- Important to screen and refer to mgt. facilities
- Plan and implement progs. to improve mental health literacy among parents to alleviate family related modifiable associated factors
Since emotional and behavioural problems are common among school-going adolescents, especially among those experiencing difficulties with schoolwork, it is important to screen and refer them, if indicated, to the relevant management facilities, while further programmes should be planned and implemented in order to improve the mental health literacy among parents, which should be aimed at alleviating family related modifiable associated factors of mental health problems.
These observations and recommendations were made in an original research article on “The contributing role of family, religious activities and school in protecting the mental well-being of school-going adolescents in a rural District of Sri Lanka” which was authored by N.H.S. Nadeeka and K. Wijewardena (both attached to the Sri Jayewardenepura University’s Medical Sciences Faculty's Community Medicine Department) and published in the Journal of the College of Community Physicians of Sri Lanka's 29th Volume’s Third Issue in October, 2023.
Adolescents’ mental health problems
Adolescence is considered as the age from 10 to 19 years and is the transient period between childhood and adulthood. During this sensitive period, a child becomes an adult with intellectual, physical, hormonal, and social changes. Therefore, as mentioned in the World Health Organisation's (WHO) “Mental health of adolescents”, it is a period of increased vulnerability to mental health problems related to the regulation of affect (the external expression of emotion where the emotional tone that a person expresses may be appropriate or inappropriate to the situation), emotions and behaviour. Childhood mental health problems can be categorised into three groups, namely, emotional disorders, externalised disorders and developmental disorders. Anxiety, depression, excessive irritability, frustration and anger are, as mentioned in R. Goodman and S. Scott’s Child and adolescent psychiatry and M.G. Gelder, N.C. Andreasen, J.J. Lopez-Ibor and J.R. Geddes's New Oxford textbook of psychiatry, some of the common emotional problems. Examples of behavioural disorders are disruptive disorders, defiant disorders, aggressive behaviours and anti-social behaviours.
As the WHO estimates, 10%-20% of children and adolescents worldwide experience mental disorders, and half of them begin by the age of 14 years. According to H. Perera’s “Mental health of adolescent school children in Sri Lanka – A national survey”, nearly one fifth of Sri Lankan students had mental health problems. Adolescents’ mental health is associated with many biological, psychological, and social factors. The more risk factors that adolescents are exposed to, the greater the impact on their mental health. The protective environment of the family, the school and the community is extremely important in order to prevent mental health problems in adolescents. Adolescents with mental health problems are more prone to social exclusion, stigma, poor academic performances, risky behaviours, and human rights violations. Therefore, as noted in the “Maturation of the adolescent brain” by M. Arain, M. Haque, L. Johal, P. Mathur, W. Nel, A. Rais, R. Sandhu, and S. Sharma, mental health problems will affect the adolescent’s development, education, and social life. Hence, identifying high risk individuals, and detecting and treating their mental health problems are a priority.
The Ampara health District is situated in the Eastern Province. The area, as observed in S.M.M. Ismail's “Post-war socio-economic development in the Eastern Province: A case study of the Ampara District”, was badly affected by the long lasting civil war. Nadeeka et al.'s study was conducted from May, 2018, to March, 2019, in the Ampara Regional Director of Health Service (RDHS) area. All the schools in this area are Sinhala medium schools and belong to three educational Zones, namely Ampara, Mahaoya, and Dehiattakandiya. The Ampara Education Zone consists of four educational Divisions, namely, Ampara, Uhana, Damana, and Lahugala. The Mahaoya Zone consists of the Mahaoya and Padiyathalawa Divisions. The Dehiattakandiya Zone consists of the Dehiattakandiya West and Dehiattakandiya East Divisions. The sampling technique used was multi-stage, stratified, cluster sampling with probability proportionate to the size of the study population of each educational Zone in the Ampara RDHS area. In 2018, there were 4,278 students in 118 schools with the student population varying from 141 to 1,156 in the education Divisions, while the number of students in a class varied from two to 44. All the educational Divisions were included in the study. A class of grade 10 of type 1AB, 1C or II schools was defined as a cluster, with an average cluster size of 26. One school in the Ampara Zone was excluded from the study as it did not belong to the Ampara RDHS area. All the students of each selected cluster (class of grade 10) were included in the study. Since there were only 160 students identified with mental health problems in the prevalence study, they were matched with 160 randomly selected individuals who did not have mental health problems. The Strengths Difficulties Questionnaire was used as the screening tool.
Out of the 1,382 students invited from all three educational Zones, 1,340 participated in the study (the response rate was 97%). There were 608 boys (45.4%). The greater proportion was Buddhists (99.4%). Nearly one third claimed that their parents were involved in farming related occupations. Most were from nuclear families (71.3%) and living with both the parents (90.7%). More than three quarters (78.9) of the students claimed that their family had enough income for their expenses.
Causes
The total abnormal (combined borderline and abnormal groups) score was made up of having difficulties in schoolwork, not having a close family member to discuss their problems with, having no regular religious activities, the tobacco smoking habit of the father, having past stressful life events, and the low education level of the mother. Emotional problems were made up of having difficulties in schoolwork, not having a close family member to discuss their problems with, the alcohol drinking habit of the father, past stressful life events, and not attending additional tuition classes. Conduct problems were made up of having difficulties in schoolwork, past stressful life events, the tobacco smoking habit of the father, and having no regular religious activities. Hyperactivity and inattention related problems were made up of having difficulties in schoolwork, not having a close family member to discuss their problems with, and not having regular religious activities. Peer problems were made up of not attending additional tuition classes, not having regular religious activities and having difficulties in schoolwork.
More girls reported a total abnormal score (11.9%) and emotional problems (16.9%), while boys had more conduct related problems (14%) and peer problems (14.8%). The proportion of students having hyperactive and inattention problems was the same for both the sexes (11.7%).
The sex of the controls and the cases showed no significant difference in relation to mental health problems. However, difficulties in schoolwork, not being involving in routine religious activities at home, not having a close family member to discuss their problems, past stressful life events, the tobacco smoking habit of the father, the alcohol drinking habit of the father (only for emotional problems), not attending additional tuition classes (only for emotional problems and peer problems), and the low educational level of the mother (only for the total abnormal score), were significantly associated with the emotional and behavioural problems of the students.
Prevalence
As the response rate was 97%, this study would represent the Sinhalese school-going adolescents in agricultural rural areas of Sri Lanka. The prevalence of the total abnormal score was 11.9% and that of emotional problems was 15.2%. These findings are not comparable with the previous national survey done in 2016 (the Ministries of Health and Education’s “Report of the 2016 Sri Lanka global school based student health survey”), in which the students reported that 8.5% felt lonely, 6.8% had attempted suicide and 38.5% were bullied. The prevalence of mental health problems among 13-15 year old students of the Jaffna District was 21% (R. Surenthirakumaran, S. Kumaran and P.A.D. Coonghe’s “Prevalence of mental health problems and associated factors among school students aged 13-15 years in the Jaffna District”), while in a national study conducted in 2004 (Perera), it was 18.9% among school-going adolescents. However, the global prevalence of mental health problems in childhood and adolescence was 10%-20%, which is comparable to the results of the current study. Having difficulties in schoolwork is associated with the total abnormal score and all subscales. Not having additional support for academic activities was associated with emotional problems and peer problems. Having additional support for academic activities may have been beneficial in school performances and lacking that facility may have caused emotional and peer problems among the students. Per S. Agnafors, M. Barmark and G. Sydsjö’s “Mental health and academic performance: A study on the selection and causation effects from childhood to early adulthood”, mental health problems in childhood increase the risk of poor academic grades during adolescence. Hence, it is important to do a mental health assessment of the students, especially those who are having difficulties in schoolwork and to refer them to mental health professionals. Not being involved in religious activities regularly at home showed a significant association with the total abnormal score, conduct related problems, hyperactivity, and inattention related problems and peer problems. C.A.M. Estrada, M.F.T.C. Lomboy, E.R. Gregorio, E. Amalia, C.R. Leynes, R.R. Quizon and J. Kobayashi's “Religious education can contribute to adolescent mental health in school settings” describes the importance of religious activities in the mental health promotion of school-going adolescents by improving religious morality, coping, respect for diversity and connectedness. According to J.C. Fruehwirth, S. Iyer and A. Zhang's “Religion and depression in adolescence”, religiosity helps to buffer against certain types of stressors through improved self esteem and coping skills in order to improve mental health. Not having a close family member to discuss their problems with is associated with the total abnormal score, hyperactivity, and inattention related problems and emotional problems. Positive family relationships had improved the mental health of adolescents in the United States, per P. Chen and K.M. Harris's “Association of positive family relationships with mental health trajectories from adolescence to midlife”, thus emphasising the importance of family relationships regarding the mental health of the students. The smoking habit of the father was significantly associated with the total abnormal score and conduct related problems. The alcohol drinking habit of the father was associated only with emotional problems. Both maternal and paternal alcohol abuse is, per K. Raitasalo, M. Holmila, M. Jääskeläinen and P. Santalahti's “The effect of the severity of parental alcohol abuse on the mental and behavioural disorders in children”, a risk factor for adolescents’ mental health problems while maternal alcohol abuse is riskier. As in the Sri Lankan culture, female alcohol consumption is minimal (P. Katulanda, C. Ranasinghe, A. Rathnapala, N. Karunaratne, R. Sheriff and D. Matthews's “Prevalence, patterns and correlates of alcohol consumption and its’ association with tobacco smoking among Sri Lankan adults: A cross sectional study”), it has not been identified as a risk factor in the instant study. In other studies, it was shown that parental smoking predicts higher levels of externalised behavioural problems in adolescents. The biological and neurological effects of smoking may, per “Prenatal and postnatal tobacco exposure and behavioural problems in 10-year-old children: Results from the German Infant Nutritional Intervention Study (GINI) - plus prospective birth cohort study” by S. Rückinger, P. Rzehak, C-M. Chen, S. Sausenthaler, S. Koletzko, C-P. Bauer, U. Hoffmann, U. Kramer, D. Berdel, A.V. Berg, O. Bayer, H-E. Wichmann, R.V. Kries, J. Heinrich and the GINI - plus Study Group, and C.M. Steeger, J.A. Bailey, M. Epstein and K.G. Hill's “The link between parental smoking and youth externalising behaviours: The effects of smoking, psychosocial factors, and family characteristics” contribute to emotional and behavioural problems among adolescents. Stressful life events during the past six months were associated with the total abnormal score, emotional problems, and conduct related problems. Per a Chinese study, negative life events increased the risk of emotional and behavioural problems among adolescents. C. Catani, N. Jacob, E. Schauer, M. Kohila and F. Neuner's “Family violence, war, and natural disasters: A study of the effect of extreme stress on children’s mental health in Sri Lanka” describes the detrimental effects of cumulative stress on children’s mental health. Parental education plays a key role in adolescents’ mental health. The current study showed that the mothers’ low education level increased the risk of the total abnormal score. The parents’ educational level, especially that of mothers, has been identified as a crucial factor in child development and their coping abilities in later life. An increase in the maternal educational level, per S. Assari’s “Parental educational attainment and mental well-being of college students: Diminished returns of blacks”, has improved the child’s mental health status. However, sex, the screening time, leisure time activities, the family income, the child’s chronic illnesses, or school culture were not associated with mental health problems in this study sample even though they had been proven to be associated locally (P.A. Senarathne’s “Emotional, psychological problems and their correlates among school-going adolescents [12-14 years] in the Polonnaruwa District”) and globally (J.M. Twenge and W.K. Campbell’s “Associations between screen time and lower psychological well-being among children and adolescents: Evidence from a population based study”, a Czech study, J.M. Kinge, S. Øverland, M. Flatø, J. Dieleman, O. Røgeberg, M.C. Magnus, M. Evensen, M. Tesli, A. Skrondal, C. Stoltenberg, S.E. Vollset, S. Håberg and F.A. Torvik's “Parental income and mental disorders in children and adolescents: Prospective register based study”, R. Pathak, R.C. Sharma, U.C. Parvan, B.P. Gupta, R.K. Ojha and N.K. Goel's “Behavioural and emotional problems in school-going adolescents” and a United Kingdom study). The prevalence of the total and all subclasses of mental health problems were more than 10% of the population, and thus, it could be considered a public health problem in Sri Lanka.
It seems that children have an unmet need for mental health services. Improving the mental health screening programmes in the school context would enable to identify at-risk students and to refer them for further management. The fact that difficulties in schoolwork have been identified as a risk factor should be highlighted among the teachers in view of identifying and referring them for mental health services. Further, the importance of a positive family environment to prevent and promote the mental health of the students has been highlighted.
In terms of public health implications, the study showed that the prevalence of emotional and behavioural problems of school-going adolescents is a public health problem and that most of their associated factors are modifiable and family related. The existing school health system could be utilised to address the mental health related issues faced by the adolescents, Nadeeka et al. concluded.