Adolescence being the critical period of human life, the state of emotional and behavioral health plays an important role in building up the life of a person. The present study addressed the issues of this important component of mental health.
Summary of findings
Even though all 311 selected students were participated for the study with a respondent rate of 100%, four of them were excluded during the analysis as they have omitted more than three questions in the SDQ.
In the present study adolescents were not distributed equally within the age groups, more than two third of them (75.9%) were 17 years while the others (19.3%) were 16 years. Only 4.8% were in the age of 18years. In the definition of late adolescents, 19years aged adolescents need to be included. However it was not included in this study as only grade 12 students were the study population that has been selected for the study.
The study sample consisted of 98.7% Sinhalese students who were Buddhists and this over representation of Sinhalese could be due to selection of only Sinhala medium schools for the study.
According to table 3 and 4 only 2.6% of fathers and 0.6% of mothers had never been attended to schools. Furthermore a significant proportion of fathers (40.5%) and mothers (44.4%) had being educated up to GCE/OL. As well most of the fathers (32.5%) were involved in skilled occupational categories while a significant proportion of mothers (81.7%) were not employed and staying at home.
Present study used a locally validated Sinhala version of SDQ to determine emotional and behavioral problems among school going late adolescents. Using the same cut-off values, the findings of the present study suggested that about 24% (n=74) of the participants were having some kind of emotional and behavioral problem that could be categorized in to either internalized or externalized symptoms.
The prevalence results were somewhat higher than the findings of other Sri Lankan studies.
Depending on the study, being a male was significantly associated with the prevalence of emotional and behavioral problems (p<0.001). Furthermore, presence of sufficient income in the family was associated significantly (p=0.001). However, age distribution, ethnicity, religion or mother is not being employed was not significantly associated.
Involvement in religious activities, habit of substance use among adolescent of this age group and satisfaction in their sleep were failed to be statistically significant, even though having a stressful life event was significantly associated (p=0.02) with the presence of emotional and behavioral problems among late adolescents.
Considering the family characteristics, not having a favorable perception about the home life was significantly associated with the presence of poor mental health status (p =0.01) while not living with both the mother and father was statistically not significant (p=0.974).
However, characteristics related to siblings, such as not having a sibling, position in the family and having a distant relationship with the siblings were not significantly associated.
According to the present study, out of school related features, only being not involved in extra-curricular activities was considered to be significantly associated (p=0.001).
Presence of low average in marks for the recent examination and getting absent more than five days were statistically significant with the presence of emotional and behavioral problems.
5.2 strengths of the method used
This prevalent study was conducted in Mawanella District, which there were no data on adolescents’ mental health issues. From the sample of 311 adolescents, all were participated in the study even though four of them were not included in the analysis as they cannot take as study units due to incompleteness of the SDQ.
The questionnaire was initially formed in English and has been translated to Sinhala and then retranslates to English to ensure that all participants comprehended the questionnaire in a similar way. It reduces the bias occurred by the different participants answering the questions.
The tool used in the study has been validated and used frequently in different studies locally and internationally (Perera, 2004; Lukumar, 2006; Goodmann et al, 2001). Based on the total difficulty score and subscale scores study participants were categorized into normal, borderline and abnormal status of emotional and behavioral mental health. Through the cut-off values for Sri Lanka were not decided in the study done by Perera, 2004, Lukumar, 2006 validated the Tamil version of the SDQ among Sri Lankan adolescents. However, recently a study done by Perera, in 2013 showed that the suggested cut-off values for the abnormal range of emotional, conduct and hyperactive subscale values were consistent with British values.
The evaluation scale is internationally accepted and therefore, the results of the present study will add to the global knowledge pool on this topic and this data can be cross-tabulated with other studies did within the country and outside the country.
Comparisons of the results and the implications of the study
In the present study prevalence of emotional and behavioral problems among school going late adolescents aged 16-18 years was found to be 24%. This was a higher value than of the prevalence rate of emotional and psychosocial problems, revealed from the recent study done in Polonnaruwa District among school going adolescents, which were 16% (Senarathna, 2014). A study did in Galle Municipality area among school going adolescents, the overall mental health problems were at 32.2% rate (Agampodi et al, 2011). A slight different was seen among these findings even though the same version of SDQ was used as the research tool to detect mental health status. This may be due to the differences in the social and cultural differences as well as in the differences in sampling techniques and especially due to sample sizes.
In studies of school going adolescents in India have been detected that the prevalence of emotional and behavioral problems was 30.4% and 24% according to Pathark et al, 2011 and Reddy et al, 2011 respectively. This shows the similarities among the range of the prevalence of emotional and behavioral problems among studies in different study populations.
Among subscales, the highest prevalence was of peer problems (33.6%) followed by hyperactivity (25.7%) which showed more in relation to externalizing symptoms many of them will have long term consequences. As apart from the total difficulties scores SDQ evaluate the state of mental health of having internalized and externalized symptoms. According to Senarathna, 2014, it was the peer problems that showed the highest prevalence in the subscales. However, some studies showed that hyperactivity was the most prevalent externalizing symptom, which according to Perera et al, 2004 it was 24.7% and Jayasinghe, 2010 it was 21.7%.
The instrument used in this study was only a self-applied questionnaire by the adolescents and is, therefore, based on their own perceptions. So, they may have either emphasized or minimized some aspects of their behavior. Even though the SDQ is considered a reliable and valid self-reporting tool a complete evaluation should contain data from interviews with the adolescent and his/her guardian as well as the teacher. Such an evaluation is not presented in this study since its objective was not to diagnose psychopathologies but identify individuals with a high risk for psychiatric disorders requiring a more detailed evaluation or differentiated care.
The morbidity pattern was found to be different in males and females. In the present study, male sex was significantly associated with the prevalence of emotional and behavioral problems (p<0.001). A similar finding was reported in Senarathna, 2014 (p<o.oo1) and in Perera et al, 2004 (p<0.05).
According to the present study, place of residence, presence of both parents at home and mother is not being employed were not significantly associated with the presence of emotional and behavioral problems. This interesting finding of that not significant association of mothers staying at home with the poor mental health status was not as in most of the studies in relation to this topic. The relationship of adolescents and the bonding with their mother and also they were not being employed showed to be significantly associated (p<0.001) with emotional and behavioral problems; which was applied both to males and females (Pathak et al, 2011).
Furthermore in a national survey done in 2004 among both the school going and out-of-school adolescents selected using the multistage stratified sampling method had discussed that most of the adolescents (50%) had good family relationships both with the parents and siblings. In that study mother was identified as the most trusted and liked person irrespective of age, sex and socio-economic status (Thalagala et al, 2004).
In the literature, it has been showed that having a good relationship with siblings is much important to build and maintain their emotional and behavioral health to a better status. This was confirmed by a study done in India showed that fights with siblings (p=0.002) and not having good attention and care by the siblings (p=0.017) were significantly associated with having mental health problems (Arumugam et al, 2013).
School provides academic and non-academic activities for teenagers. The studies did locally and internationally, high correlations were observed between school connectedness and mental health status. Agampodi et al, 2013 showed 19% of adolescents do not find the schools to be enjoyable and further, inability to enjoy schooling was significantly associated (p<0.001) with the symptoms of mental health problems. The teacher student relationship was also significantly associated (p=0.008) with the prevalence of mental health problems.
In the present study being the school environment not enjoyable and being unhappy about the school life was failed to associate significantly with the presence of emotional and behavioral problems (p=0.524)
Peer groups are important in the life of a young persons’ life. According to the subscales analysis in the study, it was the peer problems (33.6%) which scored highest externalizing symptom. This was the same results (29.7%) as in the study done in Polonnaruwa District among school going adolescents in the age group of 12-14 years using the SDQ (Senarathna, 2014), which was the study tool used in the present study. Thus the perception of making friends being difficult was failed to be significantly associated with the presence of emotional and behavioral problems (p=0.519)
As per analyzed in table 16 and 20, the relationship issues with siblings and friends respectively, were failed to be significantly associated with having emotional and behavioral issues in the present study population. So, this showed that it required further and in-depth studies to elicit actual results on these factors.
In the present study not doing extra-curricular activities was significantly associated with having these emotional and behavioral problems (p=0.001) and most of them were not participating as there were no opportunities at schools. So, this was an issue to be implementing at the national level.
As the present study showed a significant association with the poor school academic performances along with the presence of emotional and behavioral problems, it is very important to be more concern with this. Need to improve the academic performances of the late adolescents, because with poor performances they will end up in low occupational settings which will be a burden to the society.
As per having a high prevalence rates of emotional and behavioral problems among late adolescents of 16-18years age group in the area of where the study was conducted, this indicate that the health services should be concerned about the mental health needs of our adolescents and provide services at institutional and community level. In addition, educational services should focus on improving mental health literacy in school children and teachers, while taking measures to provide support and understanding to those in need.
Public health relevance
Problems in emotional and behavioral status in adolescents are a public health problem, because of the potentially heavy consequences on their mental integrity as well as the long term negative consequences in their adult life. Other than this, it will result in short term consequences, such as poor performance in the academic work (p<0.01) and getting absent frequently (p=0.008), again which were significantly associated with the presence of emotional and behavioral problems.
This shows the importance of expanding and improving the existing services available for adolescents related to this component.
future researches
The author recommends future researches to be conducted in different settings since the prevalence is very high according to this study and varies from the other areas. As these changes may be due to the methodological issues these issues can be implement by increasing the sample size and by using other SDQ versions with parents and teachers involvement. Furthermore the results of the present study can be confirmed by conducting a case control study. It will be more beneficial if could find out the importance of the life skills during adolescence in relevant to the emotional and behavioral problems which have not thought in the present study. Newer the less studies need to be done to identify the most suitable methods to approach the target populations who are suffering from such problems.