Psychiatric disorders in children and adolescents in a middle-income Latin American country

doi:10.21203/rs.2.14739/v1

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Psychiatric disorders in children and adolescents in a middle-income Latin American country

https://doi.org/10.21203/rs.2.14739/v1

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published 05 Mar, 2020

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Background Child and adolescent mental health has scarcely been studied in developing countries, though it is an important aspect of health. Mental health problems in youth often continue into adulthood if not diagnosed or treated in time.

Methods The Sistema de Evaluación de Niños y Adolescentes (SENA) [Child and Adolescent Evaluation System] was used to evaluate mental health indicators in a sample of students in Northern Chile. Two age-appropriate versions of the assessment were applied to a total sample of 5,043 students, which included an elementary education sample of 1,953 schoolchildren from fourth grade through sixth grade (ages 8 to 13 years), and a secondary education sample of 3,090 schoolchildren from seventh grade (the last year of elementary school) through the last year of secondary school (senior high school) (ages 12 to 19 years). For each group, the version of the assessment used was determined by the students’ grade level. Both samples included municipal, government-subsidized, and private schools.

Results In this student population, depression, anxiety, and behavioral disorders were the main mental health problems identified, and indicators revealed a progressive increase in cases over the years, coinciding with the global epidemiological scenario. Males showed a greater presence of externalizing behaviors related to mental health problems associated with aggression and defiant behavior. However, females showed the highest number of mental health issues overall, especially regarding problems related to internalization.

Conclusions Our sample population analysis indicates that early intervention is necessary for the diagnosis and treatment of youth, with the goal of reducing the probability that psychiatric disorders will be prolonged, evolving, and worsening in adulthood.

Psychiatry

SENA

Sistema de Evaluación de Niños y Adolescentes

ADHD

Attention Deficit Hyperactivity Disorder

ODD

Oppositional Defiant Disorder

DPD

Dissocial Personality Disorder

Mental health problems during infancy, childhood, or adolescence affect the processes of adaptation and functionality in adulthood; therefore, designing public strategies for the early diagnosis of, and interventions for, mental health issues in the youth population should be considered a priority for the management of public health [1–3].

The prevalence of mental health problems in young children is estimated to be between 17% and 20% globally, with the first symptomatic manifestations observed before age 14 on average. In addition, it has been found that the highest prevalence rates are in developing countries [4–5].

However, intervention is complicated, as findings of high comorbidity rates of mental health disorders suggest that the complexity of diagnosis and treatment is a major challenge. Between 24% and 29% of the mental health problems usually diagnosed in young children, such as depression, anxiety, and behavioral disorders, often contain characteristics that are also present in other disorders [6, 7]. For example, depression in this age group is often comorbid with anxiety and/or behavioral disorders. It also often involves somatic symptoms, such as gastrointestinal discomfort, headaches, muscle aches, excessive tiredness, and sleep or appetite disturbances, together with other internalizing symptoms of an affective and emotional states associated with hypersensitivity, irritability, aggressiveness, impulsivity, social withdrawal, demotivation, intolerance to frustration, and low self-esteem. In addition to symptomatic expression at the cognitive level, depression in youth usually includes difficulties in paying attention, concentrating, understanding, and remembering, thereby negatively affecting learning processes. It should be noted that in adolescence, depression may also be accompanied by problematic substance use, eating disorders, anti-social behavior, or suicidal ideation [8, 9].

The prevalence of depressive disorders in children and adolescents is estimated to be increasing, and the average age at which the first signs or symptoms appear is decreasing. Globally, the prevalence ranges from 2% to 5% in children and 4% to 8% in adolescents. Learning and emotional difficulties are also prevalent, and these have been shown to contribute to the development of depressive symptoms [10–12]. Thus, depression may have the most comorbidity with other mental health problems.

On the other hand, the prevalence of anxiety disorders in children and adolescents significantly surpasses that of other mental health problems usually diagnosed in this population (4% to 32% worldwide), not including those cases in which anxiety manifests itself as a symptom of other clinical conditions. Anxiety also shows comorbidity with social phobia and obsessive-compulsive disorders, and it impacts not only the affective domain but also cognitive functions.

Behavioral disorders make up another category of mental health problems that can occur in childhood and adolescence. Owing to their overt nature, behavioral disorders mainly affect social development such as in school, social, and family contexts; in addition, they have a direct correlation with adaptation disorders in adulthood. Behavioral disorders have a worldwide prevalence ranging from 5% to 7% in children and between 2% and 4% in adolescents [13]. Diagnoses of this type of disorder are higher in males, with more cases of attention-deficit/hyperactivity disorder (ADHD), which significantly affects socialization and learning processes reported in childhood, and more cases of oppositional defiant disorders (ODD) and dissocial personality disorders (DPD, or anti-social personality disorders) reported in adolescence [13]. ODD and DPD share in common characteristics associated with opposition to norms, defiant behavior vis-á-vis authority figures, irritability, and recurring emotional states of anger, along with difficulties in managing these emotions and behaviors. Impulsivity and aggression are also observed with ODD and DPD [14].

In Chile, the prevalence of mental health problems in children is 38.2%, with behavioral disorders associated with attentional deficit with hyperactivity being the most common, followed by anxiety disorders (of which separation anxiety is the most prevalent), and finally, mood disorders, of which major depression has the highest prevalence [15–18].

Several risk factors related to the mental health of young children have been identified, including low socioeconomic level, family dysfunction, physical or psychological abuse, traumatic experiences (accidents, natural disasters, wars, etc.), and insufficient stimulation. Conversely, sensitive upbringing with responsible parenting, including stimulation for the autonomous development of children and educational opportunities for development, has been shown to be a protective factor against mental health disorders [19].

It has been observed that school plans and programs aimed at safeguarding the well-being of students have managed to detect, in a timely manner, problems usually related to depression, anxiety, and behavioral disorders, in addition to mitigating the negative impact of the insufficient investment of public resources in mental health and the low use of available services by the general population. A low rate of service use has been identified as a common problem in several countries, and may be caused by the fear of social stigma associated with a diagnosis, lack of information, or the uncertainty of parents or caregivers regarding whether the changes in behavior or mood observed in their children require treatment [20].

These statistics clearly suggest that the need to detect symptoms of mental health problems and intervene in a timely manner presents a relevant challenge for educational systems, as strategies that facilitate teaching and learning processes also safeguard the psychological well-being of students [20]. In order to meet this challenge and accurately assess psychopathologies that affect optimal growth and development in children and adolescents, the use of valid and reliable instruments for comprehensive psychological assessment is key.

One such reliable instrument of assessment available is the Sistema de Evaluación de Niños y Adolescentes (SENA) [Child and Adolescent Evaluation System] [21], which facilitates the estimation of mental health problems common in the youth population as well as providing an assessment of personal resources and risk factors related to modes of interaction in family, social, and school contexts. The SENA also evaluates for specific problems, such as substance abuse, eating disorders, learning problems, developmental delay, and unusual or disruptive behavior.

The aim of this study was to conduct a descriptive analysis of mental health indicators in a sample of elementary and secondary school students in Northern Chile using the SENA.

This was a non-experimental study since variables were not manipulated. The design was cross-sectional correlational, because all measured variables were collected at the same time [22].

Participants

The total initial sample included 5,130 students. Two samples were assessed, and different versions of the SENA were applied according to the students’ grade levels. Both samples included municipal, government-subsidized and private schools.

The initial elementary school sample included 2,020 schoolchildren between the fourth and sixth years of elementary education, coming from different educational establishments in Arica. The age range was from 8 to 13 years. The initial secondary school sample included 3,110 schoolchildren between the seventh year of elementary school and the last year of secondary school. The age range was from 12 to 19 years.

Automated electronic correction of instruments allows for up to 10% of unanswered questions, so those cases that exceeded that percentage were immediately discarded. The imputation of lost values was used; this did not exceed 1% of the responses to each questionnaire. The final sample consisted of 5,043 students, 1,953 from elementary education and 3,090 from the seventh year of elementary school and the last year of secondary school. Cases with an inconsistency score equal to or greater than 1.6 were discarded.

The division of the samples was based on the students’ grade levels, which were assumed to be the same for students of a similar age. Pupils up to one year older than the upper age limit of the instruments in both samples were included, under the assumption that they would have no difficulty responding. Cases that were under the lower age limit in both versions were discarded.

Instrument

The Sistema de Evaluación de Niños y Adolescentes (SENA)21] was developed by specialists in psychopathology and psychological evaluation. Its purpose is to help in the detection of a wide range of emotional and behavioral problems in individuals between 3 to 18 years of age. It is worth noting that it has been constructed and validated entirely in the Spanish language. Among the problems it assesses for are the following:

Internalized problems: depression, anxiety, social anxiety, somatic complaints, post-traumatic symptomatology, and obsession-compulsion

Externalized problems: attention problems, hyperactivity-impulsivity, anger control problems, aggression, defiant behavior, and anti-social behavior

Contextual problems: problems with family, problems with school, and problems with peers

Specific problems: substance use, eating behavior problems, schizotypy, or unusual behavior

Other areas we assessed using the SENA included problems of emotional regulation and search for sensations. These are all associated with the onset or maintenance of more serious disorders.

Additionally, the SENA evaluates for the presence of certain personal resources, such as self-esteem, integration, social competence, and problem awareness. These may be considered protective and/or supportive factors of clinical intervention. Control scales include positive print, negative print, and inconsistency.

The SENA employs a Likert scale that ranges from 1 to 5 in the answer options for each item, from “never or almost never” (1) to “always or almost always” (5). The total of each dimension is the average of the total of the answers that constitute it, ranging from 1 to 5.

Recently, Sánchez-Sánchez, Fernández-Pinto, Santamaría, Carrasco, and del Barrio (2016) [21] found that the reliability of the subscales is greater than.7 in Spain.

This research used the self-report versions of SENA for both elementary school (8 to 12 years) and secondary school (12 to 18 years). The secondary school version has several dimensions not present in the elementary school version, namely obsessive-compulsive, antisocial behavior, schizotypy, substance use, sensation seeking, eating behavior problems, and problem awareness.

Procedure and Ethical Considerations

We applied the following four steps to complete the study:

We gained the approval of the Ethics Committee of the University of Tarapacá. This study is part of a larger Educational Justice Centre project.
Forty-two educational establishments in the city of Arica were invited to participate in the study, with 69% agreeing to participate, for a total of 29 establishments.
Consent was requested from the parents of all participating students, after the purpose and scope of the study was explained to them; then, the assent of the students themselves was requested.
Assessments were conducted in groups at each grade level. Along with the grade-level teacher, at least two trained interviewers were present at each assessment to answer questions about the meaning of the items or how to respond. The duration of each group’s assessment was approximately 45 minutes.

Data analysis

The demographics of each sample, followed by basic statistics on the dimensions, as well as the correlations between them, are presented in Tables 1, 2, and 3. The graphs for the internalized and externalized problems of both samples are shown in Figures 1 through 4. For reasons related to space, the rest of the dimensions are not graphically displayed. The values for both age groups were classified according to the criteria in the SENA manual. In the scales depicting problems and vulnerability, it is important to differentiate the highest scores, and we considered a standard score > 60 to fall within the “caution” zone, a score > 70 to fall within the “clinically significant” zone, and a score > 80 to fall within the “extreme” zone. In the scales depicting personal resources, it is important to differentiate the lowest scores, and it is considered that a standard score < 39 falls within the “precautionary” zone, < 29 falls within the “clinically significant” zone, and < 19 falls within the “extreme” zone.

Finally, a multivariate analysis of variance (MANOVA) is presented, which includes as independent variables sex and educational level, and as dependent variables all scales of problems and vulnerability, as well as personal resources. SPSS version 22 was used for the statistical analyses.

The elementary school sample was 1,953 students between the 4th and 6th grades. Of the participants, 48.6% were male and 51.4% were female. The mean age was 10.3 years and the standard deviation was 0.9 years. Additionally, 40.8% attended municipal schools, 53.7% attended establishments subsidized by the government, and 5.5% attended private establishments. Regarding participants’ nationalities, the population sample was 88.9% Chilean, 5.3% Bolivian, 3.4% Peruvian, 0.5% Colombian, 0.5% Venezuelan, 0.3% Argentinean, 0.1% Ecuadorian, and 0.9% did not specify their nationality.

The secondary school sample consisted of 3,090 students between 7th grade and the fourth year of secondary school. Of the participants, 48% were male and 52% were female. The mean age was 14.6 years and the standard deviation was 1.8 years. Additionally, 42% attended municipal establishments, 53% attended establishments subsidized by the government, and 4.7% attended private establishments. Regarding nationality, the population sample was 93% Chilean, 3.1% Bolivian, 2.3% Peruvian, 0.6% Colombian, 0.2% Venezuelan, 0.2% Ecuadorian, and 0.3% did not specify their nationality.

Elementary School Sample

The means, standard deviations, and possible range of the global indices of the SENA results in the elementary school sample are shown in Table 1.

(Insert Table 1 here)

(Insert Figure 1 here)

Percentages for internalized problems and externalized problems in the elementary school sample are shown in Figure 1 and Figure 2, respectively. This data shows that percentages were higher in the precautionary area, the clinical significance zone, and the extreme area for internalized problems.

(Insert Figure 2 here)

Secondary School Sample

The values of the means, standard deviations, and possible range of the global indices in the SENA results for the secondary school sample are shown in Table 2.

(Insert Table 2 here)

Percentages for internalized problems and externalized problems in the secondary education sample are shown in Figure 3 and Figure 4, respectively. As is shown in these figures, percentages were higher in the precautionary area, the clinical significance zone, and the extreme area for internalized problems.

(Insert Figure 3 here)

(Insert Figure 4 here)

Table 3 summarizes the marginal means by sex (male and female) and educational level (elementary or secondary), as well as the significant results for MANOVA. The assumption of multivariate homoscedasticity in the BOX test was not met; however, this would not significantly impact the analysis, especially if the groups included more than 30 participants [23–24]. This suggests that it is appropriate to select Pillai’s Trace as the most robust test statistic.

A significant effect of sex was found, Pillai’s Trace =.131(16,5024) = 47.239, p =.000, η2 =.131. We found a significant effect of educational level, Pillai trace =.167(16,5024) = 63,151, p =.000, η2 =.167. The effect of the interaction of sex and educational level was also significant, Pillai trace.027(16,5024) = 8,746, p =.000, η2 =.027.

Six of the fourteen scales depicting problems and vulnerability were significantly higher in females, five were higher in males, and three did not show any difference.

Depression, anxiety, social anxiety, somatic complaints, post-traumatic symptomatology, and emotional regulation problems were greater in females, while hyperactivity-impulsivity, aggressiveness, defiant behavior, problems with school and problems with peers were greater in males. Attention problems, anger management problems, and family problems were not significantly different between males and females. Females had significantly lower self-esteem than males, and males had less integration and social competence than females.

Secondary school students presented significantly higher values in eleven of the fourteen scales for problems and vulnerability. Specifically, they scored higher for depression, anxiety, somatic complaints, attention problems, hyperactivity, anger management problems, aggressiveness, defiant behavior, family problems, school problems, and emotional regulation problems. Meanwhile, post-traumatic symptomatology and peer problems were greater in elementary school students. The only item that did not differ between the two groups was social anxiety. In terms of personal resources, self-esteem and integration and social competence were lower in secondary school students.

An interaction effect was found in all variables except aggressiveness, problems with school, problems with peers, and social integration and competence.

(Insert Table 3 here)

The aim of this study was to describe the mental health of students in an under-developed nation using indicators measured by the SENA in a sample of elementary and secondary school students in northern Chile.

The results showed that in this youth population, depressive, anxious, and behavioral disorders continue to be the main mental health problems in elementary and secondary school students. Furthermore, indicators revealed progressive increases in prevalence during recent years, a finding that coincides with the world epidemiological scenario [25]. Pharmacological and psychotherapeutic treatments are called for, together with educational interventions and other services that not only ensure coverage and quality, but also a timely diagnosis, considering the evolutionary characteristics of development existing between childhood and adolescence [26–28].

Additionally, males showed a higher prevalence of externalizing mental health problems related to aggression and defiant behavior; however, it was females who had the highest rates of mental health problems overall, especially internalized problems. For females, low self-esteem was the main depressive symptom, parallel to somatic complaints, anxiety, and social anxiety. It has been shown that the closer a person gets to adulthood, the greater the probability is that these problems will increase over time. This finding corresponds to results from other studies indicating that anxiety and mood disorders tend to worsen and extend into adulthood to a greater degree than behavioral disorders [29–30], with different incidence rates according to gender. The highest frequency of psychopathologies of an emotional or affective nature is found in the female population [31].

Among the areas of vulnerability that predispose students to present more severe mental health problems, greater difficulties were found in regulating emotions by attending to, perceiving, and clearly expressing their own emotional states, as well as managing the intensity and duration in an appropriate way, and moderating impulses or frustrations, especially in situations of conflict. This is a finding which, according to other studies, is usually related to anxiety disorders, in which the existence of recurrent and intense fears of the negative evaluation of others makes probable the appearance of insecurities that affect cognitive and especially emotional processes. This behavior can lead to students becoming increasingly evasive and resistant to contact with others. since the emotionally destabilizing situations are all those where they are exposed to judgement or criticism [32–36].

Another important finding related to vulnerability was the search for sensation in the adolescent population, whereby the need to try varied, complex and intense experiences, the desire to take risks, and the susceptibility to boredom increased the probability of exposing oneself to dangers. The search for sensation is characteristic of adolescence, together with susceptibility to influence, fantasy of immunity or invulnerability, and the search for or reaffirmation of identity, autonomy, and group integration where the adoption of risk behaviors is expected [37]. Some studies suggest a relationship between sensation-seeking and exposure to risks, with the existence of behavioral disorders linked to hyperactivity as well as defiant and anti-social behavior [38–39].

Finally, we found that the risk factors that do not allow students to face situations perceived as problematic or threatening are due to the lack of social competence, that is, a lack of ability to establish and maintain positive relationships with classmates, and to communicate and behave in an assertive manner while respecting individual or group differences. The degree to which a student has difficulty resolving interpersonal conflicts is based on their awareness and level of self-esteem, as a negative evaluation of self-concept contributes to a reduced capacity for conflict resolution. These findings corresponded with those of other studies in which the excessive use of technology was recognized as one of the primary risk factors negatively impacting not only healthy interpersonal development but also the construction of coherent identities. Expectations and ideals can be a source of stress and anxiety in children and adolescents, as can dysfunctionality and poor familial relationships, experiences of mistreatment, harassment and discrimination, and experiencing poverty and/or humanitarian crises, among others [4, 5].

Among the main limitations of this study is the fact that the students’ reading comprehension levels turned out to be a difficulty for the execution of practical indications and instructions regarding the questionnaires. Further, the resistance of educational institutions to collaborate with the study precluded the attainment of a larger sample.

Future studies should consider the design and evaluation of psychosocial interventions aimed at strengthening emotional regulation and self-esteem in school settings, along with exploring and analyzing potential differences between subgroups, especially the most vulnerable (such as immigrants, indigenous peoples, and all those within each educational establishment who present some type of symptomatology), in an attempt to ensure plans of action are available to assist in the care of these children and adolescents.

The findings of this study showed that the main mental health problems of children and adolescents in northern Chile are anxiety, depression, and behavioral disorders. Differences by sex were observed, as the female population is the most affected, and there is a high probability that these problems will extend into adulthood. In addition, areas of vulnerability included students’ difficulties with regulating their emotions, and, in adolescents, the search for sensations and the risk factors of low self-esteem, difficulty in becoming aware of problems, and low social competence. The results suggested the importance of timely intervention for the diagnosis and treatment of children and adolescents with their families, with the aim of reducing the likelihood these psychiatric disorders will persist and even worsen in adulthood.

Ethics approval and consent to participate

Before the start of the study, written informed consent was requested and received from the parents of the children. Also an informed consent was requested from all students. The objectives of the study were explained as well as the voluntary nature of participation. No compensation was offered for participating in the study. The study was approved by the Ethics Committee of the University of Tarapacá.

Consent for publication

Not applicable.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due Government policy but are available from the corresponding author on reasonable request.

Competing interests

The Authors have declared that they have no competing interest.

Funding

This research was funded by CONICYT PIA CIE160007.

Authors’ contributions

Conception and design: A. Caqueo-Urízar, A. Urzúa, and M. Irarrázaval. Data collection and analysis of data: A. Caqueo-Urízar, J. Flores and C. Escobar. Interpretation of data: A. Caqueo-Urízar, J. Flores, C. Escobar, A. Urzúa, and M. Irarrázaval. Drafting and writing the manuscript: A. Caqueo-Urízar, J. Flores, C. Escobar A. Urzúa, and M. Irarrázaval.

Acknowledgement

This research was funded by CONICYT PIA CIE160007 and Universidad de Tarapacá, Chile.

Manuscript word count: 5655.

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Table 1 Means, Standard Deviations and possible range in global indices of the Elementary School SENA in a sample of 2,020 Chilean students ages 8 to 13 years
	M	SD
Global index	52,5	8,43
Index of Emotional problems	53,7	9,5
Index of Behavioral problems	51,0	10,1
Index of Executive functions	52,3	9,3
Index of Contextual problems	52,7	10,3
Index of Personal resources	43,1	10,9
Score < 39 is considered low, between 40 and 59 is considered medium, and > 60 is considered high.

Table 2 Means, Standard Deviations and Possible Range in Global Indices of the SENA in a sample of 3,110 Chilean Secondary School Students ages 12 to 19 years
	M	SD
Global index	52,3	7,9
Index of Emotional problems	54,2	9,8
Index of Behavioral problems	50,6	9,0
Index of Executive functions	51,7	8,8
Index of Contextual problems	51,4	8,6
Index of Personal resources	42,0	10,8
Score < 39 is considered low, between 40 and 59 is considered medium, and > 60 is considered high.

Table 3 MANOVA analysis of estimated marginal means and significance for Sex and Educational level in a sample of Chilean youth
Type	VD	Sex (S)		Educational level (EL)		Sex (S)	EL	S x EL
INT
	DEP	2.14	1.95	1.95	2.13	.000***	.000***	.000***
	ANS	2.50	2.26	2.23	2.53	.000***	.000***	.000***
	SAN	2.53	2.31	2.44	2.40	.000***	.081	.043*
	SOM	2.33	2.14	2.17	2.30	.000***	.000***	.000***
	PST	2.24	2.07	2.20	2.11	.000***	.000***	.000***
EXT
	ATTE	2.31	2.34	2.27	2.38	.109	.000***	.005**
	HYP	1.92	2.05	1.92	2.05	.000***	.000***	.000***
	ANG	2.01	2.00	1.91	2.10	.528	.000***	.000***
	AGR	1.26	1.44	1.32	1.39	.000***	.000***	.444
	DEF	1.51	1.57	1.46	1.61	.005**	.000***	.015*
CTX
	FAM	1.67	1.66	1.57	1.76	.455	.000***	.000***
	SCH	1.68	1.86	1.70	1.85	.000***	.000***	.051
	PEER	1.34	1.46	1.46	1.33	.000***	.000***	.855
VULN
	REG	2.49	2.21	2.28	2.42	.000***	.000***	.000***
PR
	SEST	3.72	3.87	3.94	3.65	.000***	.000***	.000***
	SOC	3.50	3.43	3.53	3.40	.002**	.000***	.172
INT: Internalized Problems, EXT: Externalized Problems, CTX: Contextual Problems, VULN: Vulnerability, PR: Personal Resources, DEP: Depression, ANX: Anxiety, SAN: Social Anxiety, SOM: Somatic Complaints, PST: Post-traumatic Symptoms, ATE: Attention Problems, HYP: hyperactivity-impulsivity, ANG: anger control problems, AGR: aggressiveness, DES: defiant behavior, FAM: family problems, SCH: problems with school, PEER: problems with peers, REG: problems with emotional regulation, SEST: self-esteem, SOC: integration and social competence.
p<.05 p<.01 **p<.000

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Psychiatric disorders in children and adolescents in a middle-income Latin American country

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