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Indian Journal of Community Medicine

A Clinico-Social Study of Psychiatric Morbidity in 12 - to 18 Years School Going Girls in Urban Delhi

Author(s): Amrita Mishra, A.K. Sharma

Vol. 26, No. 2 (2001-04 - 2001-06)

Deptt. of Community Medicine, Lady Hardinge Medical College, New Delhi

Abstract:

Research question: What is the prevalence of psychiatric morbidity and what are the social factors associated with psychiatric morbidity in 12 to 18 years school going girls?

Objectives: 1. To study the prevalence of psychiatric morbidity in school going girls aged 12 to 18 years. 2. To identify the pattern of psychiatric morbidity. 3. To find out socio-cultural factors associated with psychiatric morbidity.

Study design: Cross-sectional.

Participants: School girls aged 12 to 18years studying in 3 different types of schools in New Delhi.

Tools used: Youth Self-report 1989, and Self-designed questionnaire.

Sample size: 1097 school girls.

Study variables: Prevalence of psychiatric morbidity and associated socio-cultural factors.

Statistical analysis: Chi-square test and Multiple logistic regression.

Results: 13.76% girls showed psychiatric morbidity. The most common problem was anxiety/depression. The social factors most significantly associated with psychiatric morbidity were: girls relationship with father, perception of mother's love for them, self-perception of their looks, relationship with their mother and the girl being hit.

Keywords: Adolescent girls, Psychiatric morbidity

Introduction:

Twenty one percent (210 million) of India's population is in the age group of 10-19 years (Manpower Profile 1996)1. These are the adolescent years. During this period, children need special care as they undergo a complex process of emotional, physical and social changes. At times, failure to adjust with these changes leads to mental health problems. Both girls and boys are susceptible to suffer from these problems but, for adolescent girls, the problem gets compounded due to societal factors. Unfortunately, these needs of adolescents have not been addressed by the health system. Adolescents are the future citizens of a country and it is imperative to systematically address their needs.

Out of 210 million adolescents, 100 million are girls (Manpower Profile, 1996)1. They are also the future mothers. Keeping this in mind, it becomes critically important to plan for the well being of the girl child during her adolescent years. However, it is difficult due to inadequate community based research and baseline data in our country. To address this lacuna, a study on the prevalence of psychiatric morbidity in adolescent girls becomes imperative. For a comprehensive understanding of the mental health scenario of adolescent girls, it is important to understand the socio-cultural factors affecting their mental well being.

Material and Methods:

The study was conducted in three girl's schools in New Delhi area. Estimated sample size consisted of 1,050 school going girls. To get a representative sample of all social classes, one government, one government aided and one private school was chosen randomly out of the seven girl's higher secondary schools located in New Delhi. Permission to conduct the study was taken from the Directorate of Education, Delhi as well as of the principals of the concerned schools. Stratified cluster sampling was used considering the type of school as strata and sections of each standard as clusters. Students were taken from classes VIII to XII. Two sections of each class from each school were selected randomly covering at least 70 students of each class in a school and covering 210 students in a class of all three schools. Two types of questionnaires were used in the study. To identify psychiatric morbidity, Youth Self-report, 1989, (T.M. Achenbach)3 was used. This is a self-report questionnaire which identifies three major grounds of problem syndromes i.e. Internalizing syndromes, Externalizing syndromes and Neither Internalizing nor Externalizing syndromes. Within these, eight problem syndromes have been identified. The questionnaire is appropriate for 11 to 18 years old girls. To find out the association of socio-cultural factors viz. type of school, type of family, monthly income of family, mother's employment status, self perception of the girl of her looks, worry about weight, satisfaction of the girl and her parents with academic performance, worry about studies, perception of father's love, perception of mother's love, quality of relationship between parents, person the girl is closest to, presence of addictions in father, chronic illness in self or family and the girl being hit with psychiatric morbidity, a self designed questionnaire was used. Both questionnaires in English were translated to Hindi also. The students of one section were asked to fill the questionnaires at a time. This was done in the presence of the researcher so that there would be no discussions among students. Supervision by teachers was avoided to enable the students to answer the questions freely.

To find the association between socio-cultural factors and psychiatric morbidity, chi-square test was applied. Further, multivariate analysis was used on the factors, which were found to be significant by univariate analysis i.e. chi-square test.*

Results:

Table I: Class-wise distribution of students.

Class Number covered Percent Total number
of students
in the school
VIII 238 50.6 470
IX 226 50.2 450
X 213 50.0 426
XI 210 54.4 386
XII 210 57.7 364
Total 1097 52.3 2096

There were 1097 girls covered in the present study (Table I). The study revealed that 151 girls (13.76%) had psychiatric morbidity (Table II).

Table II: Age-wise distribution of psychiatric morbidity.

Age (years) Psychiatric morbidity
Present Absent Total
No. (%) No. (%) No. (%)
12 14 (9.86) 128 (90.14) 142 (100)
13 18 (7.56) 220 (92.44) 238 (100)
14 41 (18.89) 176 (81.11) 217 (100)
15 25 (10.87) 205 (89.13) 230 (100)
16 30 (17.24) 144 (82.76) 174 (100)
17 23 (23.96) 73 (76.04) 96 (100)
Total 151 (13.76) 946 (86.24) 1097 (100)

On studying the age-wise distribution of morbidity, it was revealed that 17 to 18 years old had the highest (23.96%) psychiatric morbidity followed by girls of 14 to 15 years, who had 18.89% of morbidity. Third highest morbidity was in 16 to 17 years i.e. 17.24% (Table II).*

Table III: Pattern of psychiatric morbidity.

Type of syndrome No. (%)
Internalizing syndromes 189*
Withdrawn 28 (2.55)
Somatic 48 (4.38)
Anxious/depressed 113 (10.30)
Externalizing 52*
Delinquent 4 (0.36)
Aggressive 48 (4.40)
Neither Internalizing nor Externalizing 106*
Social 55 (5.0)
Thought 6 (0.5)
Attention 45 (4.1)

*More than one morbidity was present.

Among three major problem syndromes, Internalizing syndromes, were found to be the most common (189). Problems, which were grouped as neither Internalizing nor Externalizing, were 106, while externalizing problems were 52 (Table III).

In Internalizing syndromes group, anxious/depressed syndrome was most common, 113(10.3%) girls had this syndrome. Second most common was somatic syndrome, (48 girls, 4.38%) while, 28(2.55%) girls were withdrawn.

52 girls had externalizing problems. Most (48 girls, 4.4%) of these had aggressive behaviour syndrome. 106 girls fell in neither internalizing nor externalizing syndromes group. In this group, social problems were maximum (55 girls, 5%), followed by attention problems, in 45(4.1%) girls while 6(0.5%) girls had thought problems.

Table IV: Co-morbidity by youth self-report.

Number of
psychiatric
morbidity
Number of
students
Percentage
1 64 42.4
2 35 23.2
3 29 19.2
4 11 7.3
5 and above 12 7.9
Total 151 100

Majority (57.6%) of girls had more than one problem syndrome as shown in Table IV. There were 2.29 syndromes per girl among those who had psychiatric morbidity.

Table V: Logistic regression analysis for factors most significantly associated with psychiatric morbidity in girls.

Variable Odds ratio Confidence
lower limits
Confidence
upper limits
Relationship with father 3.09 1.73 5.53
Perception of mother's love 2.99 1.96 4.55
Perception of appearance by self 2.33 1.7 3.18
Relationship with mother 2.17 1.27 3.69
Girl being hit 1.11 0.98 1.26

The association of socio-cultural factors and psychiatric morbidity was established with the help of first univariate and then multivariate analysis. By both univariate and multivariate analysis, the most significant relationship was between psychiatric morbidity in girls and the relationship with father. The girls with an unsatisfactory relationship had significantly higher morbidity (O.R. 3.09, C.I. 1.73-5.53). Perception of the girl of mother's love for her, featured next (O.R. 2.99, C.I. 1.96-4.55) (Table V). Other important factors in decreasing strength of association were; the girl's perception of her appearance, relationship with mother and the girl being physically hit.

Variables, significantly associated with psychiatric morbidity by univariate analysis only were: student's perception of being overweight (p<0.0001), girl's worry about weight (p<0.001), girl's dissatisfaction with academic, performance (p<0.001), parent's dissatisfaction with girl's academic performance (p<0.001), inadequate father's love (p<0.001), poor quality of relationship between parents (p<0.001), presence of addictions in father (p<0.001), chronic illness in self (p<0.05) and frequent worries associated with studies (p<0.05).

Factors not found to be related with psychiatric morbidity were: type of school, type of family, monthly family income, mother's employment status and presence of chronic illness in the family members.

Discussion:

Psychiatric morbidity among adolescents in other countries has been reported in the range varying from 10-40% (Roberts et al, 1998)2. In the present study, 13.76% of 12-18 years old school girls had psychiatric morbidity. The observation is similar to that of Roberts et al (1998)2 and Steinhausen et al (1998)4 who found that 15.6% and 16.5% adolescent girls respectively had psychiatric disorders. The result of this study correlates well with studies done in western countries. This is probably an indicator of the similarity between the level of stress felt by school going indian adolescent girls in this study and their western counterpart.

There was an interesting pattern of psychiatric morbidity in relation to age. Morbidity was 9.86% in 12-13 years. It rose steeply to 18.89% in the 14-15 years. The increase in psychiatric problems among 14 to 15 years girls has been reported by Cohen et al (1993)5 also and they attributed it to the post-pubertal hormone changes. Girls of 17-18 years had the highest (23.96%) morbidity and this correlates well with 24.9% in Swiss 17.5 to 18.5 year old as observed by Canals et al (1997)6.

With the help of YSR, 19893, maximum number of syndromes identified were internalizing. This group has three problem syndromes namely, anxious/depressed syndrome, somatic syndrome and withdrawn syndrome. 113(10.30%) girls had anxiety and/or depression and this was the most common problem. Kashani et al (1987)7 and Christi et al (1993)8 have also identified depression and anxiety as the most common mental problems endured by girls. Social problem syndrome was the second most common (55 girls, 5%) syndrome observed. This is in conformity with the finding of Bird et al (1998)9 who observed a prevalence of 3.4% of adjustment disorders. Besides these, 48 girls (4.38%) had somatic syndrome and 4.1% presented with attention problems. All the problem syndromes identified correlate well with studies done in western countries.

On the basis of multivariate analysis, a significant relationship was established between psychiatric morbidity and the girl's relationship with her father (O.R. 3.09, C.I. 1.73-5.53). Palossari et al (1996)10 also observed that adolescent girl's lack of closeness to her father is an important link in development of depression. A similar trend was noticed by Christi et al (1993)8 in 12-17 years. Mother's love and relationship with girls were also found to be significantly related to psychiatric morbidity on multivariate analysis (O.R. 2.99 and O.R. 2.17 respectively). These ranked second and fourth among factors significantly related to morbidity in girls, while, self perception of appearance (O.R. 2.33) was third. All other factors related to the student's appearance, viz. her perception of her weight and frequency of worry about her weight were significantly related with psychiatric morbidity on univariate analysis.

On the basis of this study, it is evident that psychiatric morbidity is a serious health concern in Indian school going adolescent girls. The primary factors associated with psychiatric morbidity have been identified as those linked to girl's relationship with parents and her perception of self in terms of appearance. These indicate that an intervention strategy aimed at the girls and their parents, is required. There is need to understand their problems and provide appropriate counselling. For a society in transition like ours, the rising trend of psychiatric morbidity in adolescent girls, who are the future mothers, is alarming. Therefore, immediate and positive measures need to be taken at appropriate levels.

References:

  1. Manpower Profile India, Institute of Applied Manpower Research, IV Edition, Manak Publications, New Delhi, Yearbook 1996.
  2. Robert ER, Attkisson C, Rosenblatt A. Prevalence of Psychopathology among children and adolescents, Am J. Psychiatry, 1998; 155(6): 715-24.
  3. Achenbach TM. Manual for the Youth Self-Report and 1989 profile, Burlington, VT: University of Vermont, Deptt. of Psychiatry, 1989.
  4. Stienhausen HC, Metzke CW, Meier M. Prevalence of Child and Adolescent Psychiatric Disorders; The Zurich Epidemiological Study, Acta Psychiatr Scand, 1989; 98: 262-71.
  5. Cohen P, Cohen J, Kasen S. An Epidemiological Study of Disorders in Late Childhood and Adolescence - Age and Gender Specific Prevalence, J. Child Psychol. Psychiat. 1993; 34(6): 851-67.
  6. Canals J, Domench E, Carbajo G. Prevalence of DSM III-R and ICD-10. Psychiatric Disorders in a Spanish Population of 18-Year-Olds, Acta Psychiatr. Scand. 1997; 96: 287-94.
  7. Kashani JH, Beck NC, Hoeper EW. Psychiatric Disorders in a Community sample of Adolescents. Am J Psychiatry. 1987; 144(5): 584-89.
  8. Christi A, Patten MA, Christian G. Depressive symptoms in California Adolescents: Family structure and parenatal support, Journal of Adolescent health, 1997; 20: 271-78.
  9. Bird HR, Canino G, Stipec MR. Estimates of the Prevalence of Childhood Maladjustment in a common survey in Puerto Rico: Arch Gen. Psychiatry, 1998; 45: 1120-26.
  10. Palossari C, Aro H, Laippala P. Parental Divorce and Depression In Young Adulthood: Adolescent's Closeness to Parents and Self-Esteem as Mediating Factor, Acta. Psychiatr Scand: 1996; 93: 20-26.
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