Participants and sampling
This is a cross-sectional study, using data randomly collected in three cities, Wuhan, Beijing and Hangzhou, during the pandemic. The data collection started on February 22, 2020, and ended on March 8, 2020. During the recruiting process, the survey, titled "A Survey to Understand Children and Adolescents' Mental Health Condition during the Pandemic", was sent out to teachers, parents, and students in Wuhan, Beijing and Hangzhou through WeChat, a popular messaging and social media app in China. We asked these individuals to pass this information along to people who meet the inclusion criteria in these cities. The inclusion criteria include: Students who are currently enrolled in grade 7 to 12, who accept the informed consent, and are willing to participate in this survey.
A total of 7866 adolescents in these three cities were recruited for the study. Deleting the data from protocols in which the adolescent answered in a total period of time less than 100 seconds (an average of approximately 3 seconds per question), a total of 7772 protocols were considered to be valid. Of the participants whose survey results were considered valid, 2850 were from the Wuhan area, and 4922 of them were from Beijing and Hangzhou. Approximately half of them were male (47.77%, n = 3713) and half were female (52.23%, n = 4059). Due to the similarity of Beijing and Hangzhou's level of severity during COVID-19, this research combined these two areas together and considered them as "Other Areas", to be compared in the aggregate with Wuhan.
Ethical approval and consent
Before beginning the survey, the participants were notified about the purpose and procedures of this study through Questionnaire Star, a survey platform used to collect information. Online informed written consent was obtained from all participants and their parents before they began to fill out the questionnaire. This study was reviewed and approved by the Committee for Ethical Affairs of Beijing Normal University, Faculty of Psychology.
Measures
To understand the relationship between students' mental health condition and their experience during the pandemic, the survey items consisted of some experimenter-generated items specifically targeted to pandemic related conditions, and some widely used questionnaires, including an anxiety measure, a depression measure, and a parenting style measure.
(1) Demographic information and Pandemic related questions
This section of the survey collected some basic demographic information, including participants’ gender, whether they were a single child, school, grade, their location, and whether they have participated the online learning. In addition, the survey asked the participants to report whether they have family members or other relatives who were identified as confirmed or suspected COVID-19 cases; whether their parents (or any one of the parents) were quarantined due to the disease; and if any of their members were involved in first-line job responsibilities related to COVID-19.
(2) Short Egna Minnen Beträffande Uppfostran (S-EMBU)
The Short Egna Minnen Beträffande Uppfostran is a widely used measurement to assess perceived parental rearing style in adolescents (Penelo, Viladrich,& Domènech, 2012). The Chinese version of S-EMBU consists of 23 items and has proven to be a measure with good psychometric properties (Jiang, Lu, Jiang, & Xu, 2010). The measure has three subscales: Rejection, Emotional Warmth, and Overprotection. For the purposes of this study, we selected a total of 10 items that appear more connected with the pandemic context; each subscale has 3 to 4 items. The items selected included, for example: "I can feel the love from my parents", "Recently I feel that my parents interfere in everything I do.", "Recently, my parents often get angry with me for no reasons." The internal consistency reliability for these three dimensions was moderate, and the total scale of the three dimensions has a Cronbach's α measurement of 0.813. (Subscale Rejection: Cronbach's α=0.780; Subscale Emotional Warmth: Cronbach's α=0.770; Subscale Overprotection: Cronbach's α=0.562). Calculating the validity of the scale using Confirmatory Factor Analysis (CFA), the Comparative Fit Index (CFI) was 0.962, and the Root Mean Square Error of Approximation (RMSEA) was 0.085, so all the model fit indexes were acceptable.
(3) Patient Health Questionnaire-9 (PHQ-9)
The Patient Health Questionnaire (PHQ-9; Kroenke , Spitzer, & Williams , 2001) is a widely used, self-administered instrument intended to assess an individual's depressive symptoms. The measurement has 9 items, asking individuals to assess their feelings during the past two weeks. Sample items included, for example, "Feeling down, depressed, irritable, or hopeless", and "Trouble concentrating on things like schoolwork, reading, or watching TV". The scores range from "0" (not at all) to "3" (nearly every day). Total PHQ-9 scores of 5, 10, 15 and 20 represent the cutoffs for mild, moderate, moderately severe, and severe depression, respectively. This means that, in this study, any score higher than 4 is an indication that the individual has depressive symptoms. PHQ-9 has been used with a Chinese population and was found to be a sensitive screening tool with high clinical reliability and validity (Xia et al., 2019).
(4) Generalized Anxiety Disorder-7 (GAD-7)
Generalized Anxiety Disorder-7 (GAD-7, Spitzer, Kroenke, Williams, & Löwe, 2006) is a well-developed short screening tool designed to assess an individual's anxiety level for the past 2 weeks. The scale has 7 items, and the response options range from "0" (not at all), to "3" (nearly every day). Sample items included, for example, "Not being able to stop or control worrying", and "Feeling afraid as if something awful might happen". Cut points of 5, 10, 15 are interpreted as representing mild, moderate, and severe levels of anxiety. This means that any score higher than 4 indicates the presence of anxiety symptoms. The Chinese version of GAD-7 has been validated with a Chinese population with good reliability and validity (He, Li, Qian, Cui, & Wu, 2010; Tong, An, McGonigal, Park., & Zhou, 2016), and was therefore employed to assess Chinese adolescents' severity of anxiety.
Data Analysis
An independent sample t-test was used to examine whether there is a clinically significant difference in anxiety, depression, and parental rearing style comparing Wuhan and other areas in China (Beijing and Hangzhou, in this case). A Chi-Square test was performed for the categorical variables such as gender, with and without depressive and anxiety symptoms, etc. The significance value was set at p<.05 in this study. SPSS Statistics software version 26 was utilized to run this analysis.
The hypothesized moderating and mediating effects were examined by Structural Equation Modeling (SEM) using R version 3.6.1. The goodness of fit was assessed by computing the comparative fit index (CFI), Tucker-Lewis index (TLI), root mean square error of approximation (RMSEA), and standardized root mean residual (SRMR). The acceptable levels of the goodness-of-fit model parameters are CFI > .90, TFI > .90, RMSEA < .05, and SRMR < .05.