Assessment of adolescent behavioral and psychologicalproblems using Strength and Difficulties Questionnaire(SDQ) in select schools of Bengaluru

Introduction

Rapid modernization and acculturation have increased the demands of society. As a result of which countries like India, who are consumer driven are slowly facing problems not only in economic sector but also in health sector too. Due to which there has been a growing rise in mental health problems among adults. The root cause of these psychiatric problems has been identified with lesser screening for such problems during the adolescent phase of life.¹

Among 243 million adolescents, 10-20% has been identified with psychiatric problems.² Lesser importance is given by doctors as well as health department in screening for such disorders. This could be attributed to the fact that there have been lesser training programs given to all health workers since more emphasis has been laid on the reproductive and physical health and also due to lesser access to healthcare facilities on the context as to how the society would treat them in future.

As a result of which, there has been a surge of psychiatric diseases in adulthood manifesting as depression, bipolar disorders, manias, Obsessive compulsive disorders etc. Since, there are fewer studies conducted in Bengaluru on assessing Psychiatric problems among adolescents, the present study was conducted to compare the psychological and behavioural problems of adolescents in a rural and an urban school using Goodman’s Strength and difficulties questionnaire. This tool has been extensively used in all countries as a simple screening method to identify Psychiatry problems in adolescents. In Britain, 70% of individuals with conduct, hyperactivity, depressive and anxiety disorders were identified using this tool.³ Therefore the following study was conducted to compare the psychological and behavioural problems of adolescents in a rural and an urban school using Goodman’s Strength and difficulties questionnaire.

Materials and Methods

A prospective cross-sectional study was conducted in urban and rural schools of Bengaluru. Two schools with 150 students each were selected to meet sample size (n288) calculated based on prevalence of global mental health disorders in adolescents.² Written consent was taken from the head of institutions and oral assent taken from the adolescents aged 11-17yrs .Study lasted for 3 months (June to August 2019).Those who gave assent to take part in the study were included and those that were absent during the study was excluded. Institutional ethical clearance was taken before the start of the study.

The questionnaires were given to the students in their classrooms during a scheduled time. The students were asked to read the questionnaire once and queries were clarified based on each student’s requirement. Complete privacy was given to students while completing the questionnaire. Utmost confidentiality and discretion was maintained while evaluating the questionnaires.

Study tool: - Strengths and difficulties questionnaire (SDQ) [3], a predesigned questionnaire was used to assess behavioural problems and mental health disorders. It can be given to students (self reported), teachers and parents. For students two versions are available i.e. one for 4 to 11 years old and other for 11- to 16-year-old. The 11-16 year old version was used in this study. The questionnaire consisted of 25 questions subdivided into five categories to be assessed i.e. conduct, hyperactivity, peer problems, emotional problems and, Prosocial. Five questions were given per category. Each category was given a score and then summed to get Total Difficulties Score (T-SDQ). Prosocial score was assigned a separate score. Four band scoring system was used i.e. normal, close to average, high and very high to calculate the score. After calculation of the scores individually as well as overall, data was entered in Microsoft excel and was analyzed using SPSS 20.0 version. Descriptive statistics like mean, percentage and standard deviation was calculated. Unpaired t- test was used to analyze association between demographic variables: sex, age, urban and rural with individual as well as total category scores.

Results

Of the study population (n-300 urban rural combined) there was little difference in sex distribution with 135 females and 165 males. The mean age of study population was 15.4 yrs.

On analysing the SDQ questionnaire it was found that 68.33% recorded normal T-SDQ scores and 19.66% recorded with very high T-SDQ scores. The Highest score was recorded among urban children.

 Overall high and very high abnormal scores were recorded in subscales conduct (8.66% and 11% respectively) and peer problems(18.66% and 19.66%) respectively. Due to which, the overall T-SDQ scores was 68.33% normal but 19.66% scored high.

Around 17.66% males were found to be having higher scores when compared to 15% females. The prosocial score was normal in 88.6% students. 13.33% students belonging to age group of 15-17 yrs in both rural and urban showed higher chances of conduct and peer problems contributing to the overall high score.

T-test performed between rural and urban students along with all the subscales used in study showed that all subscales were significant with p value <0.005. Rural students showed overall higher (mean ± SD) scores than urban students especially in subscales conduct problems (3.73±1.805), peer problems (3.73±1.744), Emotional problems (3.73±2.481) and overall T-SDQ (14.15±5.151).

Discussion

The main objective of this study was to assess adolescents, aged 11-16yrs, on behavioral and psychological problems using Strength and Difficulties Questionnaire (SDQ). It was found that 19.66% and 5.33% students had very high and high SDQ scores respectively. Other studies have reported lower levels ranging from 10% to 17% [4] [5]. But there are few Indian studies which have reported scores as high as 24%.⁶

High scores were recorded in subscales conduct(8.66% as well as 11% respectively) and peer problems(18.66% and 19.66%) respectively making it the most common health problems in the study. This was in par with another study by Kumar P et al ⁷ , where 10.4% was conduct problems and 10% was peer problems. The prevalence of peer problems in our population may correlate with 40%–70% prevalence of bullying-related involvement in urban and rural schools.⁸

Also, in the study it was found that rural students had higher scores compared to urban students. This could be explained by the fact that due to lower socio economic status, rapid urbanization, lesser social interactions with parents, peers etc and difficulties vocalising adolescent mental health problems due to issues like bullying, language barriers, stigma towards accessing healthcare facilities, financial handicap, stress to achieve academically have contributed to mental health problems rising among adolescents.

While assessing age and gender relation with the subscales it was found that 13.33% students belonging to age group of 15-17 yrs in both rural and urban had high scores .17.66% Males in rural and urban were found to be having higher peer problems and conduct scores when compared to 15% females who had higher emotional problems similar to another study by KR BK et al⁹ ,where 10.2% females had higher scores than 8.2% males. This could be explained with help of another study by Sandhya N et al¹⁰ where males were found to have higher conduct and peer problem scores(externalizing) scores when compared to females who had higher emotional problem scores(internalizing). Since, males tend to externalize i.e display emotions like agression etcc they had higher external scores.

A Study by Boyer NR et al11, described the mean ± SD for SDQ total difficulties and prosocial behaviour scores was 12 ± 3.2 and 8.3± 2.1, likewise to the current study where the (mean ± SD) for total difficulties was 14.15± 5.15 in rural and 11.11± 4.937 in urban, and prosocial behaviour scores was 8.31± 1.576 in rural and 8.83± 1.526 in urban.

Adolescents who socialised and vocalized their difficulties as well as stress and also communicated freely with parents as well as their teachers had lower SDQ score as compared with those who succumbed to peer pressures, school violence as well as difficulty communicating with their peers, teachers as well as parents. Adolescence is the period when children rely on their peers and seek their own social identity as they establish their mark in society and slowly transition into adults. Without proper guidance, financial crunches, limited healthcare infrastructure and due to stigma related to mental illness in India, identification of mental issues have gone haywire resulting in further mental morbidities in future.

This study has underlined the advantages of SDQ as a screening tool. It is short and easy to use than other questionnaires. It is available online free of charge and can be used by workers at the community level and even teachers, parents who are inadequately trained in mental health to evaluate the mental health status of adolescents and increase their chances at leading a better and sustainable life.

Conclusion

Our study has reported that 24.99% of adolescents were having high and very high scores. Peer conduct problems were found to be higher in rural male students aged 15-17 yrs and emotional problems were found to be higher in rural female students. The need of hour is to counsel and rapport with the students as well as parents regarding the abovementioned problems. And, train the teachers and parents to regularly use SDQ to score and assess the students and identify the hidden problems while doing so.

Due to limited resources in developing country like India, good BCC (Behaviour change communication) illustrating on need to evaluate mental health as well as educate the community regarding various mental health problems needs to be undertaken.

Regularizing Psychiatry OPDs of SNEHA clinics and conducting quarterly camps dedicated to screening of psychiatry disorders can effectively track the psychiatry problems in adolescents thereby avoiding the problems to manifest as disease in future.

To do so, Trainings need to be provided for the doctors, teachers as well as parents to actively screen for mental health disorders without any bias or stigmas.