The International Journal of Indian Psychology ISSN 2348-5396 (e) ISSN: 2349-3429 (p) Volume 4, Issue 3, No. 100, DIP 18.01.074/20170403 ISBN: 978-1-387-00243-6 http://www.ijip.in April-June, 2017 Prevalence and Pattern of Psychiatric Disorders in School Going Adolescents Ajitha Cholakottil 1 *, Firoz Kazhungil 2, A M Kunhi Koyamu 3 ABSTRACT Background: Studies on prevalence and pattern of psychiatric disorders in adolescents using semi structured interview techniques and sound methodology is limited in developing countries. Knowing the magnitude of problem will help us for policy making. Aim: To study the prevalence and types of psychiatric disorders in school going adolescents Methods and materials: Adolescents from 8 th, 9 th and 10 th standards of four schools in two districts of Kerala were selected by random sampling method. Students with Children Behaviour Questionnaire score (CBQ) more than 9 and their parents were evaluated using DISC-C and DISC-P for psychiatric disorders. Results: 38.3% of disturbed adolescents had psychiatric disorders. Most common psychiatric disorder was conduct disorder (12.5%) followed by oppositional defiant disorder (8.3%), depressive disorder (5%), generalized anxiety disorder (5%) and attentiondeficit hyperactivity disorder (3.3%) Conclusions: Psychiatric disorders are highly prevalent in school going adolescents in India. Such a high prevalence should be tackled using appropriate treatment and preventive strategies. Keywords: Adolescents, Psychiatric Disorders The adolescent population constitutes a quarter of Indian population which in turn constitute 20% of the world s 1.2 billion adolescents. Psychiatric epidemiological studies from highincome countries indicate that more than a quarter of children and adolescents meet lifetime criteria for a mental disorder. The awareness and need for identification and treatment of child and adolescent psychiatric disorders grew up in the last four or five decades only. 1 Associate Professor and Head of the Department, Department of Psychiatry, Government Medical College, Manjeri, Kerala, India 2 Assistant Professor, Department of Psychiatry, Government Medical College, Kozhikode, Kerala, India 3 Professor and Head of the Department, Department of Psychiatry, Malabar Medical College and Research Centre, Modakkallur, Atholi, Calicut, Kerala, India *Responding Author Received: April 23, 2017; Revision Received: May 15, 2017; Accepted: May 30, 2017 2017 Cholakottil A, Kazhungil F, Kunhi Koyamu A; licensee IJIP. This is an Open Access Research distributed under the terms of the Creative Commons Attribution License (www.creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any Medium, provided the original work is properly cited.
Child and adolescent mental health issues cause significant educational, social and emotional burden not only to the children and adolescents but also to parents and families. Knowing the magnitude of childhood psychiatric disorders are essential for policy making and to prevent progression into more severe mental disorders and dysfunction. Prevalence of psychiatric morbidities in community based epidemiological studies of children and adolescents shows wide variation ranging from 0.83% to 29.40%. School based studies shows prevalence ranging from 6.33% to 46%. School based studies on prevalence had major limitations such as diagnosis were made by interviewing the parents/teachers and not the children; some studies looked at specific disorders and some other studies were pertaining to one gender or urban/rural setting. Moreover, psychiatric problems in early childhood are different from adolescence and studying this target population only will yield more precise prevalence data on psychiatric disorders in adolescents. There is significant difference in prevalence and pattern of psychiatric disorders in developing countries from that of developed countries, hence knowing the pattern is important for policy making too. Till date only a few Indian studies have looked at psychiatric morbidity disorders specifically in school going adolescents using structured interview schedule for both children and parents. So we planned to study about psychiatric disorders in school going adolescents using structured clinical interview schedule for both the adolescents and their parents. Aim To study the prevalence and types of psychiatric disorders in school going adolescents METHODOLOGY The study was approved by the institutional ethics committee of the Government medical college, Kozhikode, India. The study was conducted in two schools each from Kozhikode and Malappuram districts of Kerala. In two schools medium of teaching was English and in other two, the local language, Malayalam. The four schools were selected following random sampling. Two divisions in each class were selected for the study. Following random sampling thirty students from each division were selected. 720 students underwent initial screening. Initially the class teachers of the two divisions of 8 th, 9 th and 10 th standards were given the necessary instructions to complete the proforma A and B of CBQ of those 720 students who were randomly selected. Teachers were given a period of two weeks to complete the questionnaires. On the basis of cot off scores of 9 on CBQ, disturbed and non-disturbed groups were identified. Those students whose CBQ was more than 9 and their parents were evaluated using DISC-C and DISC- P for psychiatric disorders. Educational and socio-demographic details were collected. We excluded subjects who have physical/visual/hearing handicap. Informed consent was obtained from school principal, class teachers and parents. The data was analysed using SPSS version 16.0. Tools used 1. Proforma for sociodemographic and educational details. The International Journal of Indian Psychology, ISSN 2348-5396 (e) ISSN: 2349-3429 (p) 124
2. Children behaviour questionnaire (CBQ) Proforma A and B 3. Alexander s Passalong Test - to rule out mental retardation. 4. Diagnostic interview schedule for children child informant (DISC-C) and Diagnostic interview schedule for children Parent informant (DISC-P) by NIMH version 2.3 RESULTS Out of 720 subjects screened 120 (16.6%) were found to be disturbed based on CBQ scores. CBQ score was significantly higher in disturbed group compared to undisturbed group. 46 (38.3%) of the disturbed group had at least a psychiatric disorder on DISC-C or DISC-P. 4(3.3%) of disturbed students had more than one psychiatric disorder. Of 120 disturbed students 64 (54%) were boys and 56 (46%) were girls. In the disturbed students 84 (70%) adolescents were from English medium school and 36(30%) to Malayalam medium schools. Table 1. Table 1. Demographic and educational characteristics of disturbed adolescents Parameter Mean+- SD or Percentage (%) Frequency (n) Age 14.04 ±1.04 -- Gender Boys 64 54% Girls 56 46% Education Standard 8 24 20% Standard 9 53 44% Standard 10 43 36% Medium of education Malayalam 36 30% English 84 70% Economic status Below poverty line 49 41% Above poverty line 71 59% Residence Rural 40 33% Urban 80 67% Positive family h/o psychiatric disorders 14 12% Table 2. Psychiatric disorders in disturbed children Disorder Frequency Percentage Conduct Disorder (CD) 15 12.5 % Oppositional Defiant Disorder (ODD) 10 8.3% Depression (MDD) 6 5% Generalized Anxiety Disorder (GAD) 6 5% Attention Deficit Hyper Activity Disorder (ADHD) 4 3.3% Avoidant Disorder (AD) 2 1.7% Obsessive Compulsive Disorder (OCD) 1 0.8% Panic Disorder 1 0.8% Enuresis 1 0.8% Total 46 38.3% The International Journal of Indian Psychology, ISSN 2348-5396 (e) ISSN: 2349-3429 (p) 125
DISCUSSION In our study, we could find that adolescents can be screened by CBQ and in CBQ positive adolescents prevalence of psychiatric disorders are alarmingly high (38.3%). In an Indian study of 460 primary rural school children of West Bengal, aged between 8 to 10 years a similarly high psychiatric morbidity was reported. This study which used Rutter-B-Scale, parental screening interview and ICD9 found a prevalence rate of 33 percent. This high rate is reported from rural primary schools alone and we have to imagine the prevalence if included elder children from urban settings. In another Indian study which included 2064 children prevalence of psychiatric disorders, in 4-16 years age group was reported to be 12 percent which is very less when compared to our study. In the Isle of Wight study over one year period prevalence rate of 10% was reported. A recent meta-analysis of prevalence of child and adolescent psychiatric disorders in India included 16 community based studies and seven school based studies. Meta-analysis found a prevalence rate of child and adolescent psychiatric disorders 6% in the community studies and 23% in the school based studies. Prevalence rate in our study was higher mainly because we included only those subjects disturbed on CBQ. Also there are differences in the samples studied, methodological differences and the tools used. Most of the other school based studies used ICD 9/10, but we used both DISC-P and DISC-C versions to increase the chance of detection. In the present study, the commonest type of psychiatric disorder encountered is conduct disorder (CD)- 12.5% followed by oppositional defiant disorder (ODD), depressive disorder (DD), Generalized Anxiety Disorder (GAD) and attention deficit hyper activity disorder (ADHD)(Table 2). Another Indian study by Tapas Banerjee also had reported conduct disorder as the commonest diagnostic category with a prevalence rate of 13% that too in primary school children alone. It was followed by mental retardation (5.4%) and enuresis (4%) in his study.[9] In our study we excluded children with mental retardation but we found very low prevalence rate for enuresis (0.8%). This may be due to the age group difference between two studies and mental retardation itself might have contributed to higher enuresis prevalence in the study by Banerjee, 1997. But in the largest prevalence study of childhood psychiatric disorders in India conducted by National institute of mental health and neurosciences reported that among 4-16 years old children common disorders were specific phobia (2.9%), social phobias (0.3%) and GAD (0.3%). In the above mentioned study prevalence conduct disorder was 0.2% which is very much lower than our study. But mean age of children in our study was higher. Studies have shown that externalizing disorders like ADHD, ODD and CD are more common in early adolescents, internalizing disorders in children and the onset of conduct disorder tends to peak in late childhood and early adolescence. The International Journal of Indian Psychology, ISSN 2348-5396 (e) ISSN: 2349-3429 (p) 126
The second commonest disorder encountered in the present study is ODD (8.3%). Jane Costello et al in the Great Smoky Mountains study of Youth revealed a prevalence rate of 3.3%. Patrica Cohen et al have reported the same prevalence and age patterns for boys and girls with low levels among the 10 and 11 year olds, rising to high levels among 13-16 year olds and a sharp fall off in prevalence thereafter. In our study prevalence of depressive disorders was 5%. Studies have shown wide variation in the prevalence rates of depression among children and adolescents from 0.1% to 18.5%. Adolescent depression predicts school dropouts, unemployment status, delinquent behaviour, marriage adjustment and substance use disorders in the adulthood and hence awareness and early detection is of utmost importance. Our study had certain advantages over previous studies that we used reports of teachers, conducted semi structured interview for both parents and adolescents, conducted in two different districts and sample was selected by random sampling method. Our study has certain limitations too. Most importantly it s a fact that we didn t look for psychiatric disorders in adolescents not disturbed on CBQ. It could have given a clear direction whether CBQ used by teachers is useful to pick up psychiatric disorders in no disturbed children too. CONCLUSIONS Psychiatric disorders in school going adolescents are quite high. Conduct disorders forms the most common disorder among school going adolescents. This alarmingly high prevalence should make us more alert to pick up the disturbances early itself, to treat and to implement necessary preventive strategies. Acknowledgments The author appreciates all those who participated in the study and helped to facilitate the research process. Conflict of Interests: The author declared no conflict of interests. REFERENCES Banerjee, T., Psychiatric morbidity among rural primary school children in west bengal. Indian J Psychiatry, 1997. 39(2): p. 130-5. Bansal, V., S. Goyal, and K. Srivastava, Study of prevalence of depression in adolescent students of a public school. Ind Psychiatry J, 2009. 18(1): p. 43-6. Bhargava, S., et al., Prevalence of behaviour problems in Ajmer school children. Indian J Pediatr, 1988. 55(3): p. 408-15. Bohman, H., et al., Long-term follow-up of adolescent depression. A population-based study. Ups J Med Sci, 2010. 115(1): p. 21-9. The International Journal of Indian Psychology, ISSN 2348-5396 (e) ISSN: 2349-3429 (p) 127
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