ARTICLE IN PRESS

Social Science & Medicine 64 (2007) 850–857

www.elsevier.com/locate/socscimed

Psychological distress among parents of children with mental

retardation in the United Arab Emirates
Vivian Khamis
United Arab Emirates University, Al-Ain, Abu Dhabi, UAE
Available online 28 November 2006

Abstract

This study was designed to identify predictors of parental stress and psychological distress among parents of children
with mental retardation in the United Arab Emirates. It examined the relative contributions of child characteristics,
parents’ sociodemographics, and family environment to parental stress and psychological distress. Participants were
parents of 225 mentally retarded children, of whom 113 were fathers and 112 were mothers. Measures of parental stress
(QRS-F), psychiatric symptom index (PSI) and family environment scale (FES) were administered in an interview format.
Hierarchical multiple regression was used to predict parental stress and psychological distress. The results indicate that the
model containing all three predictor blocks, child characteristics, parents’ sociodemographics, and family environment,
accounted for 36.3% and 22.5% of parental stress and parents’ psychiatric symptomatology variance, respectively. The age
of the child was significantly associated with parents’ feelings of distress and psychiatric symptom status, and parental
stress was less when the child was older. Parents reported more psychiatric symptomatology when the child showed a high
level of dysfunction. Fathers’ work appeared to be a significant predictor of parental stress, indicating that for fathers who
were not working the level of stress was higher than fathers who were working. Lower socioeconomic level was associated
with greater symptom rates of cognitive disturbance, depression, anxiety, and despair among parents. Among the family
environment variables, only the personal growth dimension stood out as a predictor of parental stress. An orientation
toward recreational and religious pursuits, high independence, and intellectual and recreational orientations were
associated with lower levels of parental stress. On the other hand, parents in achievement-oriented families showed
elevated levels of parental stress. Implications for prevention, and intervention as well as parent training and system-
oriented counseling programs are discussed.
r 2006 Elsevier Ltd. All rights reserved.

Keywords: United Arab Emirates; Children; Mental retardation; Parental stress; Psychiatric symptomatology; Family environment

Introduction (Crnic, Friedrich, & Greenberg, 1983; Esdaile, &

The continuing care of children with mental
retardation is often stressful for parents as these
children’s difficulties inevitably touch their lives
Tel.: +971 50 3301074; fax: +971 3 7671294.
E-mail address: vkhamis@uaeu.ac.ae.
Greenwood, 2003). The effects on the family unit
can be far-reaching, restrictive, and disruptive, and
they may be economic, social, and emotional in
nature. Although management of the daily needs of
children with mental handicaps has been extensively
documented (Baxter, Cummins, & Yiolitis, 2000;
Bradshaw & Lawton, 1978; Bristol, Gallagher, &

0277-9536/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2006.10.022
 ARTICLE IN PRESS
V. Khamis / Social Science & Medicine 64 (2007) 850–857
Holt, 1993; Butler, Gill, Pomeroy, & Fartrell, 1978;
Donenberg & Baker, 1993; Hastings & Beck, 2004;
Olsen, Marshall, Mandeleco, & Alferd, 1999), there
exists a significant hiatus in the examination of
parental stress and psychological distress among
parents of children with special needs in the United
Arab Emirates (UAE). Research in the area of
disabilities in the UAE have focused on surveys that
investigate the efficacy of the special education
placement (El-Sweidi & Abu Shehab, 1995), and on
teaching effectiveness of the special education
teachers (Dukmak & Alghazo, 2004), however,
empirical research that focuses on parents of
disabled children has been non-existent.
Researchers have indicated that parents of
children with mental retardation are generally at
risk for a variety of family life problems and
emotional difficulties (Beckman, 1991; Dumas,
Wolf, Fisman, & Culligan, 1991; Hanson, Ellis, &
Deppe, 1989; Singer & Irvin, 1989). Paramount
among their family life problems are extra caregiv-
ing demands and restrictive time demands (Beck-
man, 1983; Olsen et al., 1999). The cumulative
impact of daily hassles and difficulties in dealing
with disabled children represent significant stressors
that may subsequently affect parents and family
functioning (Baxter et al., 2000; Crnic et al., 1983;
Duvdevany & Abboud, 2003; Esdaile & Green-
wood, 2003; Singer & Irvin, 1989). In particular, a
great deal of evidence points to associations
between the severity or frequency of behavior
problems of children with intellectual disabilities
and parental stress and psychiatric problems such as
depression and anxiety (e.g., Baker, Blacher, Crnic,
& Edelbrock, 2002; Baxteret al., 2000; Blacher,
Shapiro, Lopez, Diaz, & Fusco, 1997). Additional
child characteristics such as age, and parental
characteristics such as employment predict parental
stress over time (e.g., Baker et al., 2003; Floyd &
Gallagher, 1997; Frey, Greenberg, & Fewell, 1989;
Orsmond, Seltzer, Krauss, & Hong, 2003), as do
aspects of the family environment (Bristol 1987;
Dyson, 1991; Moos & Moos, 2002; Willer, Intaglia-
ta, & Atkinson, 1981).
Despite considerable evidence for the moderating
effect of certain resources in attenuating the stress of
having a child with a disability in the family, the
parameters of resources may vary according to the
culture and the parent. If personal and family
resources are adequate to meet demands, the
individual can successfully adapt (Holahan &
Moos, 1987; Terry, 1991). The competence model
851
assumes that the family environment can facilitate
or hinder adaptive functioning of the parents and
child (Koegel, Schreibman, O’Neill, & Burke, 1983).
For this reason, current interventions advocate a
family-centered approach in which professionals
work with parents to help them cope with the
demands and challenges of parenting a disabled
child (Hallahan & Kauffman, 1997; Hardiman,
Drew, & Egan, 1996). Yet, across cultures the
role of the family has not been documented
(Nihira, Webster, Tomiyasu, & Oshio, 1987; Nihira,
Tomiyasu, & Oshio, 1988).
Children with special needs in UAE
Systematic attempts to educate children with
disabilities in the UAE began in the early 1980s.
The education of children with special needs became
a matter of concern to policy makers and advocates
in the UAE. Government figures show that about
2000 students are currently receiving special educa-
tion in 20 centers across the seven emirates that are
supervised by the Ministry of Labor and Social
Welfare (UAE Department of Information Affairs,
2005).
With respect to the mainstream public and
private school systems, the Ministry of Education
and Youth provides for children to be referred by
schools and assessed by educational psychologists
and speech-language pathologists, and schools to be
given consultative support (Bradshaw, Tennant, &
Lydiatt, 2004). The total number of children served
by special education is 3129 of which 1909 are UAE
citizens. Although there is no special legislation
concerning people with disabilities, all children who
are citizens receive free health care and education,
and are ensured housing. A family also may be
eligible to receive aid from the Ministry of Labour
and Social Welfare for sons and daughters who are
under the age of 18, unmarried, or disabled.
However, because of the feelings of denial, guilt,
shame and stigma surrounding families of disabled
children, placement and early intervention may be
delayed. Social change is beginning to take
place with the establishment of the Association of
Parents of Children with Disabilities, which extends
its work to child’s education and protection,
awareness programs, social security, and social
support (UAE Department of Research and Statis-
tics, 2004).
The current research investigates predictors of
parental stress and psychological distress among
 ARTICLE IN PRESS
852 V. Khamis / Social Science & Medicine 64 (2007) 850–857
parents of children with mental retardation in the
United Arab Emirates. It examined the relative
contributions of child characteristics, parents’ socio-
demographics, and family environment to parents’
outcomes.
Method
Participants
The participants were 225 parents of children (1
parent per child) with mental retardation, of whom
113 were fathers and 112 were mothers representing
the various United Arab Emirates (e.g., Abu Dhabi,
Dubai, etc). Individual schools and centers that
provide special education for children with mental
retardation in the various United Arab Emirates
were selected at random and asked to participate.
From these, children then were selected randomly
with the help of school personnel. The available
parent was telephoned for an interview by one of
five special education graduates. Informed consent
was obtained from participants. They were given a
full explanation of the study, and assured of the
anonymity and confidentiality of their responses.
Parents ranged in age from 21 to 85 years
(M 46.96, SD 12.20). For the entire sample, the
mean level of education for mothers and fathers was
some primary schooling, with the range extending
from no schooling to post-graduate study. Approxi-
mately 74.7% were married, 11.6% were divorced,
5.3% were widowed and 8.4% had more than one
wife. Most of the mothers reported their occupation
as housewives (79.1%) and the remainder worked
either as teachers or employees. On the other hand,
the majority of fathers (80%) were working, mainly
in the army or police (30.2%) or as employees
(24.9%), and the remainder worked in the business
sector. The family size ranged from 3 to 23 (M 9.28,
SD 4.03). Families’ monthly income ranged from
US$300 to US$8200.
The children were 136 males and 89 females. They
ranged in age from 1 to 23 years, with an average
age of 10.40 (SD 4.74).According to parents’ and
school reports 75 of the children were mildly, 111
were moderately and 39 were severely disabled. The
children’s average number of siblings with mental
retardation was 1.39 (range 0–7). The large number
of children with mental retardation in families may
be attributed to endogamy which is very prevalent
in the UAE society. More than one half (53.3%)
attended a daily center for the handicapped or a
regular school with a special education class.
Measures
The measures focused on parental stress and
psychiatric disorders in parents, as well as on risk
factors and mediators of parents’ outcome mea-
sures. The scales reported in this section were
translated into Arabic, and adapted to the UAE
culture.
Child and family data sheet
Demographic and background information about
the child and the family was collected from the
parents and school records. The child variables were
age, gender, type and level of disability, and type of
educational placement. Family sociodemographic
indicators were level of education completed by
parents, marital status, employment, family size,
and total household income.
Resources and stress short-form (QRS-F)
The Questionnaire on Resources and Stress
Short-Form (QRS-F; Friedrich, Greenberg, &
Crinc, 1983; Scott, Sexton, Thompson, & Wood,
1989) is a 54-item true–false questionnaire com-
pleted by the parents that measures the impact of
chronically ill or developmentally disabled family
member on the other family members. An example
item is, ‘‘Caring for—puts a strain on me.’’ The
Kuder-Richerdson -20 reliability coefficient is 0.95,
with item-total correlations ranging from 0.15 to
0.63 and a mean inter-item correlation of 0.26.
Factor analysis produced four factors: Factor 1,
parents and family problems; Factor 2, pessimism;
Factor 3, child characteristics; and Factor 4,
physical incapacitation. Completed by the parents,
the QRS-F yields a total scale score; the higher the
score, the higher the stress.
Psychological distress
The psychiatric symptom index (PSI) (Ilfeld,
1976) was used to measure the intensity of
psychological distress in terms of four syndromes:
depression, anxiety, anger, and cognitive distur-
bance. The PSI was adapted to the Arab culture by
Khamis (2000). The PSI was translated into Arabic
and back-translated. The four symptom dimensions
of the PSI were found with a confirmatory analysis
with varimax rotation. Most of the loadings were
higher than 0.40 and, for some items, even higher
 ARTICLE IN PRESS
V. Khamis / Social Science & Medicine 64 (2007) 850–857 853

45.15
18.26
13 than those obtained in the original study. Cron-

—
bach’s alpha for the total scale was 0.92.

0.25
35.48
The family environment scale (FES)

7.77
12

—
The FES (Moos & Moos, 2002) is a 90-item
true–false scale completed by the parents that

0.25
0.20
10.49
measures the family’s social environmental char-

2.07
11

—
acteristics. Ten scales assess three underlying
domains: Relationship, Personal Growth, and

0.57
0.26
0.44
System Maintenance. An example item is ‘‘You

25.25
5.17
can’t get away with much in our family.’’ The
10

0.22 Relationship domain, measured with Cohesion,

0.15 Expressiveness, and Conflict subscales evaluates
0.51
0.37

14.62
2.56
the degree of commitment and social support family
—
9

members provide each other, the extent of free

0.21
0.17

expression of feelings, and the amount of anger and

0.13

0.041

conflict among members. The Personal Growth

0.06

0.04

0.78
—
8

domain includes the Independence, Achievement

Orientation, and Moral- Religious Emphasis sub-
0.16
0.39
0.02

0.12
0.14

scales. This domain assesses the extent to which

0.09

7.54
5.37
—
7

family members are independent and value cultural,

religious and recreational activities. The System
0.17
0.74
0.33
0.02

0.07

Maintenance domain including the Organization

0.09
0.02

7.25
5.98
—

and Control subscales assesses the degree to which

6

organization and rules are applied to operate family

0.20

5456.74
0.28
0.21

life. The FES, normed on ‘‘normal’’ and distressed

0.02

0.12

10571
0.16
0.16
0.07

families, has internal consistencies ranging from

—
5

0.61 to 0.78 and test–retest reliabilities from 0.68 to

Intercorrelations, means and standard deviations of predictor and outcome variables

0.48
0.47
0.28
0.21

0.86. Here, alpha was 0.73.

0.02

0.08
0.01
0.03
0.05
9.28
4.03
—
4

Methods of analysis
0.48
0.50
0.30

Multivariate analysis of variance (MANOVA)

0.65
0.10

0.07
0.00
0.00
0.11

46.96
12.20

was first performed to compare mothers versus

0.02
—

fathers with respect to the total scale of the

3

Questionnaire on Resources and Stress (QRS-R)

0.18
0.15

0.18
0.03
0.01
0.04

0.01
0.08

and its four subscales (i.e., parent and family

0.13
0.08

0.08

1.84
0.69
—

problems, pessimism, child characteristics, and

2

incapacitation), and to the total scale of PSI in

0.25
0.13

terms of the four syndromes, namely depression,

0.17

0.06
0.07
0.03

0.01

0.00

10.40
0.10

0.10

0.04

0.04

4.74

anxiety, anger, and cognitive disturbance. The

—
1

results indicated that there were no significant

(13) Psychiatric symptom Index (PSI)

differences between mothers and fathers on the

two dependent measures, so they were subsequently
combined. Also there were no significant effects for
child’s gender on these measures. The intercorrela-
(12) Parental stress (QRS)
(11) System maintenance
(6) Mother’s education

tions of predictor variables and outcome variables

(7) Father’s education

(10) Personal growth

Standard deviations

are presented in Table 1. Only predictors that were

(5) Family income

(8) Father’s work

(3) Age of parent
(2) Severity level

(9) Relationship

related to parental stress (QRS-R) and PSI were

(1) Age of child

(4) Family size

 p o0.01.
 po 0.05.

entered in regression equations.

Variables

A hierarchal regression procedure was used to

Table 1

Means

assess the relation of predictor variables to the

outcome measures. Preliminary regression analyses
 ARTICLE IN PRESS
854 V. Khamis / Social Science & Medicine 64 (2007) 850–857

were undertaken to determine which characteristics
of the child and parents were significant, either
as covariates of parent outcome or in interaction
with predictor variables. The child’s age, level of
retardation, and father’s work were related to
parent outcomes. They were, therefore, included in
all regression equations.
In addition, age of parents, number of siblings,
and family size were neither related to parental
stress (QRS) nor to PSI. On the other hand, family
income and level of fathers and mothers education
were related only to PSI but not to parental stress
(QRS). As for the family environment, the three-
dimensions of the FES (i.e., relationship, personal
growth and system maintenance) were significantly
related to the QRS and PSI. The predictor blocks
were entered as follows: first child characteristics,
then parent characteristics and finally family envir-
onment.
Results
Parental stress
Table 2 indicates that the model containing all
three predictor blocks accounts for 36.3% of
parental stress variance. Each predictor block
separately accounted for the following percentage
of parental stress variance: 4.2% by child character-
istics, 3.7% by parent’s sociodemographics, and
28.4% by family environment. The absolute in-
crease in R2 is small for child characteristics 0.042,
and parents’ sociodemographics, 0.038, and med-
ium for family environment 0.308 obtained by
dividing the percentage of additional variance by
the percentage of unexplained variance prior to
entry (Cohen, 1988).
Of the child characteristics, only age of the child
was significantly associated with parental stress.
Among parents’ sociodemographics, fathers work
appeared to be a significant predictor of parental
stress, indicating that for fathers who were not
working the level of stress was higher than for
fathers who were working.
Among the family environment variables, only
the personal growth dimension stood out as a
predictor of parental stress. Active -recreational
orientation (r ¼ 0.58), intellectual–cultural orien-
tation (r ¼ 0.44), independence(r ¼ 0.42), and
moral–religious emphasis (r ¼ 0.20) were asso-
ciated with lower levels of parental stress. On the
other hand, achievement orientation (r ¼ 0.19) was
associated with higher levels of parental stress.
Psychological distress
Table 3 indicates that the model containing all
three predictor blocks accounts for 22.5% of parents’
psychiatric symptomatology variance. Each predic-
tor block separately accounted for the following
percentage of variance: 10.8% by child character-
istics, 7.9% by parent’s sociodemographics, 3.8% by

Table 3
Table 2 Prediction of psychological distress (PSI) by child characteristics,
Prediction of parental stress (QRS-F) by child characteristics, parents’ sociodemographics, and family environment
parents’ sociodemographics, and family environment
b R R2 F df p
Predictor variable b R R2 F df P
Block 1
Block 1 Child characteristics 0.329 0.108 13.44 2.222 0.0001
Child characteristics Child’s age 0.28
Child’s age 0.11 Level of disability 0.17
Level of disability 0.03 Block 2
0.205 0.042 4.87 2.222 0.009 Parents demographics 0.433 0.187 8.37 6.218 0.0001
Block 2 Family income 0.14
Parents demographics Mother’s education 0.15
Father’s work 0.12 Father’s education 0.02
0.281 0.079 6.32 3.21 o0.0001 Father’s work 0.07
Block 3 Block 3
Family environment 0.09 Family environment 0.47 0.225 6.94 7.217 .0001
Relationship 0.58 Relationship 0.06
Personal growth 0.02 0.602 0.363 20.68 6.218 o.0001 Personal growth 0.09
System maintenance System maintenance 0.08

b ¼ std beta. b ¼ std beta.

 po0.05.  po0.05.
 po0.0001.  p o0.0001.
 ARTICLE IN PRESS
V. Khamis / Social Science & Medicine 64 (2007) 850–857
family environment. The absolute increase in R2 is
small for child characteristics, 0.11, parents’ socio-
demographics 0.09, and family environment 0.05.
Of the child characteristics, age of the child and
the severity of disability were significantly asso-
ciated with parents’ psychological distress. Among
parent’s sociodemographic variables, only family
income appeared to predict parents’ psychological
distress. On the other hand, none of the family
environment variables contributed to the final
regression model.
Discussion
The findings indicated that the child’s age affected
both stress and distress, severity of the disability
affected distress, and aspects related to the parents’
economic situation affected both stress and distress.
However, aspects of the family environment were
associated with stress only, but not psychological
distress.
Consistent with previous research (Bristol, 1979;
Donovan, 1988; Floyd & Gallagher, 1997), there
was an association between child’s age and parental
stress and psychological distress. Parents experi-
enced lower levels of stress and distress when their
children were older. This result supports the
adaptation hypothesis which suggests that parents
continue to adapt to a child with disability by
expanding their coping repertoires (Dyson, 1993).
Interestingly, none of the other predictor variables
such as family environment correlated with the
child’s age, implying that cohesion, expressiveness
and conflict do not vary with the child’s age.
On the other hand, the severity of the child’s
disability has an impact on parents’ psychological
distress, but not on parental stress. Consistent with
previous research (Baker et al., 2002; Baxter et al.,
2000; Blacher, Crnic, & Edelbrock, 1997; Hastings
& Beck, 2004), the results indicated that parents
reported more psychiatric symptomatology such as
cognitive disturbance, depression, anxiety, and
despair when the child showed a high level of
dysfunction. Also, consistent with previous research
(Blacher, Nihira, & Meyers, 1987) parents of
children with more severe disabilities were lower
on two family environment domains, namely
personal growth and system maintenance which
include independence, achievement, moral–religious
orientation, organization and control.
Of the parental characteristics assessed, employ-
ment buffered the effects of the child’s disability on
855
stress (Barnet, 1993) and income reduced the impact
on psychological distress. Parent education, while
unrelated to stress or distress, did correlate with the
Personal Growth domain of the Family Environ-
ment.
Parental stress was best predicted by the personal
growth dimension of their present family environ-
ment. An orientation toward recreational and
religious pursuits, high independence, and intellec-
tual and recreational orientation were associated
with decreased levels of parental stress. Although
previous research has indicated that the relationship
and system maintenance aspects of family environ-
ment were predictive of resiliency, adaptability, and
better adjustment in parents (Bristol, 1987; Dyson,
1991), their contribution was not significant in this
study.
Caution is required in interpreting the results.
Given its cross-sectional design, the study cannot
identify causes of parental stress and distress.
Because there was no control group, it is not known
whether the findings distinguish parents of disabled
children from those of non-disabled children or
apply to both. Finally, it was not possible to recruit
mothers and fathers from the same family; only one
was available from each.
On a broader perspective, the different patterns of
predictor–outcome relations have practical as well
as theoretical implications. In the light of the
present findings and approaches to family therapy
(Moos & Moos, 2002; Pino, 1984), a variety of
interventions ranging from informal communica-
tion to parent training and systems-oriented coun-
seling programs may be proposed to aid parents
cope with stress. Treatment methods such as case
management, cognitive behavioral group interven-
tions, and parent-led support networks probably
help to reduce parental stress (Hastings & Beck,
2004). At the community level, advocacy and
education will help to make disability a more
recognized phenomenon with less stigma and great-
er community support. Professionals can help create
a unified front working for the increasing welfare
and support among parents of children with mental
retardation in the United Arab Emirates.
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