ABSTRACT

Background and objective:

Rising incidence of mental health problems is a serious issue all over the world. Adolescents living in orphanages are at a particular risk as they have numerous challenges in their life and coping with them requires adequate life skills. This study aims to assess the emotional and behavioral issues and the coping strategies adopted by adolescent orphans in Pakistan.

Methods:

This cross-sectional study comprises 109 adolescent orphans living in different orphanages. The Strengths and Difficulties Questionnaire for evaluating the emotional and behavioral problems (EBPs) was used while KIDCOPE scale was adopted to assess the coping strategies.

Results:

About 34.9% of orphans fell in an abnormal range of EBP and 22.9% were in the borderline zone. The most prevalent problem was conduct (25.7%) followed by peer problems (24.8%), emotional instability (18.3%), hyperactivity (17.4%), and prosocial behavior (11%). A significant and positive correlation was observed between peer problems and maladaptive strategies (r = 0.191, p = 0.047) and between prosocial behavior and adaptive strategies (r = 0.294, p = 0.002).

Conclusion:

Orphans residing in orphanages suffer from behavioral and emotional problems and are using maladaptive coping strategies. It is highly suggestive to monitor and maintain an optimal psychological health of this vulnerable population in our country.

Keywords:

Orphan, orphanage, adolescent, strengths and difficulties questionnaire (SDQ), emotional and behavioural problems (EBP), KIDCOPE scale, coping.

Introduction

Adolescence is an important developmental period of life that affects health and well-being throughout the life span. The way they are cared for has a deep impact on their mental well-being.¹ Parental death has a profound influence on a child’s psychological development. Orphans are at particular risk of developing mental problems because of their parent’s death as well as improper family support and substandard living conditions.² Half of all mental illnesses, especially emotional and behavioral problems (EBPs), beginning in the early teens and by the mid-20 seconds. Every fifth child or adolescent suffers from a mental issue that needs proper care and support.³ The traumatic life experiences after their parent’s death put a more negative impact on their psychological health.⁴

The orphans not only have a lack of health care providers but also have to confront stigmatization, isolation, and inequity.⁵ The high prevalence of child mental health problems is troublesome because, among these, the EBPs are considered as powerful leading factors for causing psychiatric as well as physical ailments and even earlier mortality in future life.⁶

The most frequently seen behavioral problem is aggression, destructive behavior, fighting, lying, and isolation in orphans of adolescent age groups. The institutionalized children are more prone to develop anger which may turn into aggression and hostility because of a lack of proper medical and nursing care as well as psychological and emotional support by the service providers.^7,8,9 The Strengths and Difficulties Questionnaire (SDQ) is one of the most widely used instruments. It can be used among children aged 4-17 years. It covers a broad range of behavioral and emotional problems including conduct problems, hyperactivity, emotional, peer problems, and prosocial behaviors. All five scales consist of five sub-questions. Each has scoring ranging from 0 to 10. There are in total of 25 questions.¹⁰ Utilizing standard deviation (SD), it is reported that both internalizing and externalizing problems were higher among institutionalized children.¹¹

Emotional disorders are characterized by various problems such as anxiety, depression, fear, anger, stress, frustration, low self-esteem, and somatic symptoms.¹² Orphans have to deal with multiple challenges and a sense of permanent loss and grief makes them emotionally disturbed with increased aggression and emotional fragility. Most of them often feel unhappy, fearful, and anxious.¹³ These emotional problems are frequently seen in the early years of life and considerably increase with the duration of stay in the orphanage.¹⁴

Orphans often face difficulty in coping with their environment and in dealing with their life’s variabilities.¹⁵ Most of them use negative coping mechanisms such as becoming isolated, crying a lot, skipping meals, and even substance abuse to avoid their frustrating surrounding which can be harmful to their well-being. Particularly, adolescent orphans are found to be using negative coping strategies like self-criticism, denial, and wishful thinking. Both positive and negative strategies are used by the orphans as they tend to use these strategies according to their perception and cognition.^16-18

KIDCOPE is a self-report checklist used to identify different coping strategies used by children. It consists of 15 questions revealing the following 10 common coping strategies: distraction, social withdrawal, cognitive restructuring, blaming others, self-criticism, problem-solving, emotional regulation, wishful thinking, social support, and resignation. Positive coping strategies are calculated by adding 5, 8, 9, 11, and 14 questions, and negative strategies are measured by using 1-3, 4, 6, 7, 10, 12, 13, and 15 questions.¹⁹ As adolescence is a crucial period of life, any damage during this time can leave long-term and irreparable effects on the whole life of an individual. Early age is a good time to diagnose all these problems so that they can be timely intervened.²⁰ There is a crucial need to investigate these problems and their extent. This study thus assesses the EBPs and coping strategies among institutionalized adolescents in Pakistan.

Methods

This cross-sectional study was conducted at the University of Health Sciences Lahore, Pakistan, with the collaboration of different orphanages in Pakistan from July 2020 to February 2021. After approval from the Institutional Ethical Review Committee, 109 orphans of the adolescent age group were selected through convenient sampling after meeting the eligibility criteria. Orphans who were having frequent contact with their families through regular weekend visits, those with any history of significant neurological or mental deficits, those who were taking any antipsychotic or mood stabilizers drugs, etc., at the time of the study, or with a recent head injury or any other significant physical trauma and challenged children were excluded. The SDQ questionnaire, comprising 25 questions, was used for the assessment of behavioral and emotional issues¹¹, while the KIDCOPE checklist¹⁹ was used to identify different coping strategies used by these adolescents.

Statistical analysis

The data were entered and analyzed using SPSS 25.0. Mean and SD was given for quantitative variables while frequency and percentage were given for qualitative variables. Pearson correlation was used to find the relationship between SDQ and KIDCOPE score in relation to sociodemographic variables.

Table 1. Comparison of the mean scores of SDQ between genders of orphans (n = 109).

*Independent sample t-test.

Results

Out of 109 orphans, 78 (71.6%) were males and 31 (28.4%) were females. The mean age of the orphans was 13.3 ± 1.6 years. The mean duration of the stay at the orphanages was 4.55 ± 2.52 years with a range of 1 to 11 years. The findings reveal that 34.9% (38) of children were rated as having psychological problems whereas 22.9% (25) were on borderline and 42.2% (46) were found as normal for emotional and behavioral characteristics. On individual scales, 20 (18.3%) adolescents had emotional problems, 28 (25.7%) had conduct problems, 19 (17.4%) were hyperactive, 27 (24.8%) had abnormal peer problems, and 12 (11.0%) children had abnormal prosocial behavioral issues. An independent sample t-test was used to compare the mean scores of the SDQ between genders (Table 1).

Children used a variety of coping strategies, the most common of them was to try to sort out the problem (mean = 1.56, SD = 0.54), try to feel better by spending time with others like friends (mean = 1.52, SD = 0.61), try to calm him/herself down (mean = 1.50, SD = 0.54), and try to forget it (mean = 1.50, SD = 0.62) (Table 2).

The mean KIDCOPE score was higher for the study participants belonging to the age group ≥14 years and whose duration of stay in orphanages was >5 years. Mean KIDCOPE score according to gender in positive and negative strategies is given in Table-3 which showed a significant mean score among both genders.

Pearson correlation test was applied to determine the correlation between children’s mental health rated by SDQ and coping strategies (Table 4). A negative correlation was observed between the total SDQ score and the positive adaptive coping strategies score (r = -0.098, p = 0.309) whereas a positive correlation was observed between the total SDQ score and negative or maladaptive coping strategies score (r = 0.179, p = 0.062). The correlation of the scores between prosocial domain and the total coping strategies and positive or adaptive strategies was positive and significant (r = 0.257, p = 0.007; r = 0.294, p = 0.002), respectively. The correlation between the scores for peer-related issues and negative coping strategies was negative and significant (r = 0.191, p = 0.047).

Table 2. Frequency of KIDCOPE category scores used by adolescent orphans (n = 109).

Table 3. Mean KIDCOPE score according to gender in positive and negative strategies (n = 109).

*Student t-test.

Discussion

In this study, 109 orphans of adolescent age were selected from five different orphanages in Pakistan. The age range of the participants was between 11 and 17 years, in which 71.6% were males and 28.4% were females. In Pakistan, a recent study concluded the prevalence of behavioral and emotional problems in 15.9% of the general population.²¹ But in the case of orphans, the local literature is scarce. This study reports that 34.9% of adolescent orphans had emotional and behavioral issues, whereas 22.9% of the children fall in a borderline range according to the SDQ score. Mishra and Tung ²² from India are also in favor that the EBPs are on the higher side in the institutionalized population.

Based on subscales of strength and difficulty questionnaire, the most prevalent problem in this study was conduct disorder (25.7%) followed by peer-related issues, emotional hyperactivity, and prosocial behavior. These findings are in agreement with the study from Peshawar city where conduct disorder was reported as the most common problem among orphans.²³ The high prevalence of conduct disorder could be associated with many factors as the child has to continually deal with the loss of parents, proper care and guidance, and social discrimination.²⁴ In this study, the overall SDQ score with regard to gender was insignificant; however, considering individual domain, the mean score of the males was significantly (p < 0.05) associated with the conduct disorder while females were found to have a significant relationship with a higher ratio of emotional disorders. Similar to these findings, studies from Kenya and India also found that the girls reported more internalizing problems than the boys.^25,26 The findings by Mutiso et al. ²⁷ however show that boys have higher prevalence rates of EBPs. In this study, SDQ scores are found to be insignificantly related to the age and duration of stay in the orphanages, but the mean scores for all the EBPs except conduct were higher in children above 14 years of age. Consistent with this, Kaur et al. ⁵ co-researchers from India reported an increased tendency of EBPs in older children (20.77%) as compared to the younger ones (10.09%). Mutiso et al. ²⁷ from Kenya however reported contrary findings where older children (14-18 years) were 2-3 times less likely to deal with these problems as compared to the younger ones. Life in an orphanage puts a significant impact on orphans’ coping potential. Various studies had mentioned the difference in coping behaviors of varying ages and different genders. Concerning these issues, this study reveals a significant difference between coping strategies and gender. Females have significant ratings in both types of adaptive as well as maladaptive coping. The results of a study conducted on orphans residing in the orphanages of Malaysia showed that there is a significant difference between coping potential and gender. Males indulged in using varied adaptive coping strategies like substance abuse, distraction, religion, and humor as compared to females. Both genders, however, were involved in negative coping mechanisms.²⁸ These results are in disagreement with the qualitative study performed on orphans in Zimbabwe. The study did not confirm any association between gender and choice of coping mechanisms.¹⁸ Adolescence is a transitional period of life for physical and psychological development. Being an orphan itself is a harsh experience that puts a child in vulnerable conditions. A significant number of adolescents are found to be suffering from mental health problems worldwide. Adoption of adequate and effective coping strategies is the only way forward for maintaining the appropriate physical and mental health of these deprived children. Regular surveys should be carried out to further explore and monitor the psychosocial needs of the orphans and proper systems and policies should be in place to address their physical as well as psychological issues. For the promotion of mental health and the prevention of mental disorders, the government and stakeholders should put efforts to train and recruit psychiatric nurses in both public and private hospitals who should regularly visit these orphanages and help these children through effective counseling, support, and referral services.

Table 4. Correlation between the SDQ and KIDCOPE scores in adolescent orphans (n = 109).

*Significant value

Conclusion

A positive relationship exists between an increase in EBPs and the adoption of maladaptive strategies by adolescent orphans residing in orphanages. Appropriate measures must be taken to achieve an optimal mental health status for these children for their positive development and future role as effective citizens of the country.

Limitations of the study

The study could not take into account an in-depth analysis of the psychological and mental status of these children by psychiatric evaluation. The eligibility of the participants was determined based on their own responses to our questions regarding inclusion in the study, hence a potential bias exists.

Acknowledgement

The authors are pleased to mention the Dean of Anjuman-e-Sulemania, Dar-ul-Shafqat and Kashana Social Welfare Society Lahore for their incredible support in the collection of data. Mr. Waqas Latif (Data Analyst) and Mr. Shahjahan (Librarian) at the University of Health Sciences, Lahore, Pakistan needs special acknowledgment for their technical support. We are also grateful to all orphans, who participated in this study, without whose support this research would not be possible.

List of Abbreviations

Conflict of interest

None to declare.

Grant support and financial disclosure

None to disclose.

Ethical approval

The study has been approved by the Institutional Ethical Review Committee of the University of Health Sciences Lahore vide Letter No. UHS/REG/20/ERC-1441 dated 22-06-2020.

Author’s contribution

MQ, ZA: Acquisition of data, drafting of the manuscript, intellectual input to the manuscript

MG: Conception and design of the study, intellectual input to the manuscript

SK, NUS: Critical revision with intellectual input

FK, NS: Analysis and interpretation of data

ALL AUTHORS: Approval of the final version of the manuscript to be published.

Authors’ details

Mahpara Qamar¹, Mansoor Ghani¹, Samina Kousar¹, Zeenaf Aslam², Najam ul Sabah¹, Firdous Kousar¹, Nasara Shabbir¹

1. Institute of Nursing (ION), University of Health Sciences, Lahore, Pakistan
2. Institute of Nursing Sciences (INS), Khyber Medical University, Peshawar, Pakistan

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