast, my head aches or my stomach aches	0.0	0.0–1.0	0	4
Q8: I have thoughts like “I will never be able to trust other people”	0.0	0.0–1.0	0	4
Q9: feel alone even when I am around other people	0.0	0.0–1.0	0	4
Q10: I have upsetting thoughts, pictures or sounds of what happened or is still happening come into my mind when I don’t want them to	0.0	0.0–1.0	0	4
Q11: I have trouble going to sleep, wake up often, or have trouble getting back to sleep	0.0	0.0–1.0	0	4
Category B	2.0	0.0–4.0	0	12
(Intrusion symptoms-Q4,7,10)
Category C	2.0	0.0–4.0	0	8
(Avoidance symptoms-Q 1,6)
Category D	1.0	0.0–4.0	0	12
(Negative conditions/mood symptoms-Q5,8,9)
Category E	2.0	0.0–4.0	0	12
(Arousal/Reactivity symptoms-Q2,3,11)
Total score (11Q)	8.0	3.0–15	0	41

Regarding the rating of PTSD symptoms, no PTSD symptom, minimal PTSD symptom, mild PTSD symptoms and potential PTSD were identified in 83 (15.5%), 237 (44.1%), 147 (27.4%) and 70 (13.0%) of participating children/adolescents respectively (Table 4).

Table 4

Rating of posttraumatic stress disorder symptoms.

Rating		Frequency (n)	%
	0: no PTSD symptom	83	15.5
	1–10 minimal PTSD symptom	237	44.1
	11–20 mild PTSD symptoms	147	27.4
	≥ 21 potential PTSD	70	13.0
	Total	537	100.0

Participating children/adolescents declared that symptom number 4 ‘When something reminds me of what happened or is still happening, I get very upset, afraid or sad’ is the most frequent PTSD symptom in the intrusion B category symptoms, symptom number 1‘I try to stay away from people, places or things that remind me about what happened or what is still happening’ is the most frequent PTSD symptom in the avoidance C category symptoms, symptom number 5 ‘I have trouble feeling happiness or love’ is the most frequent symptom of potential PTSD in Negative conditions/mood D category symptoms and symptom number 2 ‘I get upset easily, or get into arguments, or physical fights’ is the most frequent PTSD symptom in the Arousal/Reactivity E category symptoms (S3–S6 Tables).

Univariate analysis with comparisons of the studied variables and risk factors for PTSD in the initial set of COVID-19 exposure questions revealed that work of a close relative around people who might have COVID-19 and upsetting issues that happened to children/adolescents or their families because of SARS-CoV-2 were significantly different between the groups of no, minimal, mild and potential PTSD symptoms (X2 = 14.7, p = 0.002 and X2 = 12.2, p = 0.007 respectively) but these significant differences disappeared during multivariate regression analysis comparing potential PTSD group to the other 3 groups with no, minimal and mild PTSD symptoms (S7 and S8 Tables).

Saudi children/adolescents had significantly lower median total UCLA BSCCA PTSD score than non-Saudi children/adolescents (H = 9.41, p = 0.002) with no other significant differences detected for other studied variables. Comparisons of total UCLA BSCCA PTSD scale score by nationality, region, age group, gender, and study level are presented in Table 5.

Table 5

Comparisons of total PTSD UCLA brief scale score by nationality, region, age group, gender, and study level.

Variable	Categories Median, interquartile range (Q25-Q75)					H*      df      P
Nationality	Saudi (n = 494)	Non-Saudi (n = 43)				9.4 1.0 0.002
	7.0 (2.0–14.0)	13.0 (7.0–23.0)
Region	Central (n = 48)	Western (n = 433)	Eastern (n = 19)	Northern (n = 23)	Southern (n = 14)	4.7 4.0 0.31
	9.0 (3.0–21.0)	8.0 (2.5–15.0)	3.0 (1.0–9.0)	6.0 (3.0–17.0)	6.0 (3.0–13.25)
Age group	7–12 years (n = 276)	13–18 years (n = 261)				0.06 1.0 0.80
	8.0 (2.0–15.0)	8.0 (3.0–14.0)
Gender	Male (n = 262)	Female (n = 275)				1.12 1.0 0.30
	7.0 (2.0–15.0)	9.0 (3.0–15.0)
Study level	Primary (n = 259)	Intermediate (n = 120)	Secondary (n = 158)			0.09 2.0 0.96
	8.0 (2.0–16.0)	7.0 (3.0–14.0)	8 (3.0–14.0)

*Kruskal-Wallis H test, df: degree of freedom.

Discussion

The global COVID-19 pandemic has significant impacts and serious adverse effects on the physical and mental health of people [10, 20]. Mental health affection by serious infectious pandemic threats has been recognized as an important public health challenge since a long time [21].

Cumulative sufficient evidences demonstrated that the extremely rapidly spreading COVID-19 global pandemic is a life-threatening infection that is serious enough to cause PTSD [20]. Most studies have focused on PTSD related to serious infectious diseases in the medical staffs [22]. PTSD among children/adolescents has been studied less frequently despite the fact that the critically developing children/adolescents are more vulnerable to psychological disturbances owing to their less mature cognitive abilities and adaptive capacities [23].

The COVID-19 pandemic has emerged as an unexpected disaster currently affecting essentially every country. The closure of schools, parks, public places and malls, keeping children locked at home was implemented to prevent further SARS-CoV-2 transmission, but the psychologic consequences of lockdown measures on families and children well-being should be considered. Therefore, this cross-sectional survey study was undertaken to screen for symptoms of PTSD associated with COVID-19 and its resultant long duration of quarantine and lockdown measures in children/adolescent in Saudi Arabia.

In this survey, which was conducted in KSA after 2 months from start of quarantine for COVID-19 pandemic, the results showed that a significant proportion (71.5%) of the participants had PTSD symptoms while they were in quarantine, with 44.1% and 27.4% of participating children/adolescents experienced symptoms of minimal and mild PTSD respectively while potential PTSD that warrant further evaluation and assessment was identified in 13% of participating children/adolescents.

There are other studies documenting the prevalence of PTSD related to disasters secondary to widespread infections. One study utilized a closely similar measuring tool to (BCSCA-UCLA) which is the 17-item self-report PTSD Checklist-Civilian Version to identify PTSD symptoms [20]. It showed that the prevalence of PTSD was 12.8% within one month after the outbreak of COVID-19 in China, but the majority of participants in that study were between 21 to 30 years of age (range was from 14 to 35 years). Thus, the population screened was older than in our study where participating children/adolescents had a mean age of 12.25±3.77 years and age range from 7–18 years. The recorded COVID-19-related potential PTSD prevalence in this survey was also lower than the recorded symptoms of PTSD prevalence of 28.9% in 129 participants (64% of them were adults between 26–45 years and 68% of them were healthcare workers) who were quarantined for even a shorter period with a median duration of 10 days in response to SARS-CoV-1 pandemic in Toronto, Canada [7]. Additionally, the recorded COVID-19-related potential PTSD prevalence in this survey was also lower than the prevalence of PTSD of 30% in children who experienced quarantine for H1N1 in 6 states of USA, Mexico and Canada that was detected by University of California at Los Angeles Posttraumatic Stress Disorder Reaction Index (PTSD-RI) [16]. The PTSD-RI is so closely related and more comprehensive than (BCSCA-UCLA). However, the (BCSCA-UCLA) has the advantages of being simple, brief, self-administered by child/adolescent and designed specifically for COVID-19 related PTSD. Thus, significant variations are expected in PTSD prevalence that may be due to the differences in the age and characters of participants including their possible underlying genetic and health conditions predisposing to PTSD, research methods, diagnostic criteria or measuring tools. Variations are also expected due to differences in cultures, severity and nature of the disaster and time period passed after the main traumatic event.

It is worth to mention that it is too difficult or impossible to disentangle the effects of pandemic COVID-19 versus the lockdown in this survey because our participants were experiencing and suffering from both the ongoing COVID-19 pandemic and lockdown during the time of the study. However, in a study to evaluate the psychological, behavioral, and psychiatric assessment of Saudi children exposed to the 2009–2010 South war in Jazan compared to children unexposed to war found that the prevalence of PTSD in unexposed children was only 1.7% [24]. So, there is a remarkable significant rise in the prevalence of PTSD from a pre-pandemic level of 1.7% to 13% in children/adolescents during COVID-19 pandemic and lockdown.

In the present study, we tried to investigate the risk factors associated with potential PTSD in Saudi children/adolescents by univariate and multivariate analysis of the demographic characters and the most important traumatic events of COVID-19. The current study examined characteristics of participants such as age, school grade, gender, region of residence in KSA and family size to be predictive or associated with PTSD symptoms, yet the results were negative. In a previous research, the results were different, and it was found that younger age was predictive of disaster-induced PTSD [25]. However, younger children may be less able to recognize and estimate the dangers and consequences of COVID-19 and consequently suffer less PTSD than older children. Similarly, another study found that age has no significant association with PTSD [7].

Women have been experiencing double the rates of PTSD compared to men, highlighting the differences due to gender. Adolescence is the expected period for the emergence of these gender differences in symptoms and estrogen is likely the reason due to its effects on neurobiology, leading to increased risk for PTSD in girls [26]. On the contrary, in the present study, there is no significant gender variation in symptoms of PTSD between boys and girls, most probably because nearly 50% of participants were within the pre-pubertal age group (7–12 years). This is similar to a study that found no gender differences in PTSD symptoms in children between 7 and 11 years old [27].

In this study, work of a close relative around people who might have COVID-19 (29.8% of participants) and upsetting issues that happened to children/adolescents or their families because of COVID-19 (9.5% of participants) were significantly different between the groups of no, minimal, mild and potential PTSD symptoms but these significant differences disappeared during multivariate regression analysis. Similarly, it was reported that the impact on children of parents who are frontline fighters is different as compared to parents doing most of their work from home during the pandemic. Quarantine/home confinement is an excellent opportunity for parents-children interaction, but the parents who are providing continuous health services are tired, over pressured and can’t find enough time for their children. These children are missing their fathers and mothers due to extended periods of distancing [28].

In the current study, Saudi children/adolescents had significantly lower median total UCLA BSCCA PTSD score than non-Saudi children/adolescents. This can be explained by the impact of difficulties encountered by expatriate families to adjust to multiple challenges and stressors such as living in a non-native environment, financial constraints, need to readjust life in a new country including learning local language and culture, new schooling system, adapt to a new work and change of social environment, sense of uncertainty and displacement/isolation affecting all family members [29]. This is a unique feature and important finding in our study because up to our knowledge, no previous studies have addressed the comparison of COVID-19 related PTSD or even PTSD between children of citizens of the country and children of expatriate families.

In this study, participants declared that symptoms number 4, 1, 5 and 2 were the most frequent potential PTSD symptoms in the intrusion B category symptoms, the avoidance C category symptoms, the native conditions/mood D category symptoms, and in the arousal/reactivity E category symptoms. As expected, these 4 symptoms were present at a higher percentage in potential PTSD group compared to no, minimal and mild PTSD groups. Consequently, these simple 4 symptoms can be selected to draw the attention of parents and healthcare providers to suspect or notice the possible early evolution of PTSD in traumatized children/adolescents as soon as possible to provide them with proper timely intervention before progression into florid PTSD. Additionally, it should be realized that COVID-19 is going hand in hand with a pandemic of childhood mental illnesses including depression, anxiety and pervasive developmental disorders and childhood obsession [28].

The present study has multiple strengths. Up to our knowledge, it is the first cross-sectional study in KSA and in the Middle East for screening of COVID-19 related PTSD in both children/adolescents of Saudi families and children/adolescents of expatriate non-Saudi families. Additionally, this study is characterized by the adequate sample size with high power of the study (more than 99%), the inclusion of all 5 nationwide regions of KSA, and the use of the UCLA-BCSCA which is a validated, simple and brief measuring tool that is specifically designed for COVID-19 related PTSD and can be used by older children and adolescents themselves or with the help of their parents.

However, this study is not without limitations because there was a higher participation from the western and central regions and lower participation from eastern, northern and southern regions of the kingdom. This can mainly be attributed to the presence of the higher population densities in these 2 regions as well as the uneven distribution of the online questionnaire, which depended on social media and internet resources/accessibility. However, this online questionnaire was the only way to reach participants in view of the inability to directly approach participants in different regions due to lockdown measures. Other limitations may be related to the use of a questionnaire in two different languages and adopting both parent and self-rating with the potential of influencing the findings of this study. Moreover, the UCLA-BCSCA is considered only as a screening tool to detect mainly potential PTSD that warrant further in-depth assessment but follow up of children/adolescents who had potential PTSD to confirm and manage PTSD could not be done. Moreover, other characteristics of participants especially their underlying genetic constitution and preexisting psychiatric or chronic illness disorders that may influence the development of PTSD could not be identified and need further in-depth analysis by another detailed study.

Conclusions

In this study, COVID-19 pandemic and its resultant quarantine were associated with significant negative impact on psychological wellbeing of children and adolescents. Participating children/adolescents experienced symptoms of minimal, mild and potential PTSD in percentages of 44.1%, 27.4%, and 13% respectively. The characteristics of participants such as age, school grade, gender, region of residence in KSA and number of children in the family were not predictive or associated with PTSD symptoms. However, work of a close relative around people who might have COVID-19 and upsetting issues that happened to children/adolescents or their families because of SARS-CoV-2 were significantly associated with potential PTSD symptoms in univariate but not in multivariate regression analysis. Children and adolescents of expatriate families had higher total UCLA-BCSCA scores or more severe PTSD symptoms than children/adolescents of Saudi citizens. Specifically, 4 symptoms in the 4 main PTSD categories of intrusion, avoidance, negative mood and arousal/reactivity could be considered as alarming key symptoms that should alert parents and healthcare providers for early recognition of PTSD evolution in children/adolescents who need further in depth evaluation and management. This study highlighted the importance of COVID-19 related PTSD that should not be overlooked in different populations as it is expected in a significant proportion of children/adolescents with variable prevalence, risk factors and degree of severity. This study have public health implications with particular importance in clinical practice as parents, teachers and healthcare providers (pediatricians, psychologists, psychiatrists) must be aware of the psychological consequences of the COVID-19 pandemic including PTSD. So, they can be prepared with effective strategies/advice on how to handle the commonly expected PTSD during the ongoing COVID-19 pandemic or similar disasters in future, providing children/adolescent with effective coping mechanisms.

PASS output for calculation of the power of study.

(DOCX)

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Upsetting issues associated with or caused by COVID-19.

(DOCX)

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Frequency distribution of University of California at Los Angeles brief COVID-19 screen for child/adolescent PTSD questionnaire variables.

(DOCX)

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Frequency distribution of intrusion category B symptoms in 4 PTSD categories.

(DOCX)

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Frequency distribution of avoidance category C symptoms in 4 PTSD categories.

(DOCX)

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Frequency distribution of negative conditions/mood category D symptoms in 4 PTSD categories.

(DOCX)

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Frequency distribution of arousal/reactivity symptoms category E symptoms in 4 PTSD categories.

(DOCX)

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Univariate analysis of risk factors between categories of PTSD.

(DOCX)

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Multinomial regression for all studied variables or risk factors associated with potential PTSD compared to the other 3 combined groups (group without PTSD, group with minimal and group with mild PTSD).

(DOCX)

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19 Apr 2021

PONE-D-21-07795

COVID-19 related posttraumatic stress disorder in children and adolescents in Saudi Arabia

PLOS ONE

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Vedat Sar, M.D.

Academic Editor

PLOS ONE

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Reviewer #1: The authors present a well powered cohort of over 500 indiviudals screened with the Brief COVID-19 Screen for

Child/Adolescent PTSD to test if the COVID-19 related lockdown increases risk for PTSD in children.

While the overall study is interesting, I have some open issues to be considered before publication.

Introduction:

The authors mention previous studies focusing on pandemics and PTSD, specifically, How does it relate to the previous study from UCLA

Also with regards to the discussion the validity of the screening instrument should be considered. i.e. is it adequate to form these subgroups or not.

For example the authros state the “Few studies [7, 16] have evaluated PTSD associated with infectious disasters” It would be intersting to report the main outomces of the studies and introduce them, to better understand what was the a-priori hypothesis was, and if and why the authors would expect differences in KSA cohorts

Data acquisition:

Was the screening filled by parents or children, i.e. is it self-report or not.

In the methods the authors state that “participants under 18 years old” participated. But in the results the authors talk about parents only. I did thus not understand if only parents filled the questionnaire, and if so, if the father or the mother evaluated the child’s behaviour.

I am not a big fan of including more than one individual per family, as the environmental conditions for each individual are presumably the same and thus the effects get overestimated. Where the authors able to consider this, or how was this accounted for.

Why was age considered as binary parameter and not as a quantitative parameters

How was the translation done and how was the translation evaluated. Information can get lost during translation of screening questionnaires.

Results:

Please report effectsizes whenever possible. In the statistics section the authros report to test median group differences using KW-test, but report an F-value rather the H-value without the deegrees of freedom. In case of significant effects please also provide pairwise comparisons.

Further It is not clear to me why the main readout of the PTSD Screening questionnaire was reported as mulinomial problem only and not as a quantitative regression problem.

In regression analysis also provide the overall model significance

Was multicollinearity between the predictors investigated

Discussion

In the discussion PTSD diagnosis, PTSD symptoms present not Present and meeting the PTSD screening cutoff are mixed, please adjust accordingly. these are three different measures.

The authors report that the identified PTSD rate of 13% is lower than expected, however to my opinion it is pretty similar to the 12.8% identified within one month after the outbreak of COVID-19 in China.

Indeed it is however lower than the PTSD of 30% in children who experienced quarantine for H1N1 in 6 states of USA, Mexico and Canada [16].

A critical review of the different tools and measures within the studies would be highly recommended. Also it would be interesting to see if the rate in the expats cohorts might be similar.

I am not sure if the presented study can make a conclusion on the pandemic versus the lockdown. It would be necessary to disentangle these two dimensions at least by comparing the numbers to the frequencies of PTSD symptoms in a general pre-pandemic population.

Finally, while I agree that the current situation challenges resilience mechanisms of children, I would encourage to dig deeper into the data to understand if the individuals with parents and or siblings at home are more resilient compared to those where children are home alone during lockdown.

Also I would encourage to build a more detailed quantitative regression model predicting number symptoms.

Minor comments

Report in the abstract if the assessment is self or parental report

First the nomenclature between Sars-Cov2 (refereeing to the virus) and COVID (refereeing to the disease resulting from the virus) and the COVID19-Pandemic is not consistent and should be reviewed

provide the raw data

**********

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Reviewer #1: No

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10 May 2021

Dear Editor in Chief and Academic Editor of PLOS ONE Journal,

Thank you for the revision of this original article (PONE-D-21-07795: COVID-19 related posttraumatic stress disorder in children and adolescents in Saudi Arabia) and giving us the chance to respond and explain some issues that can answer all concerns of editor/reviewer (s).

We have responded to all comments and each point raised by the academic editor and reviewer (s) and all required necessary changes were added to the manuscript appropriately at the relevant sites highlighted in red color and within the requested time frame for revision.

Both a marked-up copy of the manuscript with highlighted changes (Revised Manuscript with Track Changes) and an unmarked version of the revised paper without tracked changes labelled (Manuscript) were uploaded as 2 separate files.

Reply to Comments of the Academic Editor:

1. The PLOS ONE's style requirements for the manuscript meets, including those for file naming were met.

2. "Male” or "Female" were changed to "Boy” or "Girl" as appropriate when used as a noun but not to “Man” or “Woman” because the participants were children and adolescents.

3. The request of additional information about the participant recruitment method and the demographic details of participants, including a description of how and from where participants were recruited.

Response/Reply:

The participant recruitment method, including a description of how and from where participants were recruited, was described in the materials and methods section of the originally submitted manuscript under:

A. The subheading (Study design and selection of participants) in page 12, lines 109-112:

Parents of children and adolescents were randomly selected and approached by an electronic online form of BCSCA. Parents were invited to answer this questionnaire if they were Saudi citizens or residents and had children/adolescents with age range of 6-18 years, who experienced the COVID-9 quarantine.

B. The subheading (Questionnaire implementation and distribution) in page 14, lines 146-150:

Both English and Arabic questionnaires were converted to Google forms, so participants can select to fill the most convenient questionnaire for them. Then, the links of both questionnaires were sent via social media, including WhatsApp’s, Facebook and Twitter, to participants. Participants were allowed to send the questionnaire’s link to their relatives and friends as a mean to increase the sample size.

Regarding the demographic details of participants, we included (Nationality, Region in KSA, Number of children in family, Age and gender of child/adolescent, School grade of child/adolescent) as in the original Brief COVID-19 Screen for Child/Adolescent (BCSCA) PTSD developed by University of California at Los Angeles UCLA (BCSCA-UCLA). An initial thinking to include more demographic details was cancelled because the questionnaire will be lengthier and participants may not be encouraged or refuse to answer such long questionnaire with inquiry about more private details of their life as monthly family income, level of education and occupation of mothers and fathers and type of home (rent or own apartment/villa). The idea was to encourage as much participants as possible to answer the main relevant questions of the (BCSCA-UCLA) which increases the sample size and power of the study. These main relevant questions have a priority and are much more important than questions for other demographic details of participants because they concentrate on risk factors of COVID-19 related PTSD such as affection of children/adolescents or their families and near relatives/friends by the COVID-19 and its serious effects to be followed by questions about the frequency of PTSD symptoms. Thus, there is an initial set of 7 questions to briefly review the traumatic event, assist the child in recalling details of the traumatic event and set the stage for the subsequent 11-item set of validated questions about the frequency of PTSD symptoms in the past month. Therefore, we did not want to make a longer questionnaire with including relatively less important questions about other demographic details of participants which may result in reluctance and unwilling of the participants to share or complete the provided (BCSCA-UCLA) questionnaire.

Reply to Comments of the Reviewer (s):

1. The reviewer was concerned about making all data underlying the findings in the manuscript fully available.

Response/Reply: The data was provided as part of the manuscript and in the supplementary materials or supporting information. Additionally, the raw data SPPS file was made available and deposited to figshare public data repository. DOI: 10.6084/m9.figshare.14565531

2. In the introduction, the reviewer asked about previous studies focusing on pandemics and PTSD, specifically, and how does it relate to the previous study from UCLA.

Response/Reply:

In the introduction, we have just mentioned 2 studies (References number 7, 16) which evaluated PTSD associated with infectious pandemic disasters in children/adolescents but we did not mention any relation to (BCSCA-UCLA) questionnaire because (BCSCA-UCLA) was presented later on in the material and methods section. However, the study of PTSD in children who experienced quarantine for H1N1 in 6 states of USA, Mexico and Canada (Reference number 16) utilized University of California at Los Angeles Posttraumatic Stress Disorder Reaction Index (PTSD-RI) which is so closely related and more comprehensive than (BCSCA-UCLA). The (BCSCA-UCLA) has the advantages of being simple, brief, self-administered by child/adolescent and designed specifically for COVID-19 related PTSD. This was added in the discussion section to compare between PTSD associated with infectious pandemic disasters in children/adolescents in Saudi Arabia and in other countries. Moreover, another recent Chinese study utilized a closely similar measuring tool (17-item self-report PTSD Checklist-Civilian Version) to identify PTSD symptoms in youth (Reference number 20). This was mentioned in discussion section of the originally submitted manuscript, page 22, lines 269-270. However, this was more emphasized and relation to (BCSCA-UCLA) was clearly mentioned.

3. In the introduction, the reviewer mentioned that it would be interesting to report the main outcomes of the studies about PTSD associated with infectious pandemic disasters in children/adolescents and introduce them, to better understand what was the a-priori hypothesis was, and if and why the authors would expect differences in KSA cohorts.

Response/Reply:

The main outcomes of these studies and the differences from our KSA cohort have been mentioned in details in the discussion section of the originally submitted manuscript, page 22, lines 268-286. This part may be more convenient to be mentioned in the discussion section while comparing outcomes of our study to outcomes of other similar studies.

4. In data acquisition, the reviewer inquired if the screening questionnaire was filled by parents or children, i.e. is it self-report or not. In the methods the authors state that “participants under 18 years old” participated. But in the results the authors talk about parents only. I did thus not understand if only parents filled the questionnaire, and if so, if the father or the mother evaluated the child’s behavior.

Response/Reply:

The screening BCSCA-UCLA questionnaire was filled by both parents and children as it was fully explained and mentioned in the materials and methods section of the originally submitted manuscript, page 14, lines 151-156 that:

The questionnaire was directed to parents of children who can fill the whole questionnaire including response to questions directed for their children after taking opinions and answers first from their eldest child. Furthermore, the parent could also enter the questionnaire link again to fill further questionnaire(s) for other children between 6-18 years. The child/adolescent was also allowed to directly answer questions if desired, and he/she understood the questions with or without the help of his/her parents.

In the results section, parents were only mentioned because they either filled the questionnaire for their younger children after taking their responses (opinions/answers) to the included questions (Parental-reported/completed questionnaire) or provide the questionnaire for older children/adolescents who can understand and answer questions without any help (Self-completed questionnaire). However, if older children/adolescents ask for the help of their parents to explain any question, parents were present beside them as interviewers to explain any raised question or issue. So, parents were mainly mentioned in the results because they were pivotal in the collection of data for this questionnaire.

However, more clarification of the method of filling the questionnaire was included in the material and methods section under the subheading; Questionnaire implementation and distribution and parents were replaced by participating children/adolescents in results section..

5. In data acquisition, the reviewer mentioned: I am not a big fan of including more than one individual per family, as the environmental conditions for each individual are presumably the same and thus the effects get overestimated.

Response/Reply:

Thanks to the reviewer for raining this issue. We agree that including more than one individual per family, as the environmental conditions for each individual may be presumably the same and thus the effects get overestimated. However, there are individual factors that may be more important than the environmental conditions (which will be constant factors for individuals of the same family) in predisposition for PTSD such as the age/study level which is closely related to developmental maturity level and ability to perceive the traumatic effects of COVID-19 resulting in PTSD. Additionally, gender and other individual risk factors are important risk factors associated with COVID-19 PTSD as mentioned in previous studies and discussed in the discussion section.

6. In data acquisition, the reviewer inquired why was age considered as binary parameter and not as a quantitative parameter.

Response/Reply:

This was done because we want to detect the difference in PTSD UCLA brief scale score between school children (7-12 years) and older adolescents (13-18 years) to have 2 main groups with considerable number in each group to get robust results when comparing such 2 groups with evident difference in age group and level of developmental maturity (i.e. there may be no marked difference in COVID-19 related PTSD between 7 and 8-year old child or between 13 and 14-year adolescent but considerable differences are expected when comparing between a group of school children and older adolescents).

7. In data acquisition, the reviewer inquired about how was the translation done and how was the translation evaluated.

Response/Reply:

It was mentioned in the materials and methods section of the originally submitted manuscript under the subheading; Questionnaire implementation and distribution, page 14, lines 143-145, that: The UCLA-BCSCA is originally available in English and it was translated into Arabic, checked by two bilingual experts and used in a pilot study for Arabic speaking participants to detect if any amendments are required.

8. In results, the reviewer mentioned that authors reported to test median group differences using KW-test, but report an F-value rather the H-value without the degrees of freedom.

Response/Reply:

Thanks for the review for detecting this point. F-value was a typographic error because it is actually and certainly the H-value and not F-value. This typographic error was corrected and degrees of freedom were added.

9. In results, the reviewer inquired why the main readout of the PTSD Screening questionnaire was reported as multinomial problem only and not as a quantitative regression problem.

Response/Reply:

This was related to the type of the studied variables included in the analysis or comparisons such as nationality (whether Saudi citizen or Non-Saudi resident), region (whether participants were from central, eastern, western, northern or southern region), age group (7-12 year old school children versus 13-18 year older adolescents), gender (either boy or girl) and study level (primary versus intermediate versus secondary school level). All the previously mentioned variables are represented in a qualitative way (whether present (Yes) or absent (No) and not in quantitative way in the form of (mean or median, standard deviation and range).

10. In regression analysis, the reviewer requested to provide the overall model significance

and asked if multicollinearity between the predictors were investigated.

Response/Reply:

The overall model significance of multivariate regression analysis wasn’t provided and multicollinearity between the predictors were not investigated because the regression model did not detect significant predictors associated with COVID-19 related PTSD. Only Saudi nationality persisted as significant factor with significantly more Saudi children with potential PTSD than non-Saudi children with potential PTSD (certainly number of Saudi participants were significantly more non-Saudi) but the total BCSCA scale score (i.e. severity of PTSD symptoms) was significantly higher in non-Saudi than Saudi children/adolescents. It was mentioned in the results section of the originally submitted manuscript, page 20, lines 234-236 and in Table S8 in the supplementary materials that: these significant differences disappeared during multivariate regression analysis comparing potential PTSD group to the other 3 groups with no, minimal and mild PTSD symptoms (Supplementary information, S8 Tables).

11. In the discussion, the reviewer mentioned that PTSD symptoms present/not present and meeting the PTSD screening cutoff are mixed, please adjust accordingly as these are three different measures.

Response/Reply:

This issue was explained and it was addressed in materials and methods section of the originally submitted manuscript, pages 13 and 14, lines: 137-141, that: The UCLA BCSCA assessment tool includes reaction index total scale score based on (DSM-5) PTSD diagnostic screener, with screener rating from 1-10 denoting minimal PTSD symptoms and rating from 10-20 denoting mild PTSD symptoms whereas rating of 21 or higher denotes potential PTSD and warrants further evaluation 140 by full PTSD-reaction index assessment and triage.

Accordingly, it was clearly mentioned in the discussion section of the originally submitted manuscript, pages 21 and 22, lines: 262-267, that: In this survey, which was conducted in KSA after 2 months from start of quarantine for COVID-19 pandemic, the results showed that a significant proportion (71.5%) of the participants had PTSD symptoms while they were in quarantine, with 44.1% and 27.4% of participating children/adolescents experienced symptoms of minimal and mild PTSD respectively while potential PTSD that warrant further evaluation and assessment was identified in 13% of participating children/adolescents

12. In the discussion, the reviewer pointed out that the authors report that the identified PTSD rate of 13% is lower than expected; however to my opinion it is pretty similar to the 12.8% identified within one month after the outbreak of COVID-19 in China.

Response/Reply:

Yes we completely agree with the reviewer on this point and we have discussed our results in comparison with this particular Chinese study in youth as it was mentioned in the discussion section of the originally submitted manuscript, pages 22, lines: 269-274, that: One study utilized a closely similar measuring tool (17-item270 self-report PTSD Checklist-Civilian Version) to identify PTSD symptoms [20]. It showed that the prevalence of PTSD was 12.8% within one month after the outbreak of COVID-19 in China, but the majority of participants in that study were between 21 to 30 years of age (range was from 14 to 35 years). Thus, the population screened was older than in our study where participating children/adolescents had a mean age of 12.25±3.77 years and age range from 7-18 years.

13. In the discussion, the reviewer mentioned that indeed it is however lower than the PTSD of 30% in children who experienced quarantine for H1N1 in 6 states of USA, Mexico and Canada [16]. A critical review of the different tools and measures within the studies would be highly recommended.

Response/Reply:

Yes we completely agree with the reviewer on this point and critical review of different tools/measures and characteristics of the participants was done and explanations for variations between outcomes of different studies were mentioned in the discussion section of the originally submitted manuscript, pages 22, lines: 281-286 as it was mentioned that: Thus, significant variations are expected in PTSD prevalence that may be due to the differences in the age and characters of participants including their possible underlying genetic and health conditions predisposing to PTSD, research methods, diagnostic criteria or measuring tool. Variations are also expected due to differences in cultures, severity and nature of the disaster and time period passed after the main traumatic event.

14. In discussion, the reviewer raised attention that also it would be interesting to see if the rate in the expats cohorts might be similar.

Response/Reply:

Thanks too much for the reviewer for raising this point as children/adolescents of expatriate families had significantly higher median total PTSD score than children/adolescents of the Saudi citizens. This is a point of strength, a unique feature and important finding in our study because up to our knowledge, no previous studies have addressed the comparison of COVID-19 related PTSD or even PTSD between children of citizens of the country and children of expatriate families.

15. In the discussion, the reviewer said that I am not sure if the presented study can make a conclusion on the pandemic versus the lockdown. It would be necessary to disentangle these two dimensions at least by comparing the numbers to the frequencies of PTSD symptoms in a general pre-pandemic population.

Response/Reply:

Thanks again for the reviewer for raising this issue. We completely agree with the reviewer that it is too difficult or impossible to make a conclusion on the pandemic versus the lockdown because our participants were experiencing and suffering from both the ongoing COVID-19 pandemic and lockdown during the time of the study. However, the reviewer promoted and alerted us to search for the frequencies of PTSD symptoms in a general pre-pandemic population. A study by El Hatw et al, 2015 to evaluate the psychological, behavioral, and psychiatric assessment of Saudi children exposed to the 2009-2010 South war in Jazan compared to children unexposed to war found that the prevalence of PTSD in unexposed children (general pre-pandemic population) was only 1.7%.

El Hatw MM, El Taher AA, El Hamidi A, Alturkait FA. The association of exposure to the 2009 south war with the physical, psychological, and family well-being of Saudi children. Saudi Med J. 2015; 36 (1): 73–81. doi: 10.15537/smj.2015.1.9494

So, there is a remarkable significant rise in the prevalence of PTSD from 1.7% in general pre-pandemic population to 13% in Saudi children during COVID-19 pandemic and lockdown. This section was added and highlighted in the discussion section and the relevant reference was added.

16. In the discussion, the reviewer encourages to dig deeper into the data to understand if the individuals with parents and or siblings at home are more resilient compared to those where children are home alone during lockdown.

Response/Reply:

This was done (please see S7 Table: Univariate analysis of risk factors between categories of PTSD in the supplementary material). The number of children/family did not differ significantly between category groups of PTSD (X2=22.6, p= 0.09) in univariate regression analysis. The work of close relative around people who might have COVID-19 was significantly higher in children/adolescents with more severe (Potential) PTSD (X2=14.7, p= 0.002) in univariate regression analysis but this significant difference disappeared in multivariate regression analysis.

17. The reviewer encourages building a more detailed quantitative regression model predicting number symptoms.

Response/Reply:

The qualitative regression analysis model was used as it was explained in response to point number 9 that:

This was related to the type of the studied variables included in the analysis or comparisons such as nationality (whether Saudi citizen or Non-Saudi resident), region (whether participants were from central, eastern, western, northern or southern region), age group (7-12 year old school children versus 13-18 year older adolescents), gender (either boy or girl) and study level (primary versus intermediate versus secondary school level). All the previously mentioned variables are represented in a qualitative way (whether present (Yes) or absent (No) and not in quantitative way in the form of (mean or median, standard deviation and range).

18. In minor comments, the reviewer asked to report in the abstract if the assessment is self or parental report

Response/Reply:

This was reported and highlighted in the abstract as the questionnaire can be parent-reported or self-completed by older children/adolescents themselves.

19. In minor comments, the reviewer requested to review the nomenclature between Sars-Cov2 (refereeing to the virus) and COVID (refereeing to the disease resulting from the virus) and the COVID19-Pandemic as it is not consistent.

Response/Reply:

The nomenclature between Sars-Cov2 (refereeing to the virus) and COVID (refereeing to the disease resulting from the virus) and the COVID19-Pandemic is reviewed and it is consistent.

Submitted filename: Reply to Editor-Reviewer Comments.docx

Click here for additional data file.

17 Jun 2021

PONE-D-21-07795R1

COVID-19 related posttraumatic stress disorder in children and adolescents in Saudi Arabia

PLOS ONE

Dear Dr. Hegazi,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Vedat Sar, M.D.

Academic Editor

PLOS ONE

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have addressed the questions adequately

And the manuscript has significantly improved, however the question rgarding the linear regression model (as opposed to the multinominal model) was not answered appropriately. I suggest to adapt a linear regression model (preferebly with fixed AND random effect (reasons below) using PTSD symptom count as dependent variable. This has much more power to detect small effects and allows to adequately correct for hierarchical biases as introduced by rater and or language.

I still have some problem with using a questionnaire in two different languages: Translation and cultural adaption of a questionnaire can bias a result. Specifically, since translation of a questionnaire to my opinion is not trivial (i.e. forward and backward translations and validation of the psychometric constructs) . The authors should mention this in the limitation section or detail their efforts in the methods and supplements.

This is specifically relevant, since the main finding is within the subcohort of expats, where I would assume most of the English questionnaires have been collected.

This potential limitation and potential bias of the study should be clearly mentioned, or even better be tested in the paper.

The second limitation is the potential bias between self and parent rating.

Thus I again strongly suggest to include a sensitivity analysis to ensure that language and/or rater do not influence the finding.

Overall the main finding reported in the Paper is a comparison between groups without correcting for potential confounders. This might also explain why the multinominal association association is not replicating the frinding sfrom the KW test.

Data Sharing:

Overall the authors provided summary statistics in the supplement, which however does not allow replicating the findings.

If the original data can be downloaded somewhere for replication purpose, the authors should highlight this.

Very minor comment

During the revison process some minor typos have slipped in (e.g. line 101)

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Reviewer #1: No

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27 Jun 2021

Dear Editor in Chief and Academic Editor of PLOS ONE Journal,

Thank you for the second revision of this original article (PONE-D-21-07795: COVID-19 related posttraumatic stress disorder in children and adolescents in Saudi Arabia) and giving us the chance to respond and reply to all concerns of the reviewer to provide the most accurate presentation of the results of this original research and significantly improving the written manuscript.

We have responded to all comments and each point raised by the reviewer and all required necessary changes were added to the manuscript appropriately at the relevant sites highlighted in red color and within the requested time frame for revision.

Both a marked-up copy of the manuscript with highlighted changes (Revised Manuscript with Track Changes) and an unmarked version of the revised paper without tracked changes labelled (Manuscript) were uploaded as 2 separate files.

Reply to the Comments of the Reviewer:

1. Regarding the question about linear regression model (as opposed to the multinomial model), the reviewer suggested to adapt a linear regression model (preferably with fixed AND random effect using PTSD symptom count as dependent variable because this has much more power to detect small effects and allows to adequately correcting for hierarchical biases as introduced by rater and or language.

Response/Reply:

We have pointed out that this was related to the type of the studied variables included in the analysis or comparisons such as nationality (whether Saudi citizen or Non-Saudi resident), region (whether participants were from central, eastern, western, northern or southern region), age group (7-12 year old school children versus 13-18 year older adolescents), gender (either boy or girl) and study level (primary versus intermediate versus secondary school level). All the previously mentioned variables are represented in a qualitative way (whether present (Yes) or absent (No) and not in quantitative way in the form of (mean or median, standard deviation and range).

Additionally and unfortunately the dependent or outcome variable (PTSD symptoms count or scale score) in this study is not normally distributed and the problem is that the results of the parametric tests including t-test generally used in linear regression for analysis, will affect the significance and reliability of the regression equation and its parameters.

Moreover, normality violation and use of non-normally distributed dependent variable in linear regression, will affect the estimates of the standard error and the confidence interval, and hence the significance of the risk factors (independent variables or predictors).

Finally, linear regression techniques still can be used even if normality is violated using a dependent variable that is not distributed normally and linear regression remains a statistically sound technique in studies of large sample sizes which provides appropriate sample sizes (i.e., >3000) and this extremely large sample size was not available in this study (Li et al, 2012).

Li X, Wong W, Lamoureux EL, Wong TY. Are linear regression techniques appropriate for analysis when the dependent (outcome) variable is not normally distributed? Invest Ophthalmol Vis Sci. 2012 May 1; 53(6):3082-3. doi: 10.1167/iovs.12-9967.

2. Regarding using a questionnaire in two different languages as translation and cultural adaption of a questionnaire can bias a result. The authors should mention this in the limitation section or detail their efforts in the methods and supplements.

Response/Reply:

In the first revision, we confirmed that necessary measures were undertaken to avoid potential bias that may arise as a result of Arabic translation and cultural difference as it was mentioned in the materials and methods section of the originally submitted manuscript under the subheading; Questionnaire implementation and distribution, lines 143-145, that: The UCLA-BCSCA is originally available in English and it was translated into Arabic, checked by two bilingual experts and used in a pilot study for Arabic speaking participants to detect if any amendments are required. However, the potential limitation of using a questionnaire in two different languages as translation and cultural adaption of a questionnaire can bias a result was also clearly mentioned in the limitations of the study.

3. Regarding the potential bias between self and parent rating to ensure that language and/or rater do not influence the finding.

Response/Reply:

The potential bias between self and parent rating was added to study limitations.

4. Regarding data sharing: The reviewer was concerned about making all data underlying the findings in the manuscript fully available.

Response/Reply: The data was provided as part of the manuscript and in the supplementary materials or supporting information. Additionally, it was clearly mentioned in the first revision that the original raw data SPPS file was made available without restriction, and deposited to figshare public data repository. DOI: 10.6084/m9.figshare.14565531 where it can be downloaded for replication purpose.

5. Very minor comment: During the revision process some minor typos have slipped in (e.g. line 101)

Response/reply: Line 101 was rechecked.

Submitted filename: Reply to Reviewer Comments.docx

Click here for additional data file.

19 Jul 2021

COVID-19 related posttraumatic stress disorder in children and adolescents in Saudi Arabia

PONE-D-21-07795R2

Dear Dr. Hegazi,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Vedat Sar, M.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

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Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I do not have any further suggestions. All my previous comments have been adressed or answered, thus I suggested publication of the manuscript

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

27 Jul 2021

PONE-D-21-07795R2

COVID-19 related posttraumatic stress disorder in children and adolescents in Saudi Arabia.

Dear Dr. Hegazi:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Vedat Sar

Academic Editor

PLOS ONE