- Adolescents experience depression, anxiety, stress, low levels of emotional and edu. functioning
- Mechanism needed for regular screening to assess nutritional and psychological status
- Significant proportion overweight/obese, not getting the recommended servings of cereals/starchy food/pulses
- Guide donors to supply food items according to the requirement of the adolescents in the institution
The majority of adolescents in childcare institutions have some degree of depression, while half of them have anxiety and a lesser percentage have stress along with low levels of emotional functioning and educational functioning. Hence, a proper mechanism should be established for regular screening to assess the nutritional and psychological status of such adolescents in order to identify the problems early while those who need treatment or counselling should be referred as early as possible. Further, since a significant proportion of such adolescents are overweight or obese despite the majority not getting the recommended servings of cereals, starchy food and pulses, in order to maintain an ideal nutritional status and to prevent being overweight and obesity, donors must be guided to supply food items according to the requirement of the adolescents in the particular childcare institution.
These findings and recommendations were made in a research article on the "Nutritional status, psychological status and quality of life (QoL) of adolescents in selected childcare institutions in the Galle District" which was authored by L.T.K. De Zilva (attached to the Ruhuna University's Allied Health Sciences Faculty's Nursing Department) and E. De Zoysa (attached to the same University's Medical Faculty's Biochemistry Department), and published in the BMC Public Health journal's 25th Volume.
Adolescence is the phase of life between childhood and adulthood, from ages 10–19. It is the most unique stage of human development and lays the foundation for future well-being and good health. Adolescents experience rapid physical, cognitive and psychosocial growth (A. Schichor's "Adolescent health").
Institutionalisation is a temporary and exceptional protective measure that does not involve the deprivation of liberty. The number of children placed in institutional settings around the world is rapidly increasing due to factors such as poverty, war, violence and substance use (C.A. Nelson's "A neurobiological perspective on early human deprivation"). Institutionalisation affects children’s nutritional and psychological status and QoL (E. DeLacey, C. Tann, N. Groce, M. Kett, M. Quiring, E. Bergman, C. Garcia and M. Kerac's "The nutritional status of children living within institutionalised care: A systematic review"). Institutionalisation is one of the alternative care choices used in Sri Lanka for children who are not protected and cared for by their original family or extended family. According to the available data, the majority of children in Sri Lankan institutions are adolescents (the Census and Statistics Department's [DCS] "Performance report of the Department for 2015"). Financial difficulties, the inability to provide education, impairments, domestic violence, physical or mental diseases, second marriages, and labour migration are the major reasons for placing children in residential care facilities in Sri Lanka (the Probation and Child Care Services Department's "National Policy for the Alternative Care of Children in Sri Lanka").
In 2013, the National Institute of Social Development (NISD) found 14,179 children living in 414 institutions spread across Sri Lanka’s nine Provinces, and 60.2 per cent of them were females. Per the DCS, in 2019, there were 379 childcare facilities, 331/87.3% of which were voluntary children’s homes.
Nutrition is a vital component in the development of children and adolescents (a Norwegian study), and healthy food is a right of every child (the United Nations Convention on the Rights of the Child, and A. Osei's "Beginning With Brandon’s interest"). Adolescence is considered to be a nutritionally vulnerable period of life. Since they grow faster in this time period, numerous nutritional malpractices increase the risk of developing non-communicable diseases in adulthood, which decreases the productivity of the young generation. Therefore, adolescents in institutions also have the same right to obtain the optimal nutrition level according to their requirements. R. Jayatissa and R.M. Ranbanda's "Prevalence of challenging nutritional problems among adolescents in Sri Lanka” revealed that stunting and being underweight are more prevalent than being overweight, and the corresponding prevalence rates were: stunting (2.2%), being underweight (47.2%), and being overweight (28.5%). R. Jayatissa, D.N. Fernando and H. Himali's "Nutritional status, dietary practices and the pattern of physical activity among schoolchildren aged six–12 years" revealed the related prevalence as follows: stunting (11.5%), thinness (30.2%), being overweight (6.1%) and obese (2.9%). The Global Nutrition Report in 2022 reported that the prevalence of thinness in children and adolescents aged five-19 years is slightly reduced over a period of 16 years and that the prevalence of being overweight and obesity is significantly increased. The quality of nutrition for children in institutions is worse than that for those living in families (an African study). Furthermore, B. Marinkovic, B. Corluka, M. Vukajlovic, B. Bjelica, N. Aksovic, S. Bubanj, E. Petkovic, A. Preljevic, L. Lilic, T. Dobrescu and A.C. Slicaru's "The relationship between psychological factors and nutritional status in adolescence" found that the correlation between psychological characteristics and the body mass index (BMI) indicates a negative low correlation with all psychological aspects: depression, anxiety, and stress, and that subjects who are of normal weight experience less pronounced depression, anxiety, and stress. An Ethiopian study reported that there is poor academic performance among female adolescent students, students whose parents are separated, and students of the first or second wealth index status households, and also better academic performance in students with a better nutritional status.
A person in good mental health is able to manage stressors in life, reach their full potential, learn and work effectively, and give back to their community (A. Verghese's "Mental health"). D. Hettiarachchi's "Mental health needs of children and adolescents in childcare institutions in Sri Lanka" has shown that the mental health of institutionalised children worldwide is significantly worse than that of their peers, with nearly 50% of institutionalised children fulfilling the criteria for 10 mental illnesses. According to a Ugandan study, compared with non-orphans, school-going orphans reported more life unhappiness and more psychosocial challenges.
QoL refers to an individual’s emotional, social, and physical well-being as well as their capacity to perform daily activities (A. Donald's "What is QoL"). The World Health Organisation defines QoL as the “perception by the entity’s position in life, in the context of the culture and value systems in which they live, and the relation to its objectives, expectations, standards and interests” (S. Helseth and N. Misvaer's "Adolescents’ perceptions of QoL: What it is and what matters"). Evaluating QoL is important for developing policies for and determining the allocation of social resources for institutionalised adolescents.
A proper nutritional status, a good psychological status and QoL are essential for the holistic development of adolescents. Proper nutrition supports better physical and cognitive health, which positively influences the psychological well-being, leading to an enhanced QoL. Furthermore, these adolescents will be a part of society in a few years and commit to the economic and social well-being of the country. Therefore, it is important to identify their nutritional and psychological problems early to improve their QoL.
Methodology
De Zilva et al.'s descriptive cross-sectional study was conducted in childcare institutions in the Galle District, which are registered under the Probation and Childcare Services Department. All the adolescents who are living in childcare institutions in the said District were considered the study population. Adolescents (aged 10–19 years) living in childcare institutions for more than three months were included. Those with severe neurological or psychiatric illness were excluded.
There are 13 registered childcare institutions under the said Department in the said District. Among those 13 institutions, one is for children with special needs and was not included. Therefore, data were collected from all the other 12 childcare institutions.
Those in-charge of the childcare institutions are the legal guardians of the children.
The total number of subjects enrolled was 320.
Results
Socio-demographic factors
The majority in the sample were females (194, 60.6%). Most were Sinhalese (289, 90.3%) and the others were Tamil (31, 9.7%). They were evenly distributed in terms of age categories (10–14 years - 154, 48.1%; 15–19 years - 166, 51.9%). A total of 94.1% were attending school, and 5.9% were not attending for various reasons.
Most had both parents (158, 49.4%), and few did not have either fathers or mothers (25, 7.8%). Very few adolescents were frequently visited by their parents or guardians (10, 3.1%). With respect to the reason for entering childcare institutions, 108/33.8% entered due to a lack of protection in their families, 85/26.6% entered due to poverty, 88/27.6% were admitted due to disobedience, 25/7.8% due to sexual abuse, and 14/4.4% due to various other reasons.
Educational performance
The majority were in Grades Eight–10 (129, 42.9%). The marks for English language were comparatively low, but for the other subjects (mathematics, Sinhala language, religion), the majority had some satisfactory marks. With respect to their ideas about future ambition and employment, they had many choices. However, the majority preferred self-employment (77, 24.1%).
Nutritional status
The majority belonged to the normal weight category (185, 57.8%). Importantly, 99/30.9% were overweight or obese, and only 11.3% were underweight.
Assessment of food servings per day via the 24-hr. dietary recall
According to the recommendations, cereals and starchy food should be consumed 11–18 servings per day, but, only 111/34.7% met this requirement, and only 95/29.7% received the recommended servings of pulses.
Psychological status
A total of 224/70% had some degree of depression varying from mild to extremely severe (mild – 20%, moderate – 36.6%, severe – 8.1%, and extremely severe – 5%), and only 96/30% were normal. Anxiety was present in 51.9% (moderate – 87/52.4%, and extremely severe – 23/7.2%), and only 48.1% were without anxiety. Most had a normal level of stress (223, 69.7%), whereas only 30.3% experienced some degree of stress.
Associations between psychological status and socio-demographic factors
There are significant associations between the availability of the parents and depression, anxiety and stress. Furthermore, there is a significant association between the reasons for institutionalisation and anxiety.
Association of the psychological status with QoL
Depression is significantly associated with emotional functioning, and anxiety is significantly associated with physical and emotional functioning. Furthermore, stress is significantly associated with physical, emotional and educational functioning, but there is no such significant association with social functioning.
Discussion
Alternative care for children living away from home, particularly from primary caregivers, has developed over the years due to the increasing pressure brought on families by the socioeconomic forces of modernisation. Government and non-governmental organisations started providing childcare services to those who were vulnerable, abandoned and separated from their families (the NISD's "Current status of childcare, institutions and institutionalised children in Sri Lanka, A situational analysis"). Different types of childcare institutions exist under the preview of the Probation and Childcare Services Department, and they include remand homes, certified schools, safe houses, receiving homes, detention homes, national training and counselling centres for children, children’s homes for disabled children and a few more types.
Approximately two-thirds were females (60.6%). The higher number of female children in childcare institutions may indicate that they are more vulnerable and have less protection and care than male children do. Approximately half had both the parents, and fewer than 25/10% had neither fathers nor mothers. Very few parents visited their children few times per month (10, 3.1%), and more than 50% of them were not visited or were rarely visited by their parents. This may affect the psychological status of this group of children and negatively affect their attitudes towards the society.
Regarding the reasons for entering childcare institutions, four main reasons are identified. A lack of protection in society, poverty and disobedience are the most common reasons, and a relatively small percentage were admitted due to sexual abuse (25, 7.8%). Importantly, 24/96% admitted due to sexual abuse are females, which is an alarming finding in relation to their protection against sexual abuse in society. According to the children’s responses, the main reason for their institutionalisation is the unfavourable conditions prevailing in their homes. This was the view of the Probation Commissioners in the various Provinces, and moreover, 65% of the parent groups interviewed in F. Dheerasinghe and D.S. Anoja's "Dheerasinghe Sinhala translation" revealed that broken families and insecure homes are the main reasons for institutionalisation. N. De Silva, A. Punchihewa and P.S.-S. Lanka's "Push and pull factors of the institutionalisation of children study based in the Eastern Province of Sri Lanka" revealed that the reasons for admission to childcare institutions are relationship difficulties (36%), educational issues (18%) and problems related to protection (12%).
Most attended school, whereas very few did not attend school for various reasons, such as early school dropout, missed school for several years and poor literacy. With respect to school attendance, some national figures have shown that the percentage of those not attending schools is 8.9%, and the percentage in this sample is relatively low (5.9%). Adolescents in this sample are in different grades in school, and sometimes, their grades are not age appropriate. With respect to their school performance, the majority had some average marks for all the subjects other than the English language. The adolescents had a variety of choices regarding their future employment, the percentage of choices is distributed almost equally, and there should also be some special vocational training programmes for the adolescents who are not attending school.
Malnutrition impacts millions of children around the world, and proper nutrition is very important for growing children. Institutionalised children belong to a special category, and there may be a risk of under-nutrition among them. Jayatissa et al.'s study conducted with adolescents in the community reported the following prevalence rates: being underweight (47.2%) and overweight (2.2%). Furthermore, Jayatissa et al. showed that the prevalence of being overweight and obesity is relatively high and the Global Nutrition Report also indicated the increasing trend of being overweight and obesity in children and adolescents aged five–19 years. However, according to the findings of the present study, the majority are in the normal weight category (185, 57.8%), and only 11.3% are in the underweight category. Importantly, 30.9% were either overweight or obese. Adolescents in most childcare institutions obtain their meals frequently from well-wishers and donors, which may be one of the reasons for their good nutritional status, but, this finding is not compatible with the findings of Jayatissa et al.’s study which was conducted in the community.
Food intake patterns play an essential role in the maintenance of health and well-being at both the individual and population levels (R. Jayawardena, N.M. Byrne, M.J. Soares, P. Katulanda and A.P. Hills's "Food consumption of Sri Lankan adults: An appraisal of serving characteristics"). According to the Health Ministry's Nutrition Division's Food-Based Dietary Guidelines for Sri Lankans, there are nine food categories: cereals and starchy food, vegetables and green leaves, pulses, fish and lean meat, eggs, fruits, fresh milk and its fermented products, oils, and finally, coconut and scraped/milk. Their overall nutritional status is satisfactory; however, they are not getting the recommended servings of cereals, starchy food and pulses, and a good proportion of them are receiving fish, lean meat and eggs.
Emotional, social and physical deprivation during early life has been linked to a wide array of acute and long-term mental health consequences (R.I. Federation's "Theoretical, empirical, and practical rationale"). Institutionalised adolescents have a greater risk of negative psychological impact. Young children with a history of institutional care often present with behavioural and emotional problems such as hyperactivity, poor attention, emotional deregulation, increased anxiety, attachment disorders, and poor peer relationships. Institutionalised children can have more internalising symptoms such as anxiety and depressive disorders (K. Bos, C.H. Zeanah, N.A. Fox, S.S. Drury, K.A. McLaughlin and C.A. Nelson's "Psychiatric outcomes in young children with a history of institutionalisation"). In the present study, the majority had some degree of depression, and only 30% of them are normal. Half have anxiety, and stress is present in only 30%.
The ultimate target of the care given to these adolescents in institutions is to offer them a good QoL. The mean scores for the four domains of QoL are good, which indicated that their overall QoL is satisfactory; however, they have relatively low mean scores for emotional and educational functioning.
Stress is significantly associated with the three domains of QoL: physical, emotional and educational functioning. Anxiety is significantly associated with physical and emotional functioning, and depression is associated with only emotional functioning. Furthermore, there is a statistically significant association between the parental status and the psychological status, and there are no significant associations of the nutritional status with the psychological status or QoL.
Conclusion
The nutritional status of the majority is satisfactory. The prevalence of stress is low. The overall QoL is satisfactory. Three domains of QoL (other than social functioning) are significantly associated with stress. The parental status and the psychological status of the adolescents are significantly associated.