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Prevalence of behavioral and emotional problems among seven to eleven year old children in selected schools in Kandy District, Sri Lanka
Journal of Affective Disorders 167 (2014) 167–170
Contents lists available at ScienceDirect
Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Research report
Prevalence of behavioral and emotional problems among seven to eleven year old children in selected schools in Kandy District, Sri Lanka P. Ginige a, S.U.B. Tennakoon b,n, W.H.M.K.J. Wijesinghe a, L. Liyanage c, P.S.D. Herath c, K. Bandara d a
Department of Psychiatry, Faculty of Medicine, University of Peradeniya, Peradeniya 20400, Sri Lanka Department of Community Medicine, Faculty of Medicine, University of Peradeniya, Sri Lanka c Ministry of Health, Sri Lanka d Nivahana Society of Kandy, Central Province, Sri Lanka b
art ic l e i nf o
a b s t r a c t
Article history: Received 26 February 2014 Received in revised form 28 May 2014 Accepted 29 May 2014 Available online 12 June 2014
Background: Behavioral and emotional problems comprising internalizing, externalizing and mixed disorders consist of psychiatric disorders in childhood and adolescents. Prevalence rates of 8.3% for preschoolers, 12.2% for preadolescents and 15.0% for adolescents have been reported from around the world. This study aimed to measure the prevalence of emotional and behavioral disorders in 7–11 yearold school children studying in Kandy District Sri Lanka which was a first for the geographic area. Method: This was a community based study at the primary section of the selected schools. The questionnaire, Child behavior Checklist-Sinhala (CBCL-S) was administered in a group setting to the main caregiver of 562 subjects selected randomly. The questionnaire identified problems in 8 subscales under three main sub categories : internalizing, externalizing and other. Data were analyzed using The Syndrome Scales for Boys and Girls developed for analyzing the questionnaire CBCL. Results: Indicated a prevalence of 13.8% of emotional and behavioral problems in the study population. 8.8% of children showed internalizing problems and 8.8% externalizing problems. These findings are in line with the prevailing rates from previous studies of the world. Children in school types 1AB and 1C had less emotional and behavioral problems compared to type 2 and 3 schools. Limitations: Only 20 schools in KEZ and Sinhala speaking population of the Kandy were studied. Conclusions: This study showed the extent of childhood emotional and behavioral problems and also confirms that the schools with advanced level classes have lesser problems amongst primary children. & 2014 Elsevier B.V. All rights reserved.
Keywords: Childhood Emotional problems Behavioral problems Internalizing Externalizing
1. Background There have been many studies on prevalence of child psychiatric disorders around the globe over the years. However there is a wide variation in demography of the study population and methodology. The influential epidemiological study, Isle of Wight (IOW) studies in the UK found that the one year prevalence rate of psychiatric disorder was about 7% (Rutter et al., 1976). A subsequent study using the same methods in an inner London burrow reports two times the prevalence found in the IOW study for all disorders (Rutter et al., 1975). Although the importance of early detection has been recognized worldwide, until recently there was little systematic research on child psychiatric disorders in developing countries (Rahman et al., 2000). Fortunately since the mid 2000s, a number of studies have been carried out in developing countries, which used instruments and n
Corresponding author. Tel.: þ 94 714568155. E-mail address: [email protected] (S.U.B. Tennakoon).
http://dx.doi.org/10.1016/j.jad.2014.05.062 0165-0327/& 2014 Elsevier B.V. All rights reserved.
methodologies similar to those of western countries. Overall, most studies from developing countries reported high prevalence rates than those in western countries. These include research from Brazil, Yemen, India, Bangladesh, Puerto Rico, Ethiopia and Mexico (Fleitlich and Goodman, 2004; Alyahri and Goodman, 2008; Srinath et al., 2005; Mullick and Goodman, 2005; Canino et al., 2004; Fekadu et al., 2006; Benjet et al., 2009). However, there have been some exceptions to this pattern. For example, the Brazilian IIhade Mare study (Goodman et al., 2005) carried out a household survey in rural settings using the same tools as the British studies, reported a much lower prevalence rate of 7% for DSM-IV based psychiatric disorders. A recent national survey among 13 to 18 year olds in United States found an overall prevalence of 22% for disorders with severe impairment and/or distress (11.2% mood; 8.3% anxiety; 9.6% behavior disorders) (Merikangas et al., 2010). However the socio-demographic features of the Kandy study sample differ from that of US survey.
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P. Ginige et al. / Journal of Affective Disorders 167 (2014) 167–170
applied to each school separately. Non Sinhala speaking students were excluded. The CBCL-S was administered to the parent/caregiver in a group setting at the meeting of Parent Teacher Association (PTA) of the school and 3 research assistants were recruited to help at the administration. A notice with a brief explanation was sent to the parent/caregiver 3 weeks in advance of the PTA meeting requesting them to be present at the meeting. Informed written consent was obtained from the caregiver after an explanation by the main researcher at the day of the survey. The parental ratings of the CBCL-S were analyzed using the Syndrome Scales for girls and boys. The syndrome scales for each sex were designed to identify the children who fell into clinically significant, borderline problematic or normal in each subcategory of internalizing, externalizing and sum disorder problem areas. The parental markings (from 0 to 2) of each of 113 statements of CBCL-S in relation to their child were converted to T values for internalizing, externalizing and sum categories using the syndrome scale. The cutoff of the T value of 69.5 is given as the mark over which the child is clinically problematic. The T value between 64.5 and 69.5 is the borderline problem area. The prevalence of total behavioral and emotional problems and also of the internalizing and externalizing sub categories was obtained. Associations between gender and the school type (1AB, 1C, 2 and 3) of the study population were investigated. Children who were detected to have clinical range of problems in internalizing, externalizing and/or sum disorder were interviewed by the main researcher—a consultant child psychiatrist, in order to provide necessary care and management. Data analysis was done using SPSS version 18.0. To investigate the association between categorical variables Chi-square test was used and for associations between continuous and categorical variables ANOVA was used.
It is known that 20% of 5–15 year olds have a diagnosable mental illness or clinically relevant mental health problems and the few epidemiological studies in Sri Lanka show similar trends among 12–18 year olds, urban pre-schoolers and those awaiting school entry. Only one study was found on childhood behavioral and emotional problems from Sri Lanka (Prior et al., 2005). There is an island wide survey conducted on adolescents' mental health and not in the age group considered in this study (Perera, 2004). No published studies on prevalence of the behavior and emotional problems amongst school children in Kandy District of Sri Lanka were found.
2. Aims of the study The main aim of this study was to calculate the prevalence of childhood behavioral and emotional problems of 7 to 11 year-old children attending selected government schools in Kandy Educational Zone, Sri Lanka utilizing the CBCL-S (Sinhala language version) and it is the first occasion an independent research employed the tool following its validation in Sri Lanka in 2007 (Senaratna et al., 2007). The study aimed at calculating the association of child's sex and school type in relation to the sub categories of disorders, internalizing, externalizing and sum.
3. Methods This was a cross sectional observational study conducted in schools within the Kandy Educational Zone (KEZ). The Ministry of Education (MoE) which is responsible for primary and secondary education in the country administrates all government funded schools in the country. For administrative purposes each of the 9 provinces of Sri Lanka are subdivided into Zones of Education by the MoE (2012). KEZ with 49 schools is one of 23 zones within the Central Province. A total of 1467 schools are functioning within the Central Province out of which 102 are type 1AB (grades 1 to 12 with science, commerce and arts streams in the advanced level), 328 type 1C (grades 1 to 13 with commerce and arts streams in the advanced level), 508 type 2 (grades 1 to 10) and 559 type 3 (grades 1 to 5). Ethical clearance was obtained from the institutional Ethical Review Committee of the University of Peradeniya. Permission to conduct the study on the childhood behavioral and emotional disorders was obtained from the authorities of the Provincial Ministry of Education and principals of the schools. Formal permission to use the instrument was obtained from the Achenbach System of Empirically Based Assessment (ASEBA). Out of the 49 schools within the KEZ 25 schools were selected randomly to represent school children of the age range 7–11 who were studying in grades 3 to 5. The sample of subjects was randomly selected from the 7,8, 9, 10 and 11 year olds studying in grades 3 to 5 using the simple random sampling method
4. Results The study sample of 562 subjects comprised of 241 male children and 321 females (data not shown). 13.8% of the study population shows total behavioral and emotional disorders (sum disorders) of clinical range. 8.8% and 12.1% show internalization problems in clinical and borderline ranges respectively. Externalizing problems are 8.8% and 8.9% in clinical and borderline ranges respectively (Table 1). Males had more externalizing problems in both clinical and borderline range when compared to females. Males also show higher figures in sum disorders in the clinical and borderline range compared to female counterparts. Further it was found that each subcategory overlapped the other, i.e. some children showed disturbances in more than one subcategory (data not shown).
Table 1 Prevalance of internalization, externalization and sum disorders in the clinical and borderline ranges by sex. Gender
Disorder Internalization
Female N (%) Male N (%) Total N (%) Significance (Chi square test) C- Clinical, B- Borderline, N- Normal.
Externalization
Sum disorder
C
B
N
C
B
N
C
B
N
31(7.1) 18 (9.7) 49(8.8) 0.15
32 (15.1) 36 (10.0) 68(12.1)
258 (77.4) 185 (80.4) 443(79.1)
24 (7.5) 25 (10.4) 50 (8.8) 0.01
19 (5.9) 31 (12.9) 50 (8.9)
277 (86.6) 185 (76.7) 462(82.3)
36 (11.2) 41 (17.1) 78 (13.8) 0.03
20 (6.2) 23 (9.6) 44 (7.7)
264 (82.5) 176 (73.3) 440 (78.6)
P. Ginige et al. / Journal of Affective Disorders 167 (2014) 167–170
169
Table 2 Occurance of internalizing, externalizing and sum disorder by school type. School type
Disorder Internalization
1AB 1C 2 3 Significance (Chi-square test) a
Externalization
Sum disorder
Problematica N (%)
Normal N (%)
Total N (%)
Problematica N(%)
Normal N (%)
Total N (%)
Problematica N (%)
Normal N (%)
Total N (%)
27 (16.4) 40 (19.0) 21 (23.1) 31 (32.3) 0.21
138 (83.6) 170 (81.0) 70 (76.9) 65 (67.7)
165 (100.0) 210 (100.0) 91 (100.0) 96 (100.0)
24 (14.5) 31 (14.8) 26 (28.6) 19 (19.8) 0.03
141 (85.5) 179 (85.2) 65 (71.4) 77 (80.2)
165 (100.0) 210 (100.0) 91 (100.0) 96 (100.0)
29 (17.6) 39 (18.6) 24 (26.4) 30 (31.3) 0.32
136 (82.4) 171 (81.4) 67 (73.6) 66 (68.7)
165 (100.0) 210 (100.0) 91 (100.0) 96 (100.0)
Problematic¼ Clinical þ Borderline.
Occurrence of problematic cases (both clinical and borderline range considered together) differed by the type of school as well. Types 1AB and 1C schools show seemingly lesser internalizing problems and sum disorders compared to types 2 and 3 schools. Yet type 1AB and 1C schools have fewer externalizing problems compared to types 2 and 3 schools (Table 2).
5. Discussion and conclusions The findings suggest that 13.8% of the children of the study population show emotional and behavioral problems in clinical range. Internalizing clinical problems were seen in 8.8% of the children of the study population. Externalizing clinical disorders were observed in 8.8% of the children studied. These 7–11 yearolds had emotional and behavioral problems that were severe enough to result in significant distress or social impairment, thereby warranting a clinical assessment and possible intervention. Previous epidemiological studies of mental health in developing countries have reported overall prevalence ranging from 7% in Brazil (Fleitlich and Goodman, 2004) to as high as 17% in PuertoRico (Canino et al., 2004). Our estimate of 13.8% of sum disorder thus falls within the range of previous studies in this region. The occurrence of externalization was significantly higher among male students. This identified gender difference is in keeping with the identified knowledge that the male child is showing more externalizing problems. The occurrence of sum disorder too is significantly higher among male students. In the Sri Lankan culture the girl child is brought up relatively conservatively when compared to boy child. The behavioral outbursts of the female are discouraged and suppressed. That may have contributed to the parental high marking of the statements that catch externalizing problems in boys. The study analyzed the behaviors in association with sex and school type. The association of disorders in relation to parental education and occupation could not be done due to the fact that most of the participants have not mentioned those data. To detect a significant difference between the individual educational levels and occupation of parents in relation to disorder categories and for purposes of more generalizability a study needs to be designed with a larger sample. However an interesting finding is found when the school type is considered against each disorder category. Out of the 20 schools that participated in the Kandy school study 1AB and 1C types have advanced level (secondary education ¼12 years) classes. Types 2 and 3 have up to ordinary level (10 years) classes and primary classes (5 years). When the internalization disorder is considered there is statistically significant difference between the different
types of schools over all. As listed in Table 2 types 1AB and 1C are having least problems and types 2 and 3 showing the highest internalizing problems. Michael Rutter in his work has established that better managed schools have lesser emotional and behavioral problems (Rutter and Taylor, 2002). The fact that students in schools with advanced level studies do better may suggest that these schools are better managed. In the Sri Lankan culture the girl child is brought up relatively conservatively when compared to boy child. The behavioral outbursts of the female are discouraged and suppressed. That may have contributed to the parental high marking of the statements that catches externalizing problems in boys. The schools with primary and advanced level classes both with lesser problems are the schools sought after by parents mostly. There is a lot of competition to enter, the parents are more educated and the children of these schools are usually from the middle class with not many problem backgrounds at home. It is known that the children of better educated parents show lower prevalence of psychiatric disorders (Merikangas et al., 2010). Most consistent association between parental characteristics and mental disorders in children emerged for parental education. Adolescents whose parents were not college graduates were at increased risk for all disorder classes (Merikangas et al., 2010). It is worth exploring these confounding factors in future research.
5.1. Limitations A major limitation of the study is the limitation of it to only 20 schools in KEZ and Sinhala speaking population of the Kandy.
Role of funding source Nothing declared.
Conflict of interest No conflict declared.
Acknowledgments The authors would like to thank Prof. Thomas Acennbach, Achenbach System of Empirically Based Assessment (ASEBA)1 South Prospect Street, St. Joseph’s Wing (3rd Floor, Room#3207), Burlington, VT 05401, Dr. W.A.L. Wickramasinghe, Consultant Psychiatrist, Teaching Hospital, Kandy and President of “Nivahana”, the local NGO for development of Mental Health in the Central Province, Mr. D.M. Jayawardena, Assistant Director, Special education, Ministry of Education, Central Province, Kandy, Mrs. Shriya Tennakoon, Executive Committee member of “Nivahana” and Mrs. Mano Basnayake, Executive Committee member of “Nivahana” for their support.
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References Alyahri, A., Goodman, R., 2008. The prevalence of DSM-IV psychiatric disorders among 7 to 10 year old Yemeni schoolchildren. Soc. Psychiatry Psychiatr. Epidemiol. 43 (3), 224–230. Benjet, C., Borges, G., Medina-Mora, M.E., Zambrano, J., Gaxiola, S.A., 2009. Youth mental health in a populous city of the developing world: results from the Mexican Adolescent Mental Health Survey. J. Child Psychol. Psychiatry 50, 386–395. Canino, G., Shrout, P.E., Rubio-Stipec, M., 2004. The DSM-IV rates of child and adolescent disorders in Puerto Rico. Arch. Gen. Psychiatry. 61, 85–93. Fekadu, D., Alem, A., Hägglöf, B., 2006. The prevalence of mental health problems in Ethiopian child labourers. J. Child Psychol. Psychiatry Allied Discip. 47, 954–959. Fleitlich, B., Goodman, R., 2004. Prevalence of child and adolescent psychiatric disorders in southeast Brazil. J. Am. Acad. Child. Adolesc. Psychiatry 43, 727–734. Goodman, R., Neves Dos Santos, D., Robatto Nunes, A.P., 2005. The Ilha de Mare study: a survey of child mental health problems in a predominantly AfricanBrazilian rural community. Soc. Psychiatry Epidemiol. 40, 11–17. Merikangas, K.R., He, J.-P., Burstein, M., Swanson, S.A., Avenevoli, S., Cui, L., Benjet, C., Georgiades, K., Swendsen, J., 2010. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication–adolescent supplement (NCS-A). J. Am. Acad. Child Adolesc. Psychiatry 49, 980–989.
Ministry of Education Sri Lanka education information 2012 [Online]. Colombo, Sri Lanka. 〈http://www.moe.gov.lk/web/images/stories/statistic/sl_edu_info_ 2012.pdf 2014〉]. Mullick, M.S., Goodman, R., 2005. The prevalence of psychiatric disorders among 5–10 year-olds in rural, urban and slum areas in Bangladesh: an exploratory study. Soc. Psychiatry Psychiatr. Epidemiol. 40, 663–671. Perera, H., 2004. Mental health of adolescent school children in Sri Lanka: a national survey. Sri Lanka J. Child Health 33, 78–81. Prior, M., Virasinghe, S., Smart, D., 2005. Behavioural problems in Sri Lankan school children. Soc. Psychiatry Psychiatr. Epidemiol. 40 (August), 654–662. Rahman, A., Mubbashar, M., Harrington, R., Gater, R., 2000. Developing child mental health services in developing countries. J. Child Psychol. Psychiatry 41, 539–546. Rutter, M. & Taylor, E. 2002. Child Adolesc. Psychiatry. Rutter, M., Cox, A., Tupling, C., Berger, M., Yule, W., 1975. Attainment and adjustment in two geographical areas. Br. J. Psychiatry 126, 493–509. Rutter, M., Tizard, J., Yule, W., Graham, P., Whitmore, K., 1976. Isle of Wight studies, 1964–1974. Psychol. Med. 6, 313–332. Senaratna, B.C.V., Perera, H., Fonseka, P., 2007. Sinhala translation of child behaviour checklist: validity and reliability. Ceylon Med. J., 40–44. Srinath, S., Girimaji, S.C., Gururaj, G., 2005. Epidemiological study of child and adolescent psychiatric disorders in urban and rural areas of Bangalore, India. Indian J. Med. Res. 122, 67–79.
Contents lists available at ScienceDirect
Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Research report
Prevalence of behavioral and emotional problems among seven to eleven year old children in selected schools in Kandy District, Sri Lanka P. Ginige a, S.U.B. Tennakoon b,n, W.H.M.K.J. Wijesinghe a, L. Liyanage c, P.S.D. Herath c, K. Bandara d a
Department of Psychiatry, Faculty of Medicine, University of Peradeniya, Peradeniya 20400, Sri Lanka Department of Community Medicine, Faculty of Medicine, University of Peradeniya, Sri Lanka c Ministry of Health, Sri Lanka d Nivahana Society of Kandy, Central Province, Sri Lanka b
art ic l e i nf o
a b s t r a c t
Article history: Received 26 February 2014 Received in revised form 28 May 2014 Accepted 29 May 2014 Available online 12 June 2014
Background: Behavioral and emotional problems comprising internalizing, externalizing and mixed disorders consist of psychiatric disorders in childhood and adolescents. Prevalence rates of 8.3% for preschoolers, 12.2% for preadolescents and 15.0% for adolescents have been reported from around the world. This study aimed to measure the prevalence of emotional and behavioral disorders in 7–11 yearold school children studying in Kandy District Sri Lanka which was a first for the geographic area. Method: This was a community based study at the primary section of the selected schools. The questionnaire, Child behavior Checklist-Sinhala (CBCL-S) was administered in a group setting to the main caregiver of 562 subjects selected randomly. The questionnaire identified problems in 8 subscales under three main sub categories : internalizing, externalizing and other. Data were analyzed using The Syndrome Scales for Boys and Girls developed for analyzing the questionnaire CBCL. Results: Indicated a prevalence of 13.8% of emotional and behavioral problems in the study population. 8.8% of children showed internalizing problems and 8.8% externalizing problems. These findings are in line with the prevailing rates from previous studies of the world. Children in school types 1AB and 1C had less emotional and behavioral problems compared to type 2 and 3 schools. Limitations: Only 20 schools in KEZ and Sinhala speaking population of the Kandy were studied. Conclusions: This study showed the extent of childhood emotional and behavioral problems and also confirms that the schools with advanced level classes have lesser problems amongst primary children. & 2014 Elsevier B.V. All rights reserved.
Keywords: Childhood Emotional problems Behavioral problems Internalizing Externalizing
1. Background There have been many studies on prevalence of child psychiatric disorders around the globe over the years. However there is a wide variation in demography of the study population and methodology. The influential epidemiological study, Isle of Wight (IOW) studies in the UK found that the one year prevalence rate of psychiatric disorder was about 7% (Rutter et al., 1976). A subsequent study using the same methods in an inner London burrow reports two times the prevalence found in the IOW study for all disorders (Rutter et al., 1975). Although the importance of early detection has been recognized worldwide, until recently there was little systematic research on child psychiatric disorders in developing countries (Rahman et al., 2000). Fortunately since the mid 2000s, a number of studies have been carried out in developing countries, which used instruments and n
Corresponding author. Tel.: þ 94 714568155. E-mail address: [email protected] (S.U.B. Tennakoon).
http://dx.doi.org/10.1016/j.jad.2014.05.062 0165-0327/& 2014 Elsevier B.V. All rights reserved.
methodologies similar to those of western countries. Overall, most studies from developing countries reported high prevalence rates than those in western countries. These include research from Brazil, Yemen, India, Bangladesh, Puerto Rico, Ethiopia and Mexico (Fleitlich and Goodman, 2004; Alyahri and Goodman, 2008; Srinath et al., 2005; Mullick and Goodman, 2005; Canino et al., 2004; Fekadu et al., 2006; Benjet et al., 2009). However, there have been some exceptions to this pattern. For example, the Brazilian IIhade Mare study (Goodman et al., 2005) carried out a household survey in rural settings using the same tools as the British studies, reported a much lower prevalence rate of 7% for DSM-IV based psychiatric disorders. A recent national survey among 13 to 18 year olds in United States found an overall prevalence of 22% for disorders with severe impairment and/or distress (11.2% mood; 8.3% anxiety; 9.6% behavior disorders) (Merikangas et al., 2010). However the socio-demographic features of the Kandy study sample differ from that of US survey.
168
P. Ginige et al. / Journal of Affective Disorders 167 (2014) 167–170
applied to each school separately. Non Sinhala speaking students were excluded. The CBCL-S was administered to the parent/caregiver in a group setting at the meeting of Parent Teacher Association (PTA) of the school and 3 research assistants were recruited to help at the administration. A notice with a brief explanation was sent to the parent/caregiver 3 weeks in advance of the PTA meeting requesting them to be present at the meeting. Informed written consent was obtained from the caregiver after an explanation by the main researcher at the day of the survey. The parental ratings of the CBCL-S were analyzed using the Syndrome Scales for girls and boys. The syndrome scales for each sex were designed to identify the children who fell into clinically significant, borderline problematic or normal in each subcategory of internalizing, externalizing and sum disorder problem areas. The parental markings (from 0 to 2) of each of 113 statements of CBCL-S in relation to their child were converted to T values for internalizing, externalizing and sum categories using the syndrome scale. The cutoff of the T value of 69.5 is given as the mark over which the child is clinically problematic. The T value between 64.5 and 69.5 is the borderline problem area. The prevalence of total behavioral and emotional problems and also of the internalizing and externalizing sub categories was obtained. Associations between gender and the school type (1AB, 1C, 2 and 3) of the study population were investigated. Children who were detected to have clinical range of problems in internalizing, externalizing and/or sum disorder were interviewed by the main researcher—a consultant child psychiatrist, in order to provide necessary care and management. Data analysis was done using SPSS version 18.0. To investigate the association between categorical variables Chi-square test was used and for associations between continuous and categorical variables ANOVA was used.
It is known that 20% of 5–15 year olds have a diagnosable mental illness or clinically relevant mental health problems and the few epidemiological studies in Sri Lanka show similar trends among 12–18 year olds, urban pre-schoolers and those awaiting school entry. Only one study was found on childhood behavioral and emotional problems from Sri Lanka (Prior et al., 2005). There is an island wide survey conducted on adolescents' mental health and not in the age group considered in this study (Perera, 2004). No published studies on prevalence of the behavior and emotional problems amongst school children in Kandy District of Sri Lanka were found.
2. Aims of the study The main aim of this study was to calculate the prevalence of childhood behavioral and emotional problems of 7 to 11 year-old children attending selected government schools in Kandy Educational Zone, Sri Lanka utilizing the CBCL-S (Sinhala language version) and it is the first occasion an independent research employed the tool following its validation in Sri Lanka in 2007 (Senaratna et al., 2007). The study aimed at calculating the association of child's sex and school type in relation to the sub categories of disorders, internalizing, externalizing and sum.
3. Methods This was a cross sectional observational study conducted in schools within the Kandy Educational Zone (KEZ). The Ministry of Education (MoE) which is responsible for primary and secondary education in the country administrates all government funded schools in the country. For administrative purposes each of the 9 provinces of Sri Lanka are subdivided into Zones of Education by the MoE (2012). KEZ with 49 schools is one of 23 zones within the Central Province. A total of 1467 schools are functioning within the Central Province out of which 102 are type 1AB (grades 1 to 12 with science, commerce and arts streams in the advanced level), 328 type 1C (grades 1 to 13 with commerce and arts streams in the advanced level), 508 type 2 (grades 1 to 10) and 559 type 3 (grades 1 to 5). Ethical clearance was obtained from the institutional Ethical Review Committee of the University of Peradeniya. Permission to conduct the study on the childhood behavioral and emotional disorders was obtained from the authorities of the Provincial Ministry of Education and principals of the schools. Formal permission to use the instrument was obtained from the Achenbach System of Empirically Based Assessment (ASEBA). Out of the 49 schools within the KEZ 25 schools were selected randomly to represent school children of the age range 7–11 who were studying in grades 3 to 5. The sample of subjects was randomly selected from the 7,8, 9, 10 and 11 year olds studying in grades 3 to 5 using the simple random sampling method
4. Results The study sample of 562 subjects comprised of 241 male children and 321 females (data not shown). 13.8% of the study population shows total behavioral and emotional disorders (sum disorders) of clinical range. 8.8% and 12.1% show internalization problems in clinical and borderline ranges respectively. Externalizing problems are 8.8% and 8.9% in clinical and borderline ranges respectively (Table 1). Males had more externalizing problems in both clinical and borderline range when compared to females. Males also show higher figures in sum disorders in the clinical and borderline range compared to female counterparts. Further it was found that each subcategory overlapped the other, i.e. some children showed disturbances in more than one subcategory (data not shown).
Table 1 Prevalance of internalization, externalization and sum disorders in the clinical and borderline ranges by sex. Gender
Disorder Internalization
Female N (%) Male N (%) Total N (%) Significance (Chi square test) C- Clinical, B- Borderline, N- Normal.
Externalization
Sum disorder
C
B
N
C
B
N
C
B
N
31(7.1) 18 (9.7) 49(8.8) 0.15
32 (15.1) 36 (10.0) 68(12.1)
258 (77.4) 185 (80.4) 443(79.1)
24 (7.5) 25 (10.4) 50 (8.8) 0.01
19 (5.9) 31 (12.9) 50 (8.9)
277 (86.6) 185 (76.7) 462(82.3)
36 (11.2) 41 (17.1) 78 (13.8) 0.03
20 (6.2) 23 (9.6) 44 (7.7)
264 (82.5) 176 (73.3) 440 (78.6)
P. Ginige et al. / Journal of Affective Disorders 167 (2014) 167–170
169
Table 2 Occurance of internalizing, externalizing and sum disorder by school type. School type
Disorder Internalization
1AB 1C 2 3 Significance (Chi-square test) a
Externalization
Sum disorder
Problematica N (%)
Normal N (%)
Total N (%)
Problematica N(%)
Normal N (%)
Total N (%)
Problematica N (%)
Normal N (%)
Total N (%)
27 (16.4) 40 (19.0) 21 (23.1) 31 (32.3) 0.21
138 (83.6) 170 (81.0) 70 (76.9) 65 (67.7)
165 (100.0) 210 (100.0) 91 (100.0) 96 (100.0)
24 (14.5) 31 (14.8) 26 (28.6) 19 (19.8) 0.03
141 (85.5) 179 (85.2) 65 (71.4) 77 (80.2)
165 (100.0) 210 (100.0) 91 (100.0) 96 (100.0)
29 (17.6) 39 (18.6) 24 (26.4) 30 (31.3) 0.32
136 (82.4) 171 (81.4) 67 (73.6) 66 (68.7)
165 (100.0) 210 (100.0) 91 (100.0) 96 (100.0)
Problematic¼ Clinical þ Borderline.
Occurrence of problematic cases (both clinical and borderline range considered together) differed by the type of school as well. Types 1AB and 1C schools show seemingly lesser internalizing problems and sum disorders compared to types 2 and 3 schools. Yet type 1AB and 1C schools have fewer externalizing problems compared to types 2 and 3 schools (Table 2).
5. Discussion and conclusions The findings suggest that 13.8% of the children of the study population show emotional and behavioral problems in clinical range. Internalizing clinical problems were seen in 8.8% of the children of the study population. Externalizing clinical disorders were observed in 8.8% of the children studied. These 7–11 yearolds had emotional and behavioral problems that were severe enough to result in significant distress or social impairment, thereby warranting a clinical assessment and possible intervention. Previous epidemiological studies of mental health in developing countries have reported overall prevalence ranging from 7% in Brazil (Fleitlich and Goodman, 2004) to as high as 17% in PuertoRico (Canino et al., 2004). Our estimate of 13.8% of sum disorder thus falls within the range of previous studies in this region. The occurrence of externalization was significantly higher among male students. This identified gender difference is in keeping with the identified knowledge that the male child is showing more externalizing problems. The occurrence of sum disorder too is significantly higher among male students. In the Sri Lankan culture the girl child is brought up relatively conservatively when compared to boy child. The behavioral outbursts of the female are discouraged and suppressed. That may have contributed to the parental high marking of the statements that catch externalizing problems in boys. The study analyzed the behaviors in association with sex and school type. The association of disorders in relation to parental education and occupation could not be done due to the fact that most of the participants have not mentioned those data. To detect a significant difference between the individual educational levels and occupation of parents in relation to disorder categories and for purposes of more generalizability a study needs to be designed with a larger sample. However an interesting finding is found when the school type is considered against each disorder category. Out of the 20 schools that participated in the Kandy school study 1AB and 1C types have advanced level (secondary education ¼12 years) classes. Types 2 and 3 have up to ordinary level (10 years) classes and primary classes (5 years). When the internalization disorder is considered there is statistically significant difference between the different
types of schools over all. As listed in Table 2 types 1AB and 1C are having least problems and types 2 and 3 showing the highest internalizing problems. Michael Rutter in his work has established that better managed schools have lesser emotional and behavioral problems (Rutter and Taylor, 2002). The fact that students in schools with advanced level studies do better may suggest that these schools are better managed. In the Sri Lankan culture the girl child is brought up relatively conservatively when compared to boy child. The behavioral outbursts of the female are discouraged and suppressed. That may have contributed to the parental high marking of the statements that catches externalizing problems in boys. The schools with primary and advanced level classes both with lesser problems are the schools sought after by parents mostly. There is a lot of competition to enter, the parents are more educated and the children of these schools are usually from the middle class with not many problem backgrounds at home. It is known that the children of better educated parents show lower prevalence of psychiatric disorders (Merikangas et al., 2010). Most consistent association between parental characteristics and mental disorders in children emerged for parental education. Adolescents whose parents were not college graduates were at increased risk for all disorder classes (Merikangas et al., 2010). It is worth exploring these confounding factors in future research.
5.1. Limitations A major limitation of the study is the limitation of it to only 20 schools in KEZ and Sinhala speaking population of the Kandy.
Role of funding source Nothing declared.
Conflict of interest No conflict declared.
Acknowledgments The authors would like to thank Prof. Thomas Acennbach, Achenbach System of Empirically Based Assessment (ASEBA)1 South Prospect Street, St. Joseph’s Wing (3rd Floor, Room#3207), Burlington, VT 05401, Dr. W.A.L. Wickramasinghe, Consultant Psychiatrist, Teaching Hospital, Kandy and President of “Nivahana”, the local NGO for development of Mental Health in the Central Province, Mr. D.M. Jayawardena, Assistant Director, Special education, Ministry of Education, Central Province, Kandy, Mrs. Shriya Tennakoon, Executive Committee member of “Nivahana” and Mrs. Mano Basnayake, Executive Committee member of “Nivahana” for their support.
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