Predictors of Adolescent Internalizing and Externalizing Mental Health Symptoms: A School-Based Study in Southern India

Mental health is enshrined in the World Health Organization’s concept of health [1,2]. While mental health conditions are prevalent in all regions of the world, accounting for one in seven, i.e., 14%, of all mental health conditions, a staggering 75% of individuals living in low-income and resource-constrained countries are reported to be affected [3]. As per the National Mental Health Survey of India, which was conducted between 2015 and 2016, the reported prevalence of mental illness among adolescents aged between 13 and 17 years old is 7.3% [4]. Mental illnesses are one of the major contributors to the overall burden of disease among the young, with the number of cases on the rise [3,5,6].

India is home to about 253 million adolescents. Adolescence is a period of rapid transition, marked by pubertal, physiological, and behavioral changes. Emerging evidence from India reports a variety of psychiatric morbidities such as depression, anxiety, stress, and schizophrenia among adolescents. The prevalence of psychiatric disorders among children and adolescents aged between 5 and 14 was 2.6 to 35.6% [7], while 2 to 3% of the population suffer from serious or incapacitating mental problems [8]. According to a review conducted in 2019 based on Indian studies, the prevalence of depression ranges between 1.2% and 21% in clinic-based studies; 3% and 68% in school-based studies; and 0.1% and 6.94% in community studies [9]. The broad range of the reported point prevalence is attributed to methodological discrepancies among the studies. Singh, M. et al. [10] assessed the prevalence of depression and the factors associated among school-going adolescents aged 13–18 and showed that 40% of the adolescents were screened positive for major depressive disorder: mild depression constituted 29.7%, moderate depression 15.5%, severely moderate depression 3.7%, and severe depression 1.1%. Bansal, V. et al. [11] estimated the prevalence of depression among adolescents studying at public school is 18.4%. Research shows that up to half of all mental health conditions begin during adolescence, and this is a universal phenomenon [2,12,13]. Precursors to emotional and behavioral problems may include immediate influences including the family, parental warmth and control [14,15,16,17], and peer relationships [18,19]. Hostile parenting is considered a risk factor for emotional and behavioral problems, whereas consistent parenting is a protective factor [20]. There is emerging evidence citing gender differences as well in the manifestation of behavioral problems, with a male preponderance towards externalizing behaviors and a female preponderance towards internalizing behaviors [21,22]. Behavioral problems are categorized into internalizing and externalizing symptoms. Internalizing symptoms are those experienced by the individual, including emotional and peer problems. Externalizing problems are behaviors aversive to others, such as behavioral problems, conduct problems, hyperactivity problems, etc. [23]. Neglecting the issue of the rise in mental health and behavioral difficulties among adolescents approaching maturity may have long-lasting consequences not just for individuals but for society as a whole. This necessitates early detection and the referral of adolescents with behavioral difficulties in order to reduce the severity and duration of their disorders; else, it might add to the existing burden on the health system. Schools in India are mainly divided into three types, which includes government, private, and aided. Government schools are governed, funded, and administrated by the state or central government. Private schools are governed, funded, and administrated by private organizations. Aided schools are supported by the government but are managed by private organizations [24]. In the present study, we explored the predictors of total difficulties as well as externalizing and internalizing problems and gender differences in all three types of schools.