253
J. Indian Assoc. Child Adolesc. Ment. Health 2016; 12(3):253-274 Award Paper Marfatia Award 2015 Parental Handling, Family Functioning and Life event in Help Seeking and non Help seeking Adolescents Kamala Deka, Sabita Dihingia, Kaberi Baruah, Dhrubajyoti Bhuyan Address for correspondence: Dr. Kamala Deka, Professor, JMCH, Jorhat, APQ- 5, Lane- L, Assam Medical College Campus, Dibrugarh. E mail:
[email protected]
ABSTRACT Background:
Worldwide 10 to 20% of Children and Adolescent experience Mental
Disorders and of concern today. Youth under stress have ADHD, Conduct problems, Learning disorders and at higher risk for Depression. They at times define problems due to harsh or rude parental handling or parental pressure on studies, demand on better performance at school. Objectives : This study was designed to asses parental handling , family functioning and life event in help seeking and non help seeking adolescent and to correlate them in development of psychopathology in both the groups. Method: The study was a case control study in which all consecutive cases of Adolescents attending the department were taken as help seeking and controls were taken from the community by cluster sampling method that constitute non help seeking. The sample size consisted of 105 Help Seeking and 112 Non Help seeking subjects. Those who were mentally challenged, psychotic and suffering from co-morbid debilitating medical illness were excluded. After Initial clinical history and examination, informed consent was taken from participants in both the study groups. Participants then were administered with a semi structured questionnaire to collect socio-demographic profile, Strengths and Difficulty
254 Questionnaire (SDQ), Parental handling questionnaire (Malhotra S), Family Assessment Device and Adolescent Life event scale (ALESS). This study was approved by the ethics committee of Assam Medical College, Dibrugarh. Results: Results observed was analyzed using SPSS 16, and Excel. The study sample was comprised of, 42 (40%) male, 63(60%) female in help seeking group whereas in non help seeking, male are 60 (53.6%) and female 52 (46.4%). Most of the cases in both the study groups belonged to nuclear family and from rural background. The adolescent life event stress score was statistically greater in help seeking (t 3.34, p <.001) when compared with non help seeking group. It had been observed that adolescent who had greater ALESS score, were positively correlated with SDQ-difficulty score (p <0.05). In parental handling, higher ‘control’ than ‘care’ was positively correlated with SDQ difficulty score. In the old adolescent, higher care was statistically negatively correlated with SDQ difficulty score . Conclusion: This study had shown that Life event stress in help seeking adolescents were significantly high and associated with psychological problems in them. Also, greater ‘control’ than ‘care’ by parent was a risk factor for development of psychological problems. Key words: parental handling, adolescent, adolescent life event stress, family assessment.
Introduction 10 to 20 % of children and adolescent experience mental disorders worldwide and of concern today. Depression is studied to be occurring at 5% in children and adolescent [1]. Prevalence of depression is much higher in adolescents than in children [2]. One in eight adolescent may experience depression [3]. Youth under stress are diagnosed to have ADHD, conduct problems, learning disorders. They are at higher risk for depression. Adolescence begins with a biologic event (puberty) and ends with a psychologic event (transition to adulthood) develop a cohesive sense of self and then separates from parents
255 both psychologically and physically [4]. It is very important to support them during this period and let them grow. Or else it may lead to different mental health problems. Adolescent, presenting with symptoms in multiple domains at times difficult to diagnose in one single category in our clinical practice. They at times define problems due to harsh or rude parental handling or parental pressure on studies, demand on better performance at school. These perhaps add to the stressful transition stage of adolescence which demands adaptability. Psychiatric problems associated with child and adolescent are of concern today. The Christchurch longitudinal study indicated that stressful life events in 15-21 years Age are associated with several fold increase in suicidal ideation and positive connection to parents and school may protect against depression and other self harming behavior [5]. There had been dearth of studies on children and adolescents especially correlating family functioning, stressful life event in adolescent and parental handling from northeastern part of India .In our set up many adolescents do present with behavioural and emotional problems that motivated us to take up the study. Aims and Objectives: To asses parental handling, family functioning and life event in help seeking and non help seeking adolescent. To study the correlation of parental handling, family functioning and life event in development of psychopathology in both the groups. Methodology: This study was a cross sectional, case control study Sample Size The sample size was calculated as 217. The number of cases collected for Help seeking is 105 and Non Help seeking is 112.
256 Sampling The samples are comprised of two groups, help seeking group and non help seeking group. Help seeking adolescents were collected from the OPD and IPD of department of psychiatry and all consecutive cases were taken. Non help seeking adolescent were collected from the community by cluster sampling method initially and finally the subjects are selected by random sampling. In the upper Assam we had selected the Dibrugarh District as our area for collection of cases. Out of the 6 (six) PHCs of Dibrugarh district, the PHCs of Khowang, Borboruah, Lahoal and Tengakhat were selected randomly which covers numbers of villages. Then random houses of different villages under each PHC’s are selected for collection of data for the study. Inclusion criteria Adolescent of age 13 to 18 of both sexes are selected. One Adolescent of a family and a key member of his or her family who can comprehend and has consented to participate in the study were taken. Exclusion criteria Adolescent who were mentally retarded, psychotic and suffering from co-morbid debilitating medical illness are excluded. Tools a) Semi Structured Socio-Demographic Performa -It is a semi-structured self designed Performa used to collect personal and socio-demographic details of the subjects had been used. This contains identification data like age, sex, education, religion, residential address, Hospital no, phone no etc. b) Strengths and Difficulties questionnaire- PY1 – Parent Report Measure for Youth aged 11-17, Baseline version; (Mental Health National Outcomes and Casemix collections:
257 Overview of Clinician Rated and Consumer Self Report measures VI. 50). It is used to assess strengths as well as difficulties in the study subjects. It has 25 items distributed into five different categories such as Emotional symptom (ES), Conduct problem scale (CPS), Hyperactivity scale (HS), Peer problem scale (PPS). Prosocial scale (PS) is not included in difficulties score. Difficulties score will be the summary score. Summary score = Sum of items scored/ No. of valid completed items X No. of items in each sub-scale. c) Parental Handling Questionnaires [6] It is used to assess pattern of parental handling of the subjects during their childhood period. It has 13 items to be rated as ‘0’ for no response to’ 1’ for some times and ‘2’ for yes responses. Two different components are generated such as ‘care’ and ‘control’ after adding up the total responses on each component. d) Adolescent Life Event Stress Scale (ALESS) [7] This is a life event scale for adolescents containing 41 items and especially adopted to Indian population. Response is made as yes or no. A total score is obtained adding up the score on individual items. It is interpreted as higher the total score more is the stress. e) Family Assessment Device (FAD) FAD is a standardized measure for assessing family functioning. It is a 60 item self report questionnaire developed by Epstein (1983) based on the McMaster model of family functioning [8]. The FAD gives a total score. Each FAD item is scored on a 4 point scale including (reverse items) with higher scores indicating poorer or worse response. The scale was translated into Assamese and again back translated into English. Crohn’s back alpha is calculated as .808 and correlation .704. Procedure
258 The study is conducted at Assam Medical College and approved by Institution’s ethical committee. In both the study groups of adolescents, after initial clinical history and examination, those who fulfilled the inclusion criteria, the family and the subjects are briefed about the study and then informed consent are taken. Subsequently the scales for specific psychopathologyStrengths and Difficulty questionnaire (SDQ), Parental handling questionnaire
[6] and
Family Assessment Device are administered to the key informant (family member). The Life event scale (ALESS) is administered to the adolescents, with special emphasis to maintain the confidentiality. Scores on different scales in both the groups of Help Seeking and non Help Seeking are then analyzed using SPSS version 16 and EXCEL. The data are compared and correlated in both the groups. Results Table 1 show that help seeking sample comprised of female 60% and male 40 % whereas male outnumbered in non help seeking group (53.6 % male and 46.4 % female). Majority in both the groups are in the age group 16 to 18 yrs (68.5% in help seeking and 58.9 % in non help seeking group). Adolescents are mostly high school educated in both help seeking and non help seeking groups. They are mostly hailing from nuclear family (help seeking84.8%, 98.2% in non help seeking) and rural back ground. Table 1 Distribution of subjects as per Socio- demographic variables Help Seeking
Non Help Seeking
n 105
n 112 No
%
No
%
M
42
40
60
53.6
F
63
60
52
46.4
33
31.4
46
41
Old Adolescent
72
68.5
66
58.9
Post High School
30
28.6
8
7.1
High School
68
64.8
103
91.96
Middle School
4
3.8
1
0.89
Primary School
2
2
0
0
Illiterate
1
1
0
0
>= 32050
4
3.8
4
3.6
16020-32049
19
18.1
10
8.9
12020-16019
6
5.7
10
8.9
8010-12019
25
23.8
8
7.1
4810-8009
17
16.2
7
6.2
1601-4809
32
30.5
73
65.2
<=1600
2
1.9
0
0
Nuclear
89
84.8
110
98.2
Extended
16
15.2
2
1.8
Urban
25
23.8
0
0
Rural
80
76.2
112
100
Sex
13 to 15 years Young Adolescent Age 16 to 18 years
Education
Family Income
Family Type
Locality
259
260 Table 2 The help seeking groups falls in middle and non help seeking falls into lower social class according to Kuppuswamy social class ( t 4.28; p .0001) ( Table 2) Study Groups
Mean
S.D
10.38
4.16
t
DF
P
4.28*
215
.0001
Non help Seeking n=112 Help Seeking 12.84
4.29
n=105 *Significant According to Kuppuswami social class, score 10 – 11 lower social class and score
12 –
14 middle social class.
5Adolescent life event stress score is greater in help seeking (t 3.346) than non help seeking and is statistically significant (Table 3). Table 3 Adolescent Life Event Score in Help Seeking & non Help Seeking ALESS
Help Seeking
Non Help Seeking
Mean
208.38
157.74
SD
106.7
115.64
* P < 0.001; it suggest that stress score is greater in help seeking
DF
t Value
215
3.346*
261 Table 4 depicts score on FAD which is statistically greater in non help seeking. Table 4 Total FAD Score IN Study Groups NON HELP HELP SEEKING
‘t’
p
2.05*
0.041
SEEKING n=105
n=112
Mean Score
148.4
151.86
SD
12.16
12.61
* P Value < 0.05 When compared parental handling score, care was greater than control (p <0.05) in both the study groups. However there was no difference noted between the groups in ‘care’ and ‘control’ variables (Table 5). It was also observed to be greater in young as well as old adolescent in help seeking group (Table 6).
262 Table 5 Parental Handling Score in Help Seeking VS Non Help Seeking VARIABLE
HELP SEEKING
NON HELP SEEKING
Mean
10.77
11.41
SD
3.11
2.7
Mean
4.53
4.27
SD
1.51
1.38
18.49*
24.91*
t
PHS
Care
1.62
Control
1.32
‘t’
No difference is noted between help seeking vs non help seeking groups. However, care is greater in both the groups. * P Value < 0.05 Table 6 PHS Age Group
Care
Control
13 to 15 years
Mean
14
4.5
n33
S.D
2.53
1.46
16 to 18 years
Mean
10.43
4.54
n72
S.D
3.07
1.47
‘t’
5.83*
0.130
P
.0000
0897
DF
103
103
P significant at < 0.05; care is greater in both Age groups in help seeking subjects.
263 In the help seeking adolescent all four components of Strength and Difficulties Score which would suggest psychopathology, are higher than non help seeking group. ES (Emotional problems) are more amongst all in help seeking followed by hyperactivity and conduct problems. Total score on SDQ was greater in help seeking than non help seeking (mean 15.11, SD 5.77 vs mean 5.72, SD 4.05) (Table7). Age wise there was no difference seen in SDQ score. Table: 7 Strength and Difficulties Score in Help Seeking & non Help Seeking ES
CPS
HS
PPS
Anova F Ratio P value
Mean SD
Mean SD
Mean SD
3.6
2.81
2.04 3,416
13.97
.0000
1.87 1.23
1.43 3,444
1.56
.197
Help Seeking
5
2.67 3.5
2.6
Non Help Seeking
1.56
1.49 1.32
1.51 1.62
T
11.81 *
Standard error of diff 0.291
DF
Mean SD 2.7
7.46 *
6.31 *
6.63 *
0.292
0.314
0.238
*For Anova, P is < 0.0001; it indicates that all four components are greater in help seeking.
264 Table 8 SDQ Score in different Age groups Age
Mean
SD
14.63
6.05
‘t’
DF
P
0.575
103
.5665
13 to 15 years (n33) 16 to 18 years
15.33
5.67
(n72) P value is insignificant so, age wise no difference in psychological symptoms observed. Table 9 shows that in the help seeking, adolescent stress score is positively correlated with conduct and hyperactivity problems. A linear correlation is seen in Graph 1. Moreover greater parental control is positively correlated with SDQ score (psychopathology score) (Table 10) which is also seen as linear correlation in Graph 2. Table 9 Correlation between ALESS & SDQ score in Help Seeking Variable
ALESS
SDQ Score
total
ES
CPS
HS
PPS
0.17
0.337 **
0.222*
0.096
** Correlation significant at 0.01 * Significant at 0.05 level;
0.373 *
265
Table 10 Correlation between PHQ and SDQ score in Help Seeking n 105 SDQ Care
-0.162
Control
0.275 **
PHS
** Significant at 0.01 Greater Parental Handling - control is associated with risk for psychopathology in adolescent.
266
In the coefficients of correlation, Life event stress score and parental handling control have significant influence on subject’s psychiatric problems (t 3.25 & t 2.16 respectively) (Table 11).
267
Table 11 Coefficientsa Standardized Unstandardized Coefficients Coefficients Model 1
B
Std. Error
(Constant)
22.310
7.449
PHS-care
-.118
.177
PHS-control
.774
LESC
.016
Beta
T
Sig.
2.995
.003
-.060
-.667
.507
.357
.196
2.166
.033
.005
.298
3.255
.002
a. Dependent Variable: total score on SDQ PHS care - parental handling care; PHS control- parental handling control; LESC-life event stress score.
When correlated between ALESS, PHS and SDQ in help seeking in different Age groups, in older adolescent care was negatively correlated with psychopathology score and in young adolescent stress score(ALESS) and control were positively correlated with psychopathology score(SDQ) (Table12)
268
Table 12 16 to 18 years (n=72)
SDQ
FAD
-0.345
ALESS
.297 Care
-.257*
Control
.216
PHS
13 to 15 years(n=33)
SDQ
ALESS
0.508* Care
.098
Control
.400*
PHS
*Correlation is significant at 0.05 It indicates that greater the care, less is the psychological difficulty score in age 16 to 18; ALESS and PHS control are positively correlated with SDQ score. Discussion Socio-demographic Data The study sample is comprised of, 42 (40%) male, 63(60%) female in help seeking group whereas in non help seeking, male are 60 (53.6%) and female 52 (46.4%). Most of the cases in both the study groups belonged to nuclear family, studied high school or post high school and from rural background (table 1). Majority of the sample are in late adolescent in the age 16 -18 yrs than 13 – 15 yrs in both the study groups (68.5% in help seeking and 58.9% in non help seeking group). The help seeking adolescents family belonged to middle socio-economic
269 class (12.84) whereas non help seeking group lie in lower socio-economic class (10.38) probably because, non help seeking sample was totally rural community based ( table 2) Comparison The adolescent life event stress score is statistically greater in help seeking (t 3.34,p <.001) ( table3) when compared with non help seeking group which is keeping with earlier studies [9,10,11] that adolescent do experience different types of stress [12]. Adolescent in both the study groups has greater ‘care’ than ‘control’ on parental handling questionnaire (table 5). In young adolescent (13 – 15) ‘care’ is statistically greater than old adolescent (16 – 18 yrs) (table 6). However there is no statistical difference in care and control of parental handling between both study groups. Family functioning is statistically (p <0.05) poor in the non help seeking in the community when compared with help seeking. This unexpected result could be possibly due to the fact that, the family being in middle socio-economic class(table2), perhaps gave a socially desirable response to items in the FAD scale to prevent exposing themselves or denying to accept being the causal factor for the same in help seeking. Help seeking adolescent scored higher on SDQ summery score means they have greater psychopathology than non help seeking adolescent .Of different component, emotional problems are statistically higher, followed by hyperactivity and conduct problems when compared with non help seeking (table 7). It replicates the findings of previous studies that states Adolescence itself a period of turmoil and so increase in depression and anxiety are seen more in these specific population especially in girls [13 and 14]. Correlation It has been observed that adolescent, who has greater ALESS Score had been positively correlated with SDQ-difficulty score (p <0.05) and statistically significant mostly to conduct
270 problems and hyperactivity in help seeking. It indicates that stressful life events are risk factors for development of psychological problems in adolescent. In our study, statistically positive correlation of SDQ summery score with ALESS is seen in young adolescent (13–15 yrs) (table 12). In a study [15] of inpatient adolescents showed that, those who had psychiatric disorders suffered more stressful events than those with physical disorders. On the other hand, Hudgens noted a relationship between a group of personal stressors and depression in adolescents with medical disorders [17]. An Indian study [7] too, showed positive relationship of stressors and CBCL score in adolescent. Next in parental handling , higher ‘control’ than ‘care’ is positively correlated with SDQ summery score suggesting that greater control on adolescent may be a risk for development of psychopathology in them. In the old adolescent ( 16-18 yrs), higher care is statistically negatively correlated with SDQ summery score indicating that care could be a protective factor against psychological problems in late adolescents (table 12). Study show that there has been a strong link between quality of parent teenager relationship and mental health problems. Good and cordial parent adolescent relationship may reduce experience of mental health problems [16]. In our study Family functioning is assessed with FAD and found a negative correlation with SDQ score in help seeking. Is this means poor family functioning has no psychological impact in adolescent? This unexpected result could be possibly due to the fact that, the families in help seeking group being in middle social class, perhaps gave socially desirable response to items in the FAD to prevent exposing themselves as contributory causal factors or denying the same. Thus direct scope for further research in this aspect. The regression analysis (table 11) in help seeking adolescent has been carried out to see whether and how much each component of independent variables (ALESS, Parental
271 handling and FAD) influence dependent variable (SDQ). It is observed that parental handling- control and ALESS are significantly associated with stress score. It is replicated by earlier Study which shows that psychosocial factors such as poor parent child attachment, family disruption are associated with high risk for mental health problems and suicidal behavior in adolescent [9]. It definitely poses stress on them. Family functioning does not have much impact on the dependent variable (SDQ) in our study. Conclusion and Implication This study have shown that Life event stress in adolescents is significantly associated with psychological problems in them and also, greater ‘control’ than ‘care’ by parent is a risk factor for development of psychological problems. So, these special group of population needs special attention in the community in order to maintain their mental health , as they constitute a bulk of population and are ,future of the growth of today’s world. Henceforth, optimal parental handling and measures perhaps will help adolescents to cope with stresses of life .Thus occurrence of psychological problems may be prevented to some extent. School health programmes and public awareness focusing parents at large are needed to help this specific population of adolescent. Limitations Parental handling scale is originally developed in children age group so retrospective recall bias cannot be ruled out in some cases as we have used them for adolescent subjects though childhood period is assessed. We assessed only one adolescent per household even if there are more than one or no other adolescent. So, perception of stress might have been different and influenced by one or more number of Adolescent in household.
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