Study reference
Survey methods
Adolescent sub-sample
Prevalence
Profile
Sethi et al. (1967) (Lucknow-urban)
Head of household/housewife interview
n = 388
11–20 years
20 patients (5.1 %)
Psychoneurosis (anxiety, conversion) was common in entire sample
Age-wise distribution of morbidity not provided
Sethi et al. (1972) (Lucknow-rural)
Head of Household interview
n = 509
10–20 years (19 % of total sample)
10 patients (1.9 %)
Mental subnormality (n = 7) and psychoneurosis (n = 3)
Rates same as in adult sample
Premrajan et al. (1993) (Pondicherry-urban)
House to house survey
n = 209
13–20 years
6 patients (2.9 %)
All six patients were females
Rates lower than adult sample
Nandi et al. (2000) (West Bengal –rural)
Door to door survey (in 1972 and 1992)
n = 488 (in 1972)
n = 851 (in 1992)
12–23 years
(22–24 % of total sample)
1972: 9.6 %
1992: 4.0 %
Age specific distribution of mental morbidity not provided for this age group
Rates lower than adult sample
Srinath et al. (2005) (Bangalore and Lucknow; urban/rural)
Screening f/u by Diagnostic interview schedule for children–parent version DISC-P and parent interview (12-16 yrs)
Bangalore: 2064
Lucknow: 2325 (0–16 years)
Figure for adolescent sub-sample not known
Bangalore: 12 %(in 4–16 yrs group)
Lucknow: 11.8 % & 3.6 % in adolescent boys and girls, respectively
Mood and anxiety disorders found in only 0.1–0.2 % of sample
Boys more psychopathology than girls, especially during adolescent years at the Lucknow centre
Pillai et al. (2008) (Goa- urban/rural)
DSM IV diagnosis (Development and well-being assessment)
n = 2,048
12–16 years
Current prevalence 1.81 %
Anxiety/depression: 1 % each
Behavioural disorders: 0.4 %
ADHD: 0.2 %
Association with urban residence, non-traditional lifestyles, lack of safety and history of abuse
While some recent surveys are now available for prevalence of psychiatric disorders in child population, but there are hardly any surveys focusing on adolescent age groups. A methodologically robust study by Srinath et al. (2005) reported a prevalence rate of 12 % among children aged 4–16 years. In such surveys with upper cut-off of 14 or 16 years, the adolescent rates have not been provided separately. It is, therefore, clear that there has been a lack of separate emphasis on adolescent mental health in the psychiatric epidemiological surveys from India.
A recent population-based survey by Pilli et al. (2008) attempted to assess current mental morbidity among 2,048 adolescents (aged 12–16 years) from urban and rural areas of Goa. The current prevalence of any DSM–IV diagnosis was 1.81 % [95 % CI 1.27–2.48]. The most common diagnoses were anxiety disorders (1.0 %), depressive disorder (0.5 %), behavioural disorder (0.4 %) and attention-deficit hyperactivity disorder (0.2 %).
In a prospective study for incidence of psychiatric disorders, school children (aged 4–11 years) were followed after 6 years, at which time the sample was aged between 10 and 17 years (Malhotra et al. 2009). The incidence for child and adolescent psychiatric disorders was 18 per thousand per year (95 % CI: 0–37), of which half had neurotic, stress-related and affective disorders; and 10 % had personality and behavioural disorders. Overall, about 40 % children presented with disorders that had onset specific to childhood, while rest of conditions were early onset psychiatric disorders which are usually seen in adults. Separate findings for adolescent sample were, however, not available.
5.1 School Surveys
Recent surveys have attempted to assess the prevalence of mental health problems in school-going adolescents (Rao 1978), Nair et al. (2012). In addition, these also provide some insight into the academic, family or personal problems affecting the mental health of students in secondary or higher secondary classes (Table 2).
Table 2
School surveys of adolescent mental health problems
Study reference | Instruments | Sample | Findings |
Rao (1978) | General health questionnaire-60; clinical interview | n = 428 urban 13–16 years | Total prevalence: 19.6 % Girls slightly higher prevalence than boys One of the initial school studies in India; part of a thesis |
Mehta et al. (1991) ICMR funded | Child behaviour questionnaire | n = 2055 rural school 6–12 years | Prevalence found to be 13.28 % (total) |
Ahmad et al. (2007) | Screening f/u by ICD-10 | n = 390 10–19 years | Prevalence: 17.9 % in overall sample; and highest in 14–15 years old (25 %) Educational problems, substance abuse, conduct disorder, anxiety, common problems |
Arun and Chavan (2009) | General health questionnaire; Mooney problem checklist | n = 2402 Standard 7–12th | 45.8 % reported psychological problems 50 % perceived problems with role as students 45 % experienced academic decline 9 % reported life as a burden and 6 % had suicidal ideation |
Bhasin et al. (2010) (NCR-Greater Noida) | DASS-1 (Depression anxiety stress scale) | n = 242 students Standard 9–12th | Median scores for depression (0–42), anxiety (0–42), stress (0–42) sub-scales were 10, 8 and 14, respectively (population norms not available for DASS) More in females More in board classes (10th/12th) |
Reddy et al. (2011) | Strength and difficulties score (SDQ) | n = 354 11–16 years Standard 10th | 10.4 % had an abnormal SDQ score Scores on hyperactivity (12 %), conduct problems (16.7 %), emotional problems (12.4 %) and peer (6.2 %) subscales were abnormal in significant percentage Emotional sub-scale score particularly high in female adolescents 19 % had definite difficulties, of which 1/4th were for over a year, which affected functioning in various areas |
Samanta et al. (2012) (Bangalore) | Self report questionnaire | n = 199 Males only Standard 8–10th | Mental health problems such as loneliness (10–17 %), worrying (11–17 %) and suicidal thoughts (14–19 %) were common, with higher figures in urban students Physical violence/bullying was more prevalent for urban students in various settings at home/school |
Singh and Mishra (2012) (Delhi, Lucknow-urban/rural) | Adolescent lifestyle survey | n = 1,500 Standard 6–11th | Suicidal attempts reported by 18 % of sample. Several lifestyle concerns (related to eating, sleeping, risk behaviours) commonly seen in the sample |
Nair et al. (2012) (Kerala) | Teenage Screening Questionnaire-Trivandrum (TSQ-T) | n = 11,501 Standard 11th | 15.2 % reported adjustment problems; 65.8 % body image-related problems; 61.2 % scholastic problems; 22.1 % family-related problems; and 31.9 % personal problems |
Bhasin et al. (2010) assessed all students from standard 9–12 for presence of depression, anxiety and stress in a purposively selected school sample, with adolescents mostly from affluent backgrounds. A significant proportion of the students had a high level of depression, stress and anxiety scores, which were correlated with each other, and inversely related to academic performance. Depression and stress was significantly associated with the number of adverse events in the student’s life over past one year. Anxiety and stress was particularly high in board classes (standards 10th and 12th).
Reddy et al. (2011) assessed urban school adolescents for mental and behavioural problems and found that 28 % had either abnormal or borderline abnormal score on the Strengths and Difficulties Questionnaire (SDQ). Nearly, one in ten had an abnormal SDQ score, and one in five had a difficulty. While male adolescents had higher scores on conduct problems, female adolescents scored particularly high on the emotional symptoms subscale.
In another large-scale school-based study, 61.2 % adolescents reported scholastic problems, 22.1 % family-related problems, 31.9 % personal problems and 15.2 % adjustment problems, with boys reporting a higher percentage. Body image disturbances were present in two-thirds of adolescents (Nair et al. 2012).
5.2 Hospital-based Studies
Several researchers have described the profile and pattern of psychiatric disorders among the treatment seeking adolescent patients, Nagaraja et al. 2005, Sidhu (2012) as summarised in Table 3. Psychosis, mood disorders, neurotic and stress-related, and somatoform disorders were the most common reasons for consultation. Conduct disorder was also a common reason for consultation in the clinic-based sample. This profile of adolescent disorders is quite different from that in children visiting psychiatry clinics.
Table 3
Hospital-based studies: pattern of psychiatric disorders in adolescent patients
Study reference | Instruments | Adolescent patients | Findings |
|---|---|---|---|
Nagaraja et al. (1981–1983) (ICMR multi-site study) (Bangalore, Delhi, Lucknow, Waltair, AP) | Semi-structured interview; Rutter’ classification and ICD-9 diagnosis used | n = 1,015 12–16 years | Psychosis (41 %), hysterical neurosis (27 %) and conduct disorder (7 %) were common; 10–20 % sample had associated abnormal psychosocial factors |
Bharath et al. (1997) (Bangalore) | Chart review for admitted patients over one-year period | 152 adolescent in-patients | Hysterical neurosis (31 %) Psychosis (25 %), conduct disorder (10 %), hyperkinetic syndrome (9.8 %) Average stay: 4–12 weeks |
Malhotra et al. (2007) (Chandigarh) | Retrospective chart review (1980–2005) of patients (≤15 years) | Average 100–144 adolescents per year—largest sub-group | Among entire sample (≤15 years), common diagnoses were mental retardation, neurotic and stress-related disorders and childhood disorders (separate analysis not provided for adolescents) |
Sidhu (2012) (Patiala, Punjab) | Semi-structured proforma ICD-10 diagnosis | n = 500 10–19 years | Mood disorders (24.8 %), neurotic, stress-related and somatoform disorders (23.6 %)-common diagnosis 13.2 % had positive family history Prevalence more in nuclear families |
6 Factors Affecting the Psychological Health of Indian Adolescents
There is often a complex socio-ecological framework of risk factors operating in various contexts, which are central to the lives of adolescents (self, home, school, peer group and neighbourhood). There is sufficient evidence, including evidence from low- and middle-income countries that factors such as dysfunctional family structure and relationships, poverty, urbanisation, academic failure, substance use, and physical and sexual abuse are associated with impaired emotional functioning in adolescents (Patel et al. 2008). There is a significant role of genetic factors as seen in many international studies, and a few hospital-based studies from India. For example, a family history of psychiatric illness was seen in about 40 % of child and adolescent sample with mood disorders (Sagar et al. 2012).
There is a dearth of large-scale systematic studies exploring population-based risk factors for adolescent psychiatric disorders. In a large community-based sample from Goa, the following emerged as significant risk factors associated with adolescent mental disorders (Pillai et al. 2008):
residence in urban areas
an outgoing ‘non-traditional’ lifestyle (frequent partying, going to the cinema, shopping for fun and having a boyfriend or girlfriend)
difficulties with studies
lack of safety in the neighbourhood
gender discrimination
a history of physical or verbal abuse
tobacco use.
Among higher secondary school-going adolescents (n = 811; average age of 16 years), nearly one-third reported experiencing some form of sexual abuse over past 12 months and 6 % reported experiencing forced sex. Both boys and girls reported experiencing sexual abuse. These adolescents had significantly poorer academic performance, poorer mental and physical health, greater substance abuse, poorer parental relationships and higher rates of consensual sexual behaviours (Patel and Andrew 2001).
Runaway adolescents were found to have high hopelessness, depression, suicidal attempts, and history of physical and sexual abuse, substance use and behavioural problems. Such vulnerable groups of adolescents are at risk of suffering from a wide array of mental health problems (Khurana et al. 2004).
Some of the psychosocial factors which are especially relevant in context of psychological health of Indian adolescents have been discussed below:
6.1 Family Factors
Having one’s family as the primary source of social support is associated with lower prevalence of mental disorders (Pillai et al. 2008). In traditional societies, the joint family system ensures a strong role of extended family members in the upbringing of children. In the past few decades, several socio-economic changes such as urbanisation, migration and consumerism have contributed to an increase in nuclear families, and if sufficient parental attention is not paid to them, adolescents may face loneliness and isolation. In general, the emotional unavailability of parents is likely to have long-term psychological consequences in the form of low self-esteem and vulnerability to depression.
In a large school-based sample (13–15 years), high levels of parental involvement (indicated by regular homework checking, parental understanding of their child’s problems, and parental knowledge of their child’s free-time activities) was significantly associated with better mental health. Adolescents with more parental involvement were less likely to have loneliness, insomnia due to anxiety, sadness and hopelessness (Hasumi et al. 2012).
6.2 School/Academic Factors
Overall, the education in India is a tremendously competitive field, though recently some measures have been taken to change the educational system. A high level of stress is frequently seen among students, and even parents, as a result of unrealistically high academic targets set for students. The parental pressure to over-perform, or enormous expectations from an adolescent in secondary or higher secondary classes, is a frequently seen stressor in clinical practice. The term ‘examination’ was found to be a fairly common life event predating the onset of depression in school-going adolescents visiting the child and adolescent clinic at the All India Institute of Medical Sciences (AIIMS), New Delhi especially in the months of February and March when the semester ends in most schools (Garg 2004). Headache was observed to a common presentation among adolescents who are high achievers in school, with rigid and perfectionistic traits in another study from the same institute (Kayal 2006). At times, adolescents may struggle hard to be a topper in order to seek parental approval. Constant comparison between siblings and parental affection conditional on the adolescent’s achievement promotes an unhealthy competition between the siblings and acts as a stressor.
6.3 Life Events and Stressors
Adolescents with psychopathology report significantly more stressful life events compared to healthy counterparts (Patel et al. 2008). An identifiable stressor or life event was reported by 50 % of the younger sample (mean age: 13.68 ± 2.53 years) with mood disorders presenting to the child and adolescent clinic of the AIIMS (Sagar et al. 2012). These were as follows (in decreasing order of frequency): illness or death of a family member, interpersonal conflicts, academic stressors like failure in examination, and change of residence or school. Parental divorce is a common stressor seen in clinics in urban settings, which may translate to peer rejection, low self-esteem, and change of school or residence, all of which may pose additional stress. The gender atypical behaviour in adolescence may lead to inner conflicts and parental or societal disapproval. The adolescent coming to terms with homosexual orientation may feel rejected and lonely and may be at a greater risk for substance use, depression and suicide (Russell and Joyner 2001). The socio-economic stressors faced by adolescents in India such as parental unemployment or poverty may lead to chronic stress among adolescents.
6.4 Lifestyle Issues and Concerns
Several lifestyle-related issues (eating behaviours, sexual behaviours and substance use) may have the potential to impact the physical as well as mental health of adolescents. In a large sample of 1,500 adolescents, inappropriate dietary practices (fast food consumption, cold drinks, low fruit and vegetable intake), sedentary activities, irregular sleeping habits, less religiosity, milder activity pattern, unhealthy daily routine and pursuance of different forms of risk behaviours were commonly seen (Singh and Mishra 2012). Between 10 and 30 % of school-going adolescents in India are overweight and nearly 5 % have obesity. It is especially more among adolescents from parts of Punjab, Maharashtra, Delhi, and south India, and among affluent urban adolescents. (National Family Health Survey-3 2007; Srihari et al. 2007; Singhal et al. 2010; Mehta et al. 2007). The prevalence of some form of sexual activity or contact varies between 8 and 30 % among adolescent boys and 6–15 % of adolescent girls (Shashikumar Ramadugu et al. 2011; Lakshmi et al. 2007). Four per cent of males and 1 % of females reported sexual intercourse (Lakshmi et al. 2007). Adolescents having unfriendly relationship with parents had higher likelihood of sex initiation, and those who reported sexual abuse, sexually transmitted disease symptoms, smoking and those who had not read scientific literature on reproductive and sexual health were more likely to have initiated sex from an early age (Sahay et al. 2013). A number of health problems may arise from risky behaviours, such as sexual activity and substance abuse initiated from an early age. Irregular dietary practices, being overweight and early initiation of sex or substance use, may influence the psychological health of the adolescent population in addition to increasing the likelihood of physical disorders.
It is also important to keep in mind that some of the abnormal adolescent behaviours or lifestyles might represent just the extreme end of normal distribution, and there may be difficulty in labelling them as pathological. It is better to take into account the normative peer behaviours, and the familial and socio-cultural context to seek a better understanding of mental health problems of adolescents.
7 Adolescent Psychiatric Disorders: Indian Studies
7.1 Behavioural Disorders with Onset in Childhood (Attention Deficit Disorders, Conduct Disorder)
Some disorders with onset during childhood may extend into adolescence and beyond. Such disorders may interfere with the normal psychological development, social skills acquisition, academic performance and adjustment at school.
Attention-deficit/hyperactivity disorder (ADHD) is a common and chronic condition requiring long-term management. While hyperactivity often subsides during early adolescence, but inattention may continue to persist. Most Indian studies on ADHD have, however, focussed only on samples of children. Few adolescents, even if included, were not described separately in terms of phenomenology, co-morbidity or management. A comparative study of DSM IV and ICD-10 criteria for diagnosing attention deficit disorders found that while there was a significant overlap between the two, the ICD-10 criteria could diagnose only 70 % of the children and adolescents in contrast to 100 % in case of DSM IV (Sitholey and Agarwal 2012). In another study on comorbidity, 13.5 % children and adolescents with ADHD also had comorbid bipolar disorder (Sivakumar et al. 2013). There is also an increased likelihood of progression to substance use disorders beginning from an early age among those with ADHD (Sringeri 2008). A 6-month outcome of children and adolescents with ADHD on treatment was assessed in a prospective study. The SDQ revealed significant reduction in total difficulty score, the conduct problem sub-scale and peer relationship problem score. Significant improvement in severity of ADHD and academic and psychosocial functioning is possible in ADHD (Deb et al. 2011).
The prevalence of the conduct disorder varies from 7 to 11 % during childhood in most studies and is more common in boys. The ratio of male to female conduct disorders is lower for the adolescent-onset type than for the childhood-onset type (Shastri et al. 2010).
Children and adolescents with conduct disorder are at increased risk of developing antisocial personality disorder and psychopathy later in life. A biological study from India sought to investigate whether any developmental abnormalities are present in the uncinate fasciculus of younger individuals (27 adolescents and 16 healthy controls) with conduct disorder using DT-MRI tractography (Sarkar et al. 2013). Participants in the conduct disorder group had a history of serious aggressive and violent behaviour, including robbery, burglary, grievous bodily harm and sexual assault. Adolescents with conduct disorder had a significantly increased fractional anisotropy and reduced perpendicular diffusivity, in the left uncinate fasciculus. The study concluded that the adolescents with conduct disorder have significant differences in the ‘connectivity’ and maturation of uncinate fasciculus.
7.2 Mood Disorders Adolescents with Depression
7.2.1 Depression
Adolescent depression shows discernible changes from childhood depression in terms of prevalence, gender differences and phenomenology (Pattanayak et al. 2012; Das 2003). The prevalence rates of depression show an increase from childhood (1–2 %) to adolescence with a cumulative probability of 10–20 % by late adolescence, which is same as adult rates. The rates of depression which are similar across both genders in children are almost twice in adolescent females compared to adolescent males. Certain depressive symptoms, e.g. subjectively depressed mood, hopelessness, guilt, atypical and melancholic symptoms are typically reported by adolescents with depression, rather than depressed children. There is a higher risk of suicidal attempts or completion among adolescents compared to children with depression. Approximately, 40–90 % adolescents with depression have a comorbid psychiatric disorder, which includes anxiety disorders, conduct disorders, substance abuse and personality disorders in case of adolescents and hyperactive and conduct disorders in childhood (Pattanayak et al. 2012; Das 2003). The issue of aetiological continuity versus discontinuity in childhood, adolescent and adult depression remains debatable. Depression and stress are prevalent in school-going adolescents, especially among girls. Further, it was found to be associated with a number of significant life events over past one year of the adolescent’s life (Bhasin et al. 2010). Few studies have attempted to assess depression in adolescents who are school dropouts. About 11 % of school dropouts had severe and extreme grades of depression on Beck’s Depression Inventory (BDI) in contrast to 3 % among school-going adolescents (Nair et al. 2004). Depression during the formative adolescent years may lead to several adverse long-term consequences. The levels of depression, stress and anxiety were inversely related to academic performance (Bhasin et al. 2010). Proper identification of depression is crucial to early management and prevention of suicidal risk. The psychometric properties of the BDI and Children Depression Rating Scale-Revised (CDRS-R) were found to be satisfactory for use among Indian adolescent subjects visiting primary-care and paediatric settings. Basker et al. (2007a, b) and Russell et al. (2012) compared the diagnostic accuracy of a self-rated (BDI) and a clinician-rated (CDRS-R) measure of depression in Indian adolescents across three schools. While BDI was found to have a better sensitivity, CDRS-R had a better specificity. It might be prudent to use both these instrument simultaneously to improve the identification of depression in primary-care settings, including school or college health clinics. Not much research is available on course or outcome of adolescent depression in India.
7.2.2 Bipolar Disorder/Mania
Few available studies have assessed the profile, comorbidity and course of adolescent bipolar disorder. Reddy et al. (1997) sought to examine the clinical profile of mania in bipolar disorder in a sample of 21 children and adolescents. The most common symptoms were pressure of speech, irritability, elation, distractibility, increased self-esteem, expansive mood, flight of ideas and grandiose delusions, which appeared to be more or less similar to adult mania. Additionally, 61 % had delusions and/or hallucinations. No subject had comorbid attention-deficit hyperactivity disorder (ADHD) in this study, but as many as 25 % of child and adolescent subjects with bipolar disorder had comorbid ADHD in another study from north India (Sivakumar et al. 2013). Anxiety disorders are another common comorbidity in early onset bipolar disorder. Among the 46 adolescent subjects with remitted bipolar disorder, the prevalence of current and lifetime anxiety disorders was 28 and 41 %, respectively. Compared with others, adolescents with anxiety had more lifetime suicidal ideation, more number of episodes, lower physical, psychosocial, and total subjective quality of life, and lower global functioning. Anxiety disorders were associated with a poorer course and low functioning in bipolar disorder. Prompt recognition and treatment of anxiety disorders in mood disorders are important for comprehensive management. Ratheesh et al. (2011), Srinath (1998) conducted a study to assess the course and predictors in early onset bipolar disorder. A total of 30 subjects in childhood and adolescence were assessed systematically at baseline and 4–5 years later. All subjects had recovered from their index episodes and none exhibited chronicity, however, two-thirds had relapsed, mostly within 2 years of recovery from index episodes. No specific predictors of recovery and relapse could be identified. The study implied that in view of the high rates of relapse in the crucial developmental phase of a young individual, long-term maintenance medication should be considered in juvenile bipolar patients, even if it is a first episode (Srinath 1998). Family stressors such as parental substance use, marital discord and lower socio-economic status are associated with poor treatment response (Kayal 2006).
7.3 Suicide and Self Harm
Suicide is a leading cause of death among young people in India. One of the earliest papers on suicidal attempts among student population was by Venkoba Rao (1972) who described 35 young people with attempted suicide, of which seven attempts proved fatal. In a study evaluating the cause of death among those aged 10–19 years in a rural population of 108,000 in south India, suicide accounted for about a quarter of all deaths in boys and between 50 and 75 % of all deaths in girls. The average suicide rate for girls was 148 per 100,000 and for boys, 58 per 100,000 (Aaron et al. 2004). These rates are one of the highest for young population across the world.
Most studies from India have found that about 4–16 % of adolescents have suicidal ideation and nearly 0.4–5 % have attempted suicide (Arun 2009; Pillai et al. 2009; Sharma et al. 2008). Females had higher prevalence of suicidal thoughts and attempts compared to male adolescents. A retrospective analysis of 222 cases of suicidal deaths in age group 10–18 found that the commonest age group was 15–18 years in both the sexes and most common method was hanging (57 % in girls, 49.5 % in boys) followed by poisoning (Lalwani et al. 2004). Adolescent suicidal behaviour is associated with female gender, premarital sex, physical abuse at home, lifetime experience of sexual abuse, probable common mental disorders, psychological distress, academic incompetence, mother’s working status and peer relationship problems (Pillai et al. 2009; Sharma et al. 2008).
Adolescent who attempted suicide had significantly higher levels of depression, hopelessness, lethality of event and stressful life events compared to adults (Sudhirkumar 2000). Poor impulse control, childhood trauma and life events are also commonly seen in association with adolescent suicide behaviours. The common life events preceding suicidal attempts are mostly failure in examinations, anticipated punishment and impending loss of love or romantic relationship, among others (Jena and Siddhartha 2004). A recent study by Nair et al. (2013) sought to characterise the need and identify the predictive factors for preventive consultation or hospitalisation for adolescent suicide in a rural community setting. Of the 500 adolescents, 2 and 0.6 % required emergency consultation and hospitalisation, respectively. Males needed more preventive action. Age, gender, and presence of anxiety or depressive disorder independently predicted a need for protective action and, together contributed to a parsimonious predictive model. More such studies assessing the preventive strategies implemented at a community level and identifying vulnerable individuals are needed.
7.4 Neurotic, Stress Related and Somatoform Disorders
7.4.1 Anxiety Disorders
Anxiety disorders are commonly encountered among adolescent population. Deb and Walsh (2010) assessed anxiety among a group of 460 adolescents (aged 13–17 years) from Kolkata using the State-trait Anxiety Inventory. Results show that anxiety was highly prevalent in the sample with 20 % of boys and 18 % of girls having high anxiety levels. Anxiety was significantly associated with following being a boy, studying in Bengali medium schools, belonging to middle socio-economic class (middle socio-economic group) and having working mothers. Results also show that a substantial proportion of the adolescents perceived they did not receive quality time from fathers (32.1 %) and mothers (21.3 %) and did not feel comfortable sharing their personal issues with their parents. Social withdrawal in adolescents is also thought to emanate from fear or social anxiety, though recent study by Bower and Raja (2011) observed that it is best conceptualized as a multifaceted construct.
7.4.2 Chronic Headache
Chronic headache is a frequent cause of distress for adolescents, often prompting them to seek medical or paediatric consultations. Many a times, the chronic headache is associated with psychological or psychiatric, rather than medical reasons. Chronic headaches of all kinds and not just due to somatoform pain disorder are discussed here. In a clinic-based study on phenomenology of chronic daily headache in Indian children and adolescents, majority had a more or less specified time of onset of regular headache spells. In all patients, phenomenology of headache included a significant vascular component. Heightened level of anxiety mostly related to academic stress and achievement was noted in the majority (Chakravarty 2005). Presence of high ambitions, perfectionist traits and need to succeed were observed in the adolescents with migrainous headaches (70 %) and tension type headaches (47 %). Parents also had high expectations of academic achievement from these adolescents (Mehta 2002).
In a large-scale study of 2,235 adolescents, 58 % reported having recurrent headaches in past one year (Gupta et al. 2009). Migraine was the most prevalent type of headache (17.2 %), followed by unspecified type of headache (15 %), and tension type of headache (11 %). Average age of onset of headache was 11.33 years, and it was progressive in 37 % since its onset. Family history of headache was common in adolescents with headache. Headache was more prevalent in higher grades and among girls. In another study from Delhi, headache types seen in adolescents were migraine, tension-type headache and unspecified headache, in that order. Stress was seen to be a major precipitant in 40 % of headaches irrespective of type. Majority had been suffering for 1–2 years before taking a formal consultation (Mishra 2013). Stress management techniques may help in effective prevention and control of triggers for headache.
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