Summary of Findings
Even though all 311 selected students participated in the study with a respondent rate of 100%, four of them were excluded during the analysis as they had omitted more than three questions in the Strengths and Difficulties Questionnaire (SDQ).
In the present study, adolescents were not distributed equally within the age groups; more than two-thirds of them (75.9%) were 17 years old, while the others (19.3%) were 16 years old. Only 4.8% were 18 years old. In defining late adolescents, 19-year-old adolescents need to be included. However, they were not included in this study as only grade 12 students were selected for the study.
The study sample consisted of 98.7% Sinhalese students who were Buddhists, which could be due to the selection of only Sinhala medium schools for the study. According to tables 3 and 4, only 2.6% of fathers and 0.6% of mothers had never attended school. Furthermore, a significant proportion of fathers (40.5%) and mothers (44.4%) had been educated up to GCE/OL. Most of the fathers (32.5%) were involved in skilled occupational categories, while a significant proportion of mothers (81.7%) were not employed and stayed at home.
The present study used a locally validated Sinhala version of the SDQ to determine emotional and behavioral problems among school-going late adolescents. Using the same cut-off values, the findings suggested that about 24% (n=74) of the participants were experiencing some kind of emotional and behavioral problem that could be categorized as either internalized or externalized symptoms.
The prevalence results were somewhat higher than the findings of other Sri Lankan studies. Depending on the study, being male was significantly associated with the prevalence of emotional and behavioral problems (p<0.001). Furthermore, the presence of sufficient income in the family was significantly associated (p=0.001). However, age distribution, ethnicity, religion, or the mother not being employed was not significantly associated.
Involvement in religious activities, substance use among adolescents, and satisfaction with sleep were not statistically significant, although experiencing a stressful life event was significantly associated (p=0.02) with the presence of emotional and behavioral problems among late adolescents.
Considering family characteristics, not having a favorable perception of home life was significantly associated with poor mental health status (p =0.01), while not living with both mother and father was statistically not significant (p=0.974). Characteristics related to siblings, such as not having a sibling, position in the family, and having a distant relationship with siblings, were not significantly associated.
According to the present study, out of school-related features, only not being involved in extra-curricular activities was significantly associated (p=0.001). The presence of low average marks in recent examinations and being absent for more than five days were statistically significant with the presence of emotional and behavioral problems.
Strengths of the Method Used
This prevalent study was conducted in Mawanella District, where there were no data on adolescents’ mental health issues. From the sample of 311 adolescents, all participated in the study, even though four were not included in the analysis due to incomplete SDQ responses.
The questionnaire was initially formed in English, translated to Sinhala, and then retranslated to English to ensure that all participants comprehended the questionnaire similarly. This process reduced the bias caused by different participants interpreting the questions differently.
The tool used in the study has been validated and frequently used in different studies locally and internationally (Perera, 2004; Lukumar, 2006; Goodman et al., 2001). Based on the total difficulty score and subscale scores, study participants were categorized into normal, borderline, and abnormal statuses of emotional and behavioral mental health. Though the cut-off values for Sri Lanka were not decided in the study by Perera (2004), Lukumar (2006) validated the Tamil version of the SDQ among Sri Lankan adolescents. Recently, a study by Perera (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; therefore, the results of the present study will add to the global knowledge pool on this topic. This data can be cross-tabulated with other studies conducted within and outside the country.
Comparisons of the Results and the Implications of the Study
In the present study, the 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 the prevalence rate of emotional and psychosocial problems revealed in a recent study in Polonnaruwa District among school-going adolescents, which was 16% (Senarathna, 2014). A study in the Galle Municipality area among school-going adolescents found the overall mental health problems rate to be 32.2% (Agampodi et al., 2011). A slight difference 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 social and cultural differences as well as differences in sampling techniques and especially sample sizes.
Studies of school-going adolescents in India detected that the prevalence of emotional and behavioral problems was 30.4% and 24% according to Pathak et al. (2011) and Reddy et al. (2011) respectively. This shows the similarities in the prevalence of emotional and behavioral problems among 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 these issues will have long-term consequences. Apart from the total difficulties scores, the SDQ evaluates the state of mental health concerning internalized and externalized symptoms. According to Senarathna (2014), peer problems showed the highest prevalence in the subscales. However, some studies showed that hyperactivity was the most prevalent externalizing symptom, as per Perera et al. (2004) and Jayasinghe (2010).
The instrument used in this study was only a self-applied questionnaire by the adolescents and is, therefore, based on their own perceptions. 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, their guardian, and the teacher. Such an evaluation is not presented in this study since its objective was not to diagnose psychopathologies but to identify individuals at 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 by Senarathna (2014) and Perera et al. (2004).
According to the present study, place of residence, presence of both parents at home, and the mother not being employed were not significantly associated with the presence of emotional and behavioral problems. This interesting finding of no significant association of mothers staying at home with poor mental health status contrasts with most studies related to this topic. The relationship of adolescents and bonding with their mother, who was not employed, showed a significant association (p<0.001) with emotional and behavioral problems; this applied to both males and females (Pathak et al., 2011).
Furthermore, a national survey conducted in 2004 among both school-going and out-of-school adolescents selected using the multistage stratified sampling method discussed that most adolescents (50%) had good family relationships with parents and siblings. In that study, the 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, having a good relationship with siblings is important for building and maintaining better emotional and behavioral health. This was confirmed by a study in India showing that fights with siblings (p=0.002) and not receiving good attention and care from siblings (p=0.017) were significantly associated with mental health problems (Arumugam et al., 2013).
Schools provide academic and non-academic activities for teenagers. Studies conducted locally and internationally observed high correlations between school connectedness and mental health status. Agampodi et al. (2013) showed that 19% of adolescents do not find schools enjoyable, and the inability to enjoy schooling was significantly associated (p<0.001) with 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, finding the school environment unenjoyable and being unhappy with school life 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 person. According to the subscales analysis in the study, peer problems (33.6%) scored the highest as an externalizing symptom. This was consistent with the results (29.7%) from the Polonnaruwa District study among school-going adolescents aged 12-14 years using the SDQ (Senarathna, 2014). Thus, the perception of making friends being difficult failed to be significantly associated with the presence of emotional and behavioral problems (p=0.519).
As per the analysis in tables 16 and 20, relationship issues with siblings and friends were not significantly associated with emotional and behavioral issues in the present study population. This indicates that further and in-depth studies are needed to elicit actual results on these factors.
In the present study, not participating in extra-curricular activities was significantly associated with emotional and behavioral problems (p=0.001), and most students did not participate due to a lack of opportunities at schools. This issue needs to be addressed at the national level. The study also showed a significant association between poor school academic performance and the presence of emotional and behavioral problems. Improving academic performance in late adolescents is crucial, as poor performance can lead to low occupational settings, burdening society.
Given the high prevalence rates of emotional and behavioral problems among late adolescents aged 16-18 years in the study area, it is imperative that health services address the mental health needs of adolescents and provide services at both institutional and community levels. Educational services should also focus on improving mental health literacy among school children and teachers while providing support and understanding to those in need.
Public Health Relevance
Problems in emotional and behavioral status in adolescents are a public health issue due to the potentially heavy consequences on their mental integrity and long-term negative impacts on their adult life. Additionally, these issues result in short-term consequences, such as poor academic performance (p<0.01) and frequent absenteeism (p=0.008), both significantly associated with the presence of emotional and behavioral problems. This highlights the importance of expanding and improving existing services for adolescents related to this component.
Future Research
The author recommends future research in different settings, as the prevalence is very high according to this study and varies from other areas. These differences may be due to methodological issues that can be addressed by increasing the sample size and using other SDQ versions with parent and teacher involvement. Furthermore, the results of the present study can be confirmed by conducting a case-control study. It would be beneficial to explore the importance of life skills during adolescence concerning emotional and behavioral problems, which was not covered in the present study. Further studies are also needed to identify the most suitable methods for approaching target populations suffering from such problems.
Works Cited
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- Dashiell, Eddith A. “Radio in the United States.” The 1930s in America, edited by Thomas Tandy Lewis, Salem, 2011. Salem Online.
- Shuman, R. Baird. “Great Depression.” Historical Encyclopedia of American Business, edited by Richard L. Wilson, Salem, 2009. Salem Online.
- Senarathna, I. “Mental Health Problems Among Adolescents in Polonnaruwa District.” Journal of Mental Health, vol. 23, no. 2, 2014, pp. 123-130.