Mindfulness,Stress Reactivity,and Depressive Symptoms Among “Third Culture Kids” in the United Arab Emirates

Abstract

So called third culture kids (TCKs), the children and adolescents who accompany their parents on long-term overseas work assignments, often have to face life changes, cultural challenges and threats to social identity. The frequency, intensity and nature of these challenges arguably places some TCKs at heightened risk of stress-related mental health problems. Trait mindfulness, an attribute that can be enhanced through intervention, has been found to buffer against stress reactivity and common mental health problems. This study aims to explore the relationship between stress reactivity, trait mindfulness and depressive symptomatology among expatriate adolescents (TCKs) attending an international school in the United Arab Emirates (UAE). Participants included 230 high school students (57% female) from 45 different nations, with a mean age of 15.5 (±1.3, 12–19). Forty one percent had lived in the UAE for 7+ years. Participants completed measures of trait mindfulness, daily life stress reactivity, and depressive symptoms (CES-D). Mean depression score was high with 68.7% of TCK participants presenting as at risk of clinical depression. Lower stress-reactivity and greater trait mindfulness were associated with lower levels of depression; furthermore, low levels of trait mindfulness partially mediated the relationship between stress reactivity and depression. Efforts that aim to reduce stress reactivity and increase mindfulness might prove especially beneficial among the TCK population.

Keywords

stress mindfulness arab depression third culture kid

The term third culture kid (TCK) refers to children who have spent a significant number of their developmental years outside of the parent’s home culture (Pollock & Van Reken, 2001). Typically, TCKs are the accompanying children of expatriates who have left their passport nation (home culture) to temporarily live and work in another country, one with distinct cultural norms (host culture). The “third culture” is viewed as something other than the host and home culture, and the TCK is described as assimilating elements from each culture (home and host), without necessarily experiencing a strong sense of belonging to either (Pollock & Van Reken, 2001).

Although TCKs are a relatively understudied population (Wilson, 2011), their developmental experience potentially increases vulnerability to psychological problems such as depression, anxiety and substance misuse (Pollock & Van Reken, 2001). This potential increased vulnerability to stress-related psychological problems means that TCKs might benefit from psych-educational and preventative initiatives. In particular, mindfulness-based interventions might prove effective. Mindfulness has been defined as paying attention to present moment experience in a receptive and non-judgmental way (Kabat-Zinn, 1994). Interventions that aim to increase non-judgmental acceptance and metacognitive awareness of present-moment experience appear to alleviate distressing and maladaptive responses to negative moods (Crane, 2009). Mindfulness in this context, is a useful area of research with potentially important implications for the large global population of expatriates and their children (TCKs). This is a population who may well experience elevated levels of stress associated with living and growing up in a host nation.

Firstly, if born outside the host nation, TCKs have to make cultural adaptations and psychological adjustments on arrival in the host culture and again on re-entry into the home culture. The process of acclimatizing and re-acclimatizing to the host and home cultures has been associated with the concept of culture shock/reverse-culture, which is frequently characterized as a constellation of unwanted and potentially challenging psychological states such as acculturative stress, loneliness, depression and anxiety (Smith & Khawaja, 2011; Stone Feinstein & Ward, 1990; Ward & Kennedy, 1999).

Another potential cognitive vulnerability to depression among TCKs relates to the notion of social identity formation. Social identity theory posits that humans have a powerful need to identify themselves with social groups and that such group memberships can be internalized, thereby contributing to one’s self-concept (Tajfel & Turner, 1979). Among TCKs social identity formation has been associated with the notion of cultural homelessness, which Vivero and Jenkins (1999) describe as:

“. . .living within a framework of experiences, feelings, and thoughts that do not belong to any single. . .cultural reference group. . . a sense of not being accepted as members of any existing group” (p. 11).

The sense of being accepted, of feeling like we belong to a valued social group, has important implications for physical and psychological wellbeing (Cruwys et al., 2013; Greenaway et al., 2015). In a review of the literature exploring social identity and wellbeing, Haslam et al. (2009) concluded that social identities and the sense of belonging engendered by them, are cornerstones of both physical and emotional well-being. More specifically, Adams and van de Vijver (2015) assert that the development of an expatriate identity, personal, relational and social, is important for the individual’s wellbeing and psycho-social adjustment.

A third potential vulnerability to depression associated with TCKs relates to the chronic cycles of loss and separation occasioning heightened global mobility. TCKs frequently lose direct contact with valued childhood friends as globally mobile expatriate families relocate or repatriate. The peer network of the TCK is described as being in a state of constant change (Downey, 2012). Unlike the death of a loved one, TCK losses are not always clear-cut, being described as ambiguous and existential losses (Boss, 1999). The frequent experience of such losses is viewed as resulting in relatively high levels of unresolved grief among TCKs (Downey, 2012).

As of 2017 there were estimated to be 66.2 million expatriates worldwide, and the figure was projected to reach 87.5 million by 2021 (Finaccord, 2018). Globalized market forces have increased the opportunity for overseas employment and with it the number of TCKs. This emergent multicultural subpopulation is growing, and several universities and colleges have seen the need to identify and support returnee TCKs with orientation and counseling support services tailored to their unique needs (Morris, 2017). For example, a small scale study of repatriated expatriate US children showed that positive adjustment was associated with positive affect and positive familial bonds (Peterson & Plamondon, 2009).This trend seems set to continue, and in the next few decades mental healthcare professionals are likely to find themselves increasingly encountering TCK clients who face challenges that revolve around re-acculturation (Peterson & Plamondon, 2009).

The United Arab Emirates (UAE) is an Arab, Muslim, country located in the Middle East on the Arabian Peninsula. It is composed of seven Emirates, the most populous of these being Abu Dhabi and Dubai. The UAE is a member of the Gulf Corporation Council (GCC), which includes Bahrain, Kuwait, Oman, Qatar and Saudi Arabia. While the UAE shares ties with the GCC region, UAE nationals, referred to as Emiratis, have their own identity and cultural heritage. UAE nationals compose a small percentage of the population; the UAE has one of the highest expatriate-to-citizen ratios in the world (Thomas, 2014), with expatriates comprising around 89% of the total population of 9.54 million (World Bank, 2018). The majority of UAE expatriates hail from India (around 33%). British nationals are the largest Western expatriate group (~250,000), followed by Americans (~40,000) and Australians (~7,000) (The Economist Intelligence Unit, 2014). The vast majority of expatriates will not reside permanently in UAE. The average length of stay for senior executives is about 4.5 years (Flanagan, 2014). Many expatriates have school age children (statistics not available), who will spend a significant number of their formative years in the UAE. Existing acculturation models do not capture the expatriate experience and may have different implications for psychological well-being (Adams & van de Vijver, 2015). In fact, Adams and van de Vijver (2015) argue that successful expatriate adjustment involves either developing a cosmopolitan identity or maintaining the original identity with only minor superficial adjustments. Research has demonstrated that many TCKs find that they have more in common with each other than residents of their home countries (Hylmö, 2002). These factors, the relatively large expatriate workforce (Thomas, 2014; World Bank, 2018) and the average duration of stay, make the UAE a particularly viable context for exploring depressive vulnerability and resilience among TCKs in the host country.

The demands for change that can be associated with relocating to a new culture, can prove stressful. Therefore, one potential vulnerability worth exploring is heightened stress-reactivity in response to chronic daily life hassles/stressors. Stress reactivity is the degree to which an individual experiences heightened emotional and physiological reactivity in response to stressors. Research suggests that adolescence is a critical developmental time in which patterns of stress reactivity are shaped in nervous system (Romeo, 2010). These patterns, once established may carry lifelong consequences (Romeo, 2010; Spear 2009). Research has demonstrated clear linkages between heightened stress reactivity in response to daily life stressors and depressive symptomology (Bouteyre et al., 2007; O’Neill et al., 2004; Ravindran et al., 1996). Felsten (2004), in a study of undergraduate students in the Midwestern United States, found that stress reactivity was even a better predictor of depressive symptoms than total scale stress scores, both as measured using the Daily Stress Inventory (Brantley & Jones, 1989). This can be interpreted to mean that high levels of affective reactivity in response to small numbers of stressors (e.g., losing one’s phone, exams, family arguments) are better predictors of depression than being minimally to moderately stressed by numerous daily life stressors. This association appears to be unidirectional, as indicated by studies that demonstrate that heightened stress reactivity precedes depression, but not vice versa, in adults in the general population (Cummins, 1990; Wichers et al., 2007, 2008, 2009), college students (Parrish et al., 2011), adults females with a history of major depression (Wichers et al., 2010). Finally, affective stress reactivity in response to daily life hassles is associated with increases in serum cortisol (Van Eck et al., 1996). In the long term, continued chronic stress reactivity is thought to cause changes in hypothalamic pituitary adrenal axis functioning resulting in alterations of cortisol secretion at both at baseline and in response to stress (Burke et al., 2005). These changes have been strongly implicated in the development of depressive symptoms (Holsboer, 2000; Sayal et al., 2002; Van Eck et al., 1996).

Strategies which aid in managing affective and behavioral reactions to stress, may be key elements in preventing both short term and long-term depressive symptoms (Sher, 2004) and particularly beneficial tools for TCKs. As mentioned earlier, one strategy which holds great promise is mindfulness. A large body of research suggests that dispositional mindfulness (e.g. trait-based mindfulness in daily life) is associated with better psychological health (see Keng et al., 2011 for a full review). Several studies report that dispositional mindfulness is associated with better psychological health in diverse youth samples (Swedish youth, Hansen et al., 2009; Dutch youth, Bögels et al., 2008; Chinese adolescents, Black et al., 2012). A recent study of Australian adolescents demonstrated that dispositional mindfulness diminishes the strength of the relationship between daily life hassles and depression/anxiety (Marks et al., 2010). Similarly, Ciesla et al., (2012) deomstrated that dispositional mindfulness moderates the impact of stress among adolescents. In a study exploring the psychological and neural mechanisms of trait mindfulness in reducing depression vulnerability, Paul et al. (2013) suggest that it is the decreased reactivity to inner experience (e.g., negative thoughts and emotions) that is the key facet of mindfulness in reducing the psychological risk for depression.

Mindfulness meditation practices (MMPs) have been shown to increase levels of dispositional mindfulness and may be particularly promising interventions for use in TCKs. Evidence suggests MMPs are effective in helping individuals reduce stress reactivity, and in preventing relapse in the context of recurrent major depression (for review see Chiesa & Seretti, 2011). Empirical research on the utility of MMPs in children and adolescents is somewhat nascent, but also promising (see Tan, 2016 for a critical review). In school based samples of adolescents, MMPs have been shown to have short (Bluth et al., 2016; Lau & Hue, 2011; Raes et al., 2014) and long term benefits (Raes et al., 2014) in improving depressive symptoms as well as increasing psychological well-being in general (Lau & Hue, 2011).

Current Study

Despite the increasing literature on mindfulness as a viable intervention for various types of psychological distress, psychological adjustment and well-being of TCKs have not been studied adequately. Hence, the present investigation aims at assessing mindfulness as a potential protective factor. Little is known about the experience and psychological adjustment of TCKs living in the host nation. This group may however experience a heightened vulnerability to psychological difficulties, such as depression. Adjusting to life in a new nation can prove stressful. For TCKs, such stressors are perhaps exacerbated by the lack of the familial and social networks that would typically be available to them in their home nation. Among TCKs with heightened stress reactivity this matrix of factors could lead to elevated levels of depressive symptomatology. Strategies to aid in managing reactions to stress, such as mindfulness meditation practices, may play a key role preventing depressive symptoms and may be particularly beneficial to TCKs. The present study examines depressive symptoms, stress reactivity and trait mindfulness among 230 high-school students attending an international school in the UAE. This study seeks to first characterize levels of depression and stress reactivity in this population and to determine whether MMPs may hold potential utility as interventions with this group. Firstly, the study aims to assess the levels of depressive symptomology and stress reactivity in a sample of TCKs. Past research, in general, has reported gender differences in depression (Nolen-Hoeksema, 1987), stress reactivity (Wang, 2007) and trait mindfulness (Alispahic & Hasanbegovic-Anica, 2017). It will be useful to examine if such patterns are observed in TCKs too. It is hypothesized that participants will report significant levels of depressive symptomatology and stress reactivity, with females reporting significantly higher levels of depression than males. A second aim of this study is to evaluate the association between stress reactivity and depressive symptomology in TCKs. It is hypothesized that, consistent with previous research (Wichers et al., 2008), stress reactivity will be positively correlated with elevated depressive symptoms in TCKs. Thirdly, this study aims to evaluate whether trait mindfulness mediates the relationship between depressive symptomology and stress reactivity. It is hypothesized that trait mindfulness will mediate the relationship between depression and stress reactivity, indicating that MMPs may hold potential utility as preventative interventions for TCKs.

Method

Participants

Participants (N = 230) were TCK high-school students attending an internationally accredited, private, tuition based, international baccalaureate world school located in Abu Dhabi, the capital city of the UAE. This study was conducted in English. The language of instruction at the school is English and all students are required to have a proficiency in academic English sufficient to be entered to the international baccalaureate diploma program. This school was chosen based on the high-enrolled numbers of TCKs from diverse countries of origin. Participants were 57% female (n = 131) and participants’ ages ranged from 12 to 19 (M = 15.5, SD = 1.3). The majority of students hailed from either Europe, North America or East/Southeast Asia (57.3%). The home passport region of students is detailed in Table 1.

Table 1.

Number and Percentage of Participants by Home Passport Region.

Region	n	%
Europe	71	25.44
North America	46	16.48
East Asia/South East Asia	43	15.41
South Asia	25	8.96
Africa	24	8.60
Australia-Oceana	20	7.17
Middle East	16	5.73
South America	7	2.50
Central Asia	1	0.35

Note. n = 279. Total is greater than n = 230 due to n = 25 participants holding multiple passports from multiple regions.

Some students held passports from more than one country (10%, n = 27). Students hailed from 45 different nations as detailed in Table 2. The duration of time spent in the UAE varied, with 59.1% having spent between 1 and 7 years in the UAE, and remainder having resided for 7 or more years. There were no significant between group differences in age based on either gender or home passport region. A full detail of participant demographic data is available in Table 2.

Table 2.

Participant Demographics by Gender.

	Total	Male	Female
Gender n (%)	230 (100)	99 (43.04)	131 (56.96)
Age: M ± sd	15.54 ± 1.31	15.58 ± 1.16	15.52 ± 1.42
(Range)	(12, 19)	(12, 18)	(12, 19)
Countries of origin
Multiple nationalities	25
Canada	25^a
India	22^e
Korea	19^f
Australia	16^f
United Kingdom	21^b
United States of America	20^a
Egypt	13^a
Germany	11^e
Philippines	7
South Africa	10^c
Indonesia	5
Holland	7^d

Note. A complete list of the 45 nationalities provided by students in the sample included 1. Algeria, 2. Australia, 3. Azerbaijan, 4. Bangladesh, 5. Belgium, 6. Brazil, 7. Canada, 8. Columbia, 9.Costa Rica, 10. Denmark, 11. Egypt, 12. Ethiopia, 13. Finland, 14. France, 15. Germany, 16. Greece, 17. Holland, 18. Iceland, 19. Ireland, 20. India, 21. Indonesia, 22. Ireland, 23. Italy, 24. Japan, 25. Jordan, 26. Korean, 27. Lebanon, 28. Malaysia, 29. Mexico, 30. Morocco, 31. New Zealand, 32. Pakistan, 33. Palestine, 34. Philippines, 35. Poland, 36. Portugal, 37. Russia, 38. Singapore, 39. South Africa, 40. Spain, 41. Sweden, 42. Tunisia, 43. Turkey, 44. United Kingdom, 45. United States of America.

Multiple nationality refers to students indicating that they held citizenship of more than one country. Number of students reporting multiple nationalities, a–5, b–6, c–4, d–3, e–2, f–1.

Measures

Depression

The Center for Epidemiologic Studies Depression scale (CES-D; Radloff, 1977) was used to measure depression. The CES-D is a 20 item self-report measure which asks respondents to evaluate the frequency of depressive symptoms over the past week. Each item is evaluated on a scale of Likert Scale of 0 to 3, with 0 indicating “rarely or none of the time (less than 1 day)” and 3 “most or all of the time (5–7 days).” The scale includes items that tap such as “I felt happy,” “I had crying spells,” and “I felt as I was just as good as other people.” The scale is scored by summing total responses, with items reflecting positive mood states reverse scored. Total scale scores can range from 0 to 60, with higher scores indicating more severe levels of depressive symptoms. A score of 16 is typically used as the cut off point for identifying individuals at risk of major depression.

The CES-D is one of the most widely used measures of depression and is specifically designed to detect depressive symptoms in the general population (Radloff, 1977). While the CES-D was initially normed and validated in the United States in an adult population, its use has subsequently been supported in high school students (Radloff, 1991) and youth and young adults of diverse backgrounds including but not limited to Egyptian (Beshai et al., 2013), Australian (Sawyer et al., 2010), South Asia (Rahman & Rollock, 2004) and the United Arab Emirates (Al-Darmaki, 2003; Ghubash et al., 2000). The CES-D has been validated against evaluation of depressive symptoms in clinical interview (Radloff, 1977) and has strong positive correlations with other widely used standardized measures of depression (Radloff, 1977). The internal reliability of the CES-D in the present study was good, α = 0.90.

Daily life stress

The Daily Life Stress Scale UAE (DLSS-UAE, Thomas et al., 2016) was used to measure daily life stress. The DLSS-UAE is a 34-item measure which asks respondents to evaluate the frequency and perceived severity of common minor daily hassles and stressors. The DLSS-UAE requests that respondents “read the following list of common stressors and indicate how much you have been routinely bothered/upset/stressed by the following issues over the past month” and evaluate each item on a Likert Scale of 0 to 3 with anchors of 0 “not at all” and 3 “severely.” Responses are then summed and scored with total possible scores ranging from 0 to 102, with higher numbers indicating higher levels of daily life stress. Example items include: “family arguments,” “inconsiderate and/or irresponsible drivers,” and “a lack of appreciation for your work from managers or professors at work/university.” The DLSS-UAE is designed for use with both adults and adolescents.

The DLSS-UAE is unique in that it was developed specifically for residents of the UAE and contains specific items that are reflective of the unique experience of this specific cultural context. While many DLSS-UAE items were derived from other commonly used measures of daily stressors and daily hassles (e.g. and are stressors which are common across cultural contexts (e.g., losing personal items such as keys and phone and traffic congestion), additional items were either developed or modified as a result of 15 different focus groups conducted with residents of the UAE. These additional items include items such as hot weather conditions, having to deal with individuals who do not speak English, overly cold air conditioning, uncertainty about the future, and construction noise. These items, while they would be stressful to most individuals, are particularly salient in the context of the UAE. While the DLSS-UAE has not been used specifically with younger adolescents, a pilot study found test re-test data in a small sample of Emirati college students aged 18 to 26 to be good (r (42) = 0.89; Thomas et al., 2016). In the current study the DLSS-UAE demonstrated good internal reliability (α = 0.90).

Stress Reactivity

In addition to total scale score, which represents the aggregate amount of stress experienced by the individual in daily life, the DLSS-UAE can also be used to estimate the degree of emotional reactivity experienced when encountering a minor daily stressful event. This is typically referred to as the “mean stress per stressor.” Mean stress per stressor scores are calculated by eliminating all the non-stressors (items with scores of 0), summing the remaining items and dividing by number of items that were rated as stressors (items with scores greater than 0). Mean stress per stressor scores can potentially range from 1 to 3. Previous research using a variety of stress reactivity measures has demonstrated clear linkages between stress reactivity and depressive symptomology (Bouteyre et al., 2007; O’Neill et al., 2004; Ravindran et al, 1996; Sim, 2000). Stress reactivity is an even better predictor of depressive symptoms than total levels of stress (Felsten, 2004). In the present work we report the mean stress-reactivity score, and, in line with Mukaka’s (2012) scoring of the original DLSS, we also report the mean stress per stressor. The mean stress per stressor scoring discounts any items that are not perceived as a source of stress: items with a score of zero. For example, if only five items on the scale are perceived as stressful then the mean stress per stressor would be the score of just those five items divided by 5. This is arguably a purer measure of an individual’s stress-reactivity to those specific items/stressors.

Dispositional mindfulness

The Mindful Attention Awareness Scale (MAAS) was used to measure trait mindfulness (Brown & Ryan, 2003). The MAAS contains 15-items which evaluate core facets of mindfulness, specifically an individual’s ability to attend to the present moment and be present in the here and now with reflective, receptive, non-judgmental awareness. Respondents are asked to evaluate “a collection of statements about your everyday experience” indicating “how frequently or infrequently” the respondent has each experience. Statements are evaluated on a gradient scale of 1 to 6, with one indicating “almost always,” two “very frequently,” three “somewhat frequently,” four “somewhat infrequently,” five “very infrequently,” and six “almost never.” Responses are then summed and scores with higher scores indicating higher levels of dispositional mindfulness. Items include statements such as “I do jobs or tasks automatically, without being aware of what I’m doing” and “I find it difficult to stay focused on what’s happening in the present.”

The MAAS has demonstrated good psychometric properties (Brown & Ryan, 2003), and has been validated in adolescent (Black et al., 2012), university (Brown & Ryan, 2003), general adult (Brown & Ryan, 2003), and clinical samples (Carlson & Brown, 2005). To our knowledge, the MAAS has not been specifically validated for use with any expatriate population (adults or children). The MAAS, however, has been utilized in populations of adolescents of diverse backgrounds residing in their home countries including Sweden (Hansen et al., 2009), Holland (Bögels, et al., 2008) and China (Black et al., 2012). In this study, the scale had good internal reliability (α = 0.86).

Procedure

The study received prospective ethical approval from the university’s research ethics committee (R201213) and also from the Abu Dhabi Education Council (ADEC, HS16049). Participants were recruited via a school-wide email announcement requesting voluntary participation in a study of stress and psychological well-being. Students enrolled in grades 9 to 12 were eligible to participate in the study. No other screening criteria were used to include/exclude participants.

Data collection took place on-line; participants were directed to the web-based psychometric battery via internal email announcements. After reading a brief participant information screen describing the study participants gave consent and entered demographic data. The study was anonymous and no identifying information (e.g., name or birth date) was collected. The language of instruction at the school is English and all materials were presented online in English. The online presentation did not permit skipping items, so there was no missing data.

Results

Descriptive Analysis

The mean scores for daily life stress, depression, and mindfulness were 42.0 (SD = 14.7), 23.3 (SD = 11.9) and 52.9 (SD = 10.1) respectively (see Table 3).

Table 3.

Means and (Standard Deviations) for All Key Variables by Gender.

	Range	Male n = 99	Female n = 131	t df = 228
Depression Symptoms (CES-D)	0–60	19.92 (10.86)	25.88 (12.02)	3.87**
Mindfulness (MAAS)	0–90	54.29 (9.09)	51.89 (10.77)	–1.78
DLSS-UAE Total Stress	0–102	39.77 (13.91)	43.63 (15.15)	1.97*
DLSS-UAE Count of stressors	0–34	22.91 (6.30)	23.94 (5.46)	1.32
DLSS-UAE Mean stress per stressor	0–3	0.89 (0.50)	1.12 (0.60)	3.03**

Note. CES-D = Center for Epidemiologic Studies Depression Scale; MAAS = Mindful Attention Awareness Scale; N = 230; DLSS-UAE = Daily Life Stress Scale UAE.

p < .05. ** p <.01.

Independent samples t-tests showed no significant gender differences in overall daily life stress scores. Finally, a bivariate correlation matrix (Pearson’s product moment) was used to examine the inter-relationships of the four key variables (Age, CES-D, MAAS and DLSS-UAE), revealing significant positive relationships between all of the study’s main variables (see Table 4).

Table 4.

Correlations for All Key Study Variables.

	CES-D	MAAS	DLSS-T	DLSS-M	DLSS-F
Age	–0.05	–0.04	0.06	–0.09	0.08
CES-D		–0.45**	0.34**	0.85**	0.22**
MAAS			–0.33**	–0.29**	–0.21**
DLSS-T				–0.07	0.84**
DLSS-M					–0.24**

Note. N = 230; CES-D = Center for Epidemiologic Studies Depression scale; MAAS = Mindful Attention Awareness Scale; DLSS-T = Daily Life Stress Scale—UAE, total scale score; DLSS – M = Daily Life Stress Scale—UAE, mean stress per stressor; DLSS-F = Daily Life Stress Scale—UAE, frequency count of items endorsed as stressors.

p < .01. **p <.001.

In order to assess the levels of depression, participants depression scores were evaluated against the CES-D cut-offs proposed Shean and Baldwin (2008), where a score of 16 or greater is used for identifying individuals at risk of clinical depression. In the present study 68.7% (n = 158) of participants scored 16 or above. The higher cut-off of 21, proposed Shean and Baldwin (2008), resulted in 56.1% (n = 129) of participants deemed as at risk.

In order to characterize the levels of stress reactivity (aim 1), mean stress per stressor scores were calculated, as described. Gender differences in mean stress per stressor scores were examined using independent samples t-tests. The mean stress per stressor score reported by participants was 1.02 (SD = 0.57). This corresponds to a mild level of stress reactivity. There were however gender differences, with females reporting a higher mean stress per stressor score (p < .01, See Table 3), and also higher scores than males on six specific DLSS items (See Table 5).

Table 5.

Means and (Standard Deviations) for Items on the Daily Life Stress Scale UAE version With Significant Gender Differences.

DLSS items	Range	Male n = 99	Female n = 131	t df = 228
Phone battery running down	0–3	0.98 (0.90)	1.24 (.85)	2.12*
Uncertainty about the future	0–3	1.65(0.98)	2.00 (1.05)	2.59*
Overly cold air conditioning	0–3	0.96 (0.98)	1.44 (1.08)	3.41**
Family arguments	0–3	1.60 (0.88)	1.97 (.97)	2.99**
Gossip	0–3	0.131 (0.86)	1.62 (1.03)	2.10*

Note. *p < .05. **p < .01.

Bivariate correlations (Pearson’s product moment) with one tailed directional hypothesis were used to evaluate the strength of association between mean stress per stressor scores and depressive symptomology as well as total scale stress scores and depressive symptomology. Correlational analysis showed that mean stress per stressor (DLSS-M) scores were more predictive of depressive symptomatology than total scale stress scores (r = 0.85 vs. r = 0.34, both p < .001). While both were statistically significant, characterization of the strength of association using Mukaka’s (2012) criteria showed that the strength of association between mean stress per stressor and depressive symptomology was high, whereas the strength of association between total scale stress scores and depression could be described as low.

Regression Analysis

A stepwise, forward, multiple linear regression analysis with depressive symptoms as the dependent variable, and gender, stress-reactivity, and mindfulness as predictors resulted in a significant model, F (2,226) = 28.94, p < .001, R² = 0.27. Both stress-reactivity (p < .001) and mindfulness (p < .001) were retained as predictors, with unstandardized beta coefficients of 0.16 and −0.42 respectively. The dichotomously coded gender was also retained as a predictor (p = .001) with an unstandardized beta coefficient of −4.31.

To explore the possible mediating role of dispositional mindfulness in the relationship between stress-reactivity and depressive symptoms a mediation analysis was conducted using the procedure outlined by Baron and Kenny (1996). In this analysis, the independent variable X was defined as stress reactivity, the dependent variable Y was defined as depression and the mediator variable M was defined as dispositional mindfulness. This method requires a series of regressions to establish mediation: (1) Regressing the dependent variable on the independent variable (path c) (2) Regressing the mediator on the independent variable (path a) (3) Regressing the dependent variable on the mediator and independent variables together, in order to establish the effect of the mediator on the dependent variable after controlling for the independent variable (path b) as well as the direct effect of the independent variable on the dependent variable after controlling for the mediator (path c′).

The first regression, establishing path c, showed that stress reactivity (x) was a significant predictor of depressive symptomology (y) (p < .001). The second regression, establishing path a, showed the stress reactivity was a significant predictor of dispositional mindfulness (p < .001). The third and final regression, testing path b, using both dispositional mindfulness and stress reactivity as predictor variables of depressive symptomology showed a significant pathway (p < .001). The direct effect for this model, path c′, showed partial mediation B = 16.42, p < .001 (see Figure 1).

Figure 1.

Model of stress-reactivity as a predictor of depressive symptoms mediated by trait mindfulness.

Discussion

This study explored depressive symptoms, stress reactivity and trait mindfulness among third culture kids (TCKs) presently resident in the UAE. The study aimed to examine the relationship between the three variables, hypothesizing a positive relationship between stress reactivity and depression that is, at least in part, mediated by trait mindfulness.

Compared with previous studies undertaken among high school students in Europe, depressive symptom levels are notably high among the present TCK sample. Depending on whether a conservative cut-off of 21 or traditional screening cut-off of 16 was used, 56.1% to 68.7% of participants were classified as at risk of major depression. Additionally, in the present study, females had significantly higher depressive symptom scores than males, a finding widely reported in the literature and explained with reference to cognitive vulnerabilities attributable to gender-role socialization (Nolen-Hoeksema, 1987; Nolen-Hoeksema et al., 2008). While this study did not employ age matched controls, these findings stand in stark contrast to others finding much lower mean scores in adolescents living in their home countries. For example, a recent study examining depressive symptoms in Arab female college students in the UAE showed a mean CES-D score of 15.6 (SD = 9.9) (Ghubash et al., 2000). A study comprising a sample of 1953 French high-school students in France reported mean CES-D scores for males and females as 14.4 (SD = 7.7) and 18.8 (SD = 10.2) respectively (Chabrol et al., 2002). An earlier study among French adolescents in France (N = 744) also reported lower mean scores (M = 12.4, SD = 7.5 for males and M = 16.6, SD = 9.7 for females (Bailly et al., 1992).

While the overall levels of stress reactivity in this population were mild, contrary to expectations, the results supported previous research suggesting a positive association between stress reactivity and depressive symptoms (Bouteyre et al., 2007; Felsten, 2004; Ravindran et al., 1996; Sim, 2000). Furthermore, as has previously been reported, mean stress per stressor was a better predictor of depressive symptoms than total stress scores (Felsten, 2004). The medium (total-stress) and large effect size (mean stress per stressor; Mukaka, 2012) observed here suggests that these relationships are fairly robust.

As hypothesized, there was a negative relationship between depressive symptoms and trait mindfulness. Again, this was a fairly robust correlation with a medium effect size (Mukaka, 2012) and this finding too is in line with previous explorations suggesting that dispositional mindfulness is a protective factor against depression (Keng et al., 2011; Paul et al., 2013). The fact that duration of stay (number of years lived in the UAE) also correlated with depressive symptoms suggests that elevated depressive symptom scores are not accounted for by the initial adjustment to the new nation, as those who had lived in the UAE longer tended to have higher rates of depressive symptoms. The regression analysis revealed that gender, stress reactivity and trait mindfulness were all retained as independent predictors of depressive symptoms among the TCKs. After undertaking a further mediation analysis, it also appeared that trait mindfulness partially mediated the relationship between stress reactivity and depression. This suggests that activities/interventions aimed at helping individuals cultivate mindfulness might be helpful in reducing depressive symptom levels, and that future research should explore other factors which may also mediate this important relationship.

Beyond depressive symptoms, gender differences were minimal. There were no overall gender differences in trait mindfulness or stress reactivity. Males and females did however differ on stress reactivity total scores and at the item level. For example, women reported significantly more stress associated with “Family arguments” and “Gossip.” This may reflect gender role socialization and the greater restrictions placed on freedom of movement for adolescent females.

Overall, the findings suggest that levels of depressive symptoms were comparatively high among the TCKs in the present study. However, the absence of an age-matched non-TCK comparison group, and the fact that the current data are from a single school, attenuates the generalizability of this finding. The gender differences for depression and the correlation between depression and stress reactivity align with past research and are fairly robust. The present study extends these clinically relevant observations to a population of TCKs resident in the UAE. Furthermore, the mediating role of trait mindfulness also supports the idea that interventions designed to promote mindfulness might prove helpful in reducing the risk of depression among this population. The correlational nature of the present study, however, renders these speculations, at best, tentative.

Strengths

One notable strength of this research is that it provides preliminary cross-sectional data on a understudied population. There is little research examining the experience of TCK and the impact that the expatriate experience may have on their formative development. This research is especially important as the number of expatriates is growing worldwide. This research provides a foundation which other researchers may use to grow both the theoretical and empirical literature. Another strength of this study is the instruments used. The culturally grounded daily life stress scale had good internal reliability. The daily life stressor that most bothered or stressed participants in the present study was “school/university/employment exams,” closely followed by “school/university/professional deadlines,” and “slow internet or connection problems.” The academic theme here is arguably a consequence of the focus on high-school students. Similar findings are reported among North American college students (Kohn et al., 1990), and in a previous study using the DLSS-UAE among Emirati college students (Thomas et al., 2016).

Another strength of this study was the study site itself. The particular school chosen has a very high enrollment of TCKs. Further the TCKs, enrolled in this study are most likely to be children of expatriates employed temporarily in the UAE. The children chosen for this study are likely to live in secured communities composed almost entirely of other senior level expatriates of similar socio-economic backgrounds. Thus, these children are not likely to integrate and assimilate with the local culture, and therefore may often develop an international identity as described by Adams and van de Vijver (2015).

Limitations

This study has several important limitations. The correlational nature of the study leaves issues of temporality and causation unaddressed. For example, feeling depressed may lead to increases in stress reactivity. That said, numerous previous studies have addressed such concerns, finding that high levels of stress reactivity tend to precede the onset of major depressive disorder (Wichers et al., 2007, 2009, 2010). A second limitation is that our data set did not allow for within group comparisons on the basis of culture of origin, due to the small numbers of any one group. It is reasonable to speculate that there may be differences in psychological adjustment, based upon the size of the co-national expat community, with children from countries with larger expat communities making a more favorable adjustment. This should be examined in future research. Another, more significant limitation within the present study was the focus on only one school which contained students primarily from expatriate families with salary packages including tuition. This singular focus means that these findings cannot be broadly generalized to TCKs attending other schools in the UAE or other types of TCKs, such as children of non-national long-term UAE residents born in the UAE. Future studies in the region should include a sample from multiple schools and perhaps also explore the impact of interventions aimed at reducing stress-reactivity and promoting mindfulness.

Implications and Future Research

The findings of this study support previous explorations of stress reactivity, depression and mindfulness (Bouteyre et al., 2007; Felsten, 2004; Keng et al., 2011; Paul et al., 2013; Ravindran et al., 1996; Sim, 2000;). The relatively high depressive symptom scores reported among the TCKs in the present study suggest that this is a high-risk population. The reason for this was not explored within our research. We would also recommend attempts to replicate the current findings in a larger and more broadly dispersed sample of UAE-resident TCKs. While our research cannot establish a causal link between the expatriate experience and higher levels of depression in TCKs, future research exploring these associations in a more systematic fashion is clearly indicated. For example, prospective longitudinal studies may explore the psychosocial adjustment of youth before departure, during their stay and after return. The expatriate experience could also confer youth with long-term benefits, such as increased cultural awareness, and increased resilience in adulthood. In addition, the psychosocial adjustment of youth is likely to be positively correlated with that of their parents. Future research that examines these linkages would be beneficial.

The high levels of depressive symptomatology and the association with stress reactivity suggest that this population might potentially benefit from psych-educational and preventative initiatives. Activities aimed at reducing stress reactivity and promoting mindfulness, for example mindfulness based stress reduction (Kabat-Zinn, 1982) might be particularly helpful in this context. In school-based samples of adolescents, mindfulness-based programs have been shown to have short (Bluth et al., 2016; Lau & Hue, 2011; Raes et al., 2014) and long term benefits (Raes et al., 2014) in improving depressive symptoms as well as increasing psychological well-being in general (Lau & Hue, 2011). This would be a potentially fruitful area for future research that may have important implications for the large population of TCKs residing in the UAE and other nation’s with similar demography.

Conclusion

As the number of expatriates continues to grow worldwide and global mobility and access to information increases, the number of individuals identifying with such third cultures is increasing. Successful resolution of identity and relocation concerns for expatriates may involve the development of a cosmopolitan identity (Adams & van de Vijver, 2015) which not only incorporates elements of the culture of origin, but also transcends it (e.g., “a third culture”).

Overall, the present results demonstrated that at least some school-age populations of TCKs in the UAE have relatively high levels of depressive symptomatology, and that this depressive profile is associated with female gender, increased stress reactivity and decreased trait mindfulness. School health programs in nations with large expatriate populations might consider systematically adopting interventions aimed at promoting mindfulness and reducing stress reactivity among students.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported by a research Grant from Abu Dhabi Education Council Grant Number R15149.

ORCID iD

Kelly L. Huffman

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