Evaluation of the relationship between emotional and behavioral problems and quality of life of adolescents in school

Abstract

This study was conducted to determine the quality of life and difficulties of adolescents in school age. This descriptive study was conducted in a city center three secondary School. Similarly from each school 114,114,116 people participated in the study, 4 students could not be included in the study due to insufficient data and the study was completed with 344 students. Questionnaire developed by the researcher, the Strengths and Difficulties Questionnaire (SDQ), and the Pediatric Quality of Life Inventory (PedsQL) were used for data collection. Research was completed in line with the ethical principles. According to the evaluations, it was observed that 50.6% of the students was 13 years old, 52% was male, and 53.5% was in the seventh grade. The total score average for PedsQL was 81.58 ± 13.65, and the mean total score for SDQ was 25.02 ± 4.813. A positive and significant correlation was found between “behavioral problems” subscale score of the SDQ and all subscales of PedsQL except the “physical health” subscale as well as the positive and significant correlation between the mean total scores of PedsQL and SDQ. It was observed that the quality of life of the students is affected negatively as the difficulties experienced during adolescence increase. Some recommendations were made to reveal the problems experienced by school-age adolescents and to increase their quality of life.

Keywords

adolescents behavioral problems quality of life school

Introduction

School health is defined as all the interventions performed to assess and measure the health of students, teachers, and other staff in school, to ensure and maintain a healthy school life, and to provide health education to the students and community as a whole (T.R. Ministry of Health, 2008). Schools are the most suitable environments in terms of health promotion and diseases prevention (Öncel et al., 2016).

In the school age, adolescents are the most remarkable group due to the major changes they experience. Psychosocial development characteristics of children in school age can be grouped as preadolescence period and postadolescence period (Tuna, 2010). Adolescence is generally defined as the period of preparation for life between childhood and adulthood. Since each individual shows unique patterns of growth and development, it is difficult to draw boundaries for this period chronologically. According to World Health Organization (WHO), the 10–19 age-group has been accepted as adolescent (http://www.who.int/topics/adolescent_health). According to the data of Turkish Statistical Institute (TURKSTAT) in 2014, the ratio of young population in Turkey is 16.5% (www.tuik.gov.tr). According to the WHO estimates, 1.3 million adolescents each year lose their lives due to accidents, suicide, HIV, violence, and psychological conditions experienced in school and social life (http://www.who.int/mediacentre/commentaries/investing-in-adolescents). The problems of the period of adolescence can be very different from those of childhood or adulthood (http://www.phdernegi.org). Adolescents in the school age face with many difficulties and health problems. Common problems include obesity, eating disorders, diabetes, anemia, tooth decay, growth-development disorders, harmful habits, and many other physical and psychological problems (Havlioğlu, 2011). Many problems and difficulties experienced during childhood and adolescence affect the life of this group significantly. In particular, the inadequacies in coping with problems experienced by adolescents directly affect their quality of life (Tuna, 2010). The changes in adolescence and young adulthood affect their quality of life by in line with the change of health behaviors. Since adolescents experience many physical, social, and psychological changes, focusing on provision of care, preventing health problems, and improving health of adolescents will enable us to assess their quality of life accurately (Yılmaz and Hacıalioğlu, 2018). One of the groups that can best identify the children with problems in school age is nurses (Kurt and Savaşer, 2013). A school health nurse makes physical and mental assessments of the student, plans training for both students and school staff, provides effective communication with parents, identifies school health problems, and implements early diagnosis and treatment (Öncel et al., 2016). The school health nurses also have very important role in identifying health-related difficulties that affect learning negatively, in helping children to cope with health problems and difficulties experienced as well as helping them for being healthy during their school years and adulthood, and plan their interventions in this direction (Ceylan and Turan, 2009). This study was conducted to determine the quality of life and difficulties of adolescents in schools.

Methods

Participants and procedures

The study population consists of seventh and eighth graders in three central secondary schools affiliated to Provincial Directorate of National Education. The sample of the study was determined by sampling method used in cases where the universe is known, and the sample selection process was made by simple random sampling method after being divided into strata according to classes (n = 344).

Instruments

A questionnaire developed by the researcher in line with the literature, the Strengths and Difficulties Questionnaire (SDQ), and the Pediatric Quality of Life Inventory (PedsQL) were used for the collection of study data.

Questionnaire

It contains items about sociodemographic characteristics of adolescents.

Pediatric Quality of Life Inventory

The scale developed by Varni et al. in 1999 measures the general quality of life in the 2–18 age-group (Varni et al., 1999). The Turkish validity and reliability study of PedsQL for the “13–18 age-group” has been conducted by Memik et al. The Cronbach’s α value of the adolescent questionnaire has been given as .82 for the 13–18 age-group, and the Cronbach’s α value was found to be .89 in our study. The Quality of Life Scale consists of four subscales that determine physical, emotional, social, and school-related functionality. There are eight items in the physical functioning subscale, five items in the emotional functioning subscale, five items in the social functioning subscale, and three items in the two–four age-group and five items in other age-groups in the school-related problems subscale. Items are scored between 0 and 100. PedsQL the higher the total score, the better the quality of health-related quality of life (Memik et al., 2007).

Strengths and Difficulties Questionnaire

SDQ has been developed by Goodman in 1997 to diagnose psychological problems in children and adolescents (Goodman, 1997). The scale adapted to Turkish by Güvenir et al. was observed to be consistent and reliable (Güvenir et al., 2008). In all studies for total difficulty score, the Cronbach’s α value for the entire sample has been given as .70 (http://www.sdqinfo.com/py/sdqinfo/b3.py?language=Turkish). In our study, the Cronbach’s α value was found to be .86. SDQ consists of 25 items on positive and negative behavioral characteristics. These items are addressed in five subscales. These subscales are behavioral problems, attention deficit and hyperactivity, emotional problems, peer problems, and social behaviors. As each subscale is scored separately, the sum of the first four subscales gives the “total difficulty score” (Güvenir et al., 2008). The subscale scores and total score are evaluated as “normal,” “borderline,” and “abnormal.” The high scores obtained from the first four subscales indicate that the student is in the high-risk group, and the high score obtained from the social behaviors which is the fifth subscale shows that the student is strong in social skills (Goodman, 1997). Also, the scale does not have a break point. The strength of the scale used for the study is that its reliability is high and its weakness is that it was not used for diagnostic purposes.

Compliance with ethical standards

Ethical committee approval and permission from the related institution was obtained for conducting the research. The study was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. All persons gave their informed consent prior to their inclusion in the study. Permissions were obtained for the scales to be used in the study.

Evaluation of data

Eleven different statistical analyses were used in the evaluation of the data, including frequency, percent, Pearson correlation analysis, t-test, ANOVA, Durbin–Watson test, simple linear regression analysis, Dunnett T3 post hoc test, LSD post hoc test, Mann–Whitney U test, and χ² analysis.

Results

Findings obtained from the study are as follows.

Considering Table 1, 50.6% of the students included in the study was 13 years old, 52% of them was male, 53.5% was seventh grader, 28% was the first child of the family, 45.1% had primary school graduate mother, 33.2% had secondary school graduate father, father of 49% was self-employed, mother of 87.9% was housewife, and 92.8% was living in nuclear family.

Table 1.

The research findings regarding the students handle features.

Features (n = 344)		Number	%
Age	The age of 13	175	50.6
	The age of 14	148	42.8
	The age of 15	23	6.6
Gender	Female	166	48.0
Gender	Male	180	52.0
Class	Seventh	185	53.5
Class	Eighth	161	46.5
How many children	First	97	28.0
	Second	98	28.3
	Third	82	23.7
	Four and above	69	19.9
Educational status of the mother	Literate is not	34	9.8
	Elementary school	156	45.1
	Graduated from secondary school	114	32.9
	High school graduate	34	9.8
	College graduates	8	2.3
Educational status of the father	Literate is not	4	1.2
	Elementary school	86	24.9
	Graduated from secondary school	115	33.2
	High school graduate	104	30.1
	College graduates	37	10.7
Father’s occupation	Officer	64	18.6
	Employee	91	26.4
	Self-employed	169	49.0
	Retired	21	6.1
Mother’s occupation	Officer	8	2.3
	Employee	10	2.9
	Self-employed	20	5.8
	Retired	4	1.2
	Other: housewife	304	87.9
Status of parents of togetherness	Married	321	92.8
	Divorced	14	4.0
	Mother or father died	11	3.2

According to Table 2, when the quality of life scores of adolescents are examined, it was determined that the mean PedsQL total score was 81.58 ± 13.65 high level that, highest the mean social functioning subscale score was 89.30 ± 16.28 points and the lowest mean score, the mean school functioning subscale score was 75.16 ± 17.41 shows that, the quality of life is above average.

Table 2.

The Strength and Difficulties Questionnaire Scores and the Quality of Life Scale for children and students.

	n	Minimum	Maximum	Arithmetic average	Standard deviation
Physical health score	344	19	100	83.71	15.79
Emotional functionality score	344	0	100	76.88	21.43
Social functioning score	344	0	100	89.30	16.28
School functioning score	344	0	100	75.16	17.41
Total PedsQL Score	344	29	100	81.58	13.65
Attention deficit and hyperactivity symptoms subscale	344	0	10	5.78	1.77
Affective symptoms subscale	344	0	9	3.90	2.12
Conduct problems subscale	344	0	10	3.97	2.00
Peer relationships subscale	344	0	9	4.17	1.75
Social behavior subscale	344	0	10	7.19	1.97
Total difficulty score	344	0	37	25.02	4.81

Note: PedsQL: Pediatric Quality of Life Inventory.

Despite the high quality of life of adolescents, according to the evaluation of their difficulties, The mean difficulty score was found to be 25.02 ± 4.81 has been identified as. When we evaluate this result, it was determined to be “abnormal.” According to the results, they reported that they had a very emotional–behavioral problem. The most problematic area of adolescents is social relations. The mean social behavior subscale score was 7.19 ± 1.97 that is, least problem, the mean affectivity subscale was 3.90 ± 2.12 stated that they live in the field. Considering the distribution of the scores of the students about the emotional–behavioral problems, 0.9% was in the normal group, 2.3% was in the borderline group, and 96.8% was in the non-normal group in terms of emotional–behavioral problems (Table 3).

Table 3.

The SDQ obtained from the emotion–behavior issues: Classification and distribution.

Emotion—Classification of behavior problems	Number	Percent (%)
Normal (0–13 points)	3	0.9
Borderline (14–16 points)	8	2.3
Non-normal (17–40 points)	333	96.8
Total	344	100.0

Note: SDQ: Strengths and Difficulties Questionnaire.

In Table 4, a positive and significant correlation was found between “behavioral problems” subscale score of the SDQ and all subscales of PedsQL except the “physical health” subscale as well as the positive and significant correlation between the mean total scores of PedsQL and SDQ. According to this result, there was no significant relationship between SDQ subscale with ‘Attention deficit and hyperactivity’ sub-dimensions of PedsQL ‘‘Physical health, Social functionality, School functionality’. However, they stated that “emotional function, social function, and school functioning,” which are the components of quality of life, cause feelings and behavior problems and have difficulty. Social function, which is the subdimension of quality of life of adolescents, does not affect social behavior, and also the quality of life component school function, “attention deficit and hyperactivity sympoms,” and “social behavior” are not affected.

Table 4.

The Strength and Difficulties Questionnaire Scores for children and students: The relationship between the Quality of Life Scale.

	SDQ subscale
PedsQL subscale	Attention deficit and hyperactivity symptoms	Affective symptoms	Conduct problems	Peer relationships	Social behavior	Total difficulty score
Physical health	.074	.252**	.060	.153**	.123*	.169**
Emotional functionality	.111*	.303**	.193**	.189**	.156**	.260**
Social functioning	.071	.191**	.114*	.259**	.105	.209**
School functioning	.096	.307**	.160**	.180**	.025	.294**
Total PedsQL score	.113*	.339**	.164**	.243**	.137*	.293**

Note: SDQ: Strengths and Difficulties Questionnaire; PedsQL: Pediatric Quality of Life Inventory.

Bold values indicate a positive and significant correlation between the factors. *p < .05; **p < .001.

Factors affecting the quality of life of the adolescents are age, gender, grade of education, their rank among the children in the family, and parental education level, whereas the factors that affect the difficulties they experience were found to be age, gender, their rank among the children in the family, maternal level of education, and paternal occupation.

Discussion

Within the scope of the study, PedsQL was used to determine how the adolescents’ quality of life is affected by the problems they experienced. In our study, the mean PedsQL score was found to be 81.58 ± 13.65. In a study conducted with adolescents with chronic illness, the PedsQL total score has been found to be 68.27 ± 17.64 (Eyüboğlu et al., 2017). Looking at the two studies, it can be seen that the PedsQL averages vary depending on the problems children experience.

It was determined that the social function score was 89.30 ± 16.28 and the school function score was 75.16 ± 17.41. In the present study, the social function subscale score was 91.27 ± 10.63, and the other subscales were the highest scores for healthy adopters in the study, which was assessed in terms of psychosocial characteristics and quality of life of children with autism spectrum disorders. In the study conducted by Meeske and his colleagues, the lowest PedsQL subscale score of the children was found to be 81.5 and school functional score was found to be 74.6 (Meeske et al., 2006). This study supports our work results. In another study, PedsQL subscale score is similar to our study (Eren et al., 2018).

In another study, the highest subscale of PedsQL belongs to social function and 94.35 ± 8.09 points were found to be the lowest subscale of school functionality and 84.10 ± 12.65 points were found to be the lowest subscale (Beşer and Çam, 2009). SDQ, which is used to identify behavioral and emotional problems in children and adolescents, was used in our study to identify the problems experienced by adolescent students. The mean total difficulty score in our study was 25.02 ± 4.81. In a study conducted to identify adolescents who were prone to crime, the total difficulty level of students has been found to be 13.26 ± 4.56 (Çetin, 2009). The examination system in Turkey is entering a key test for these students to study in high school. This situation is thought to increase the difficulties experienced by students. In addition, familial and sociodemographic factors can be considered as another reason for the high levels of difficulties.

When the distribution of the scores of the students regarding the emotional–behavioral problems was examined, 0.92% were normal, 2.3% were borderline, and 96.8% were in the non-normal group. In a study of the sleep habits of primary school students, the scores of the students regarding the emotional and behavioral problems were 68.3% normal, 13.0% borderline, and 18.7% abnormal in the group in terms of emotional–behavioral problems (Uyan, 2014). In the study, considering the distribution of the scores of the students about the emotional–behavioral problems, 0.9% was found to be normal, 2.3% was on the borderline, and 96.8% was in the non-normal group in terms of emotional–behavioral problems. It can be argued that internal and environmental reasons may be effective on the difficulties faced by the adolescents and their non-normal scoring.

In our study, the correlations between PedsQL and SDQ scores of the adolescent students were determined. A significant correlation was found in positively between the “PedsQL Total and Total Difficulty” scores, and it was seen that the difficulties experienced affected the quality of life in many ways. In particular, adolescents experiencing “affectivity problems” according to the SDQ are more likely to be affected by “physical health” problems as well as having their quality of life being affected in terms of “school functioning” and “affective functioning.” It has been shown in studies that various problems experienced by adolescents (such as the presence of a chronic illness, migraine, sleeping disorders, low self-esteem, attention deficit, and hyperactivity problems) affect the quality of life of adolescents. It has also been stated that adolescents living without a source of social support and living a stressful life are affected negatively (Uyan, 2014).

Conclusions

When the quality of life scores of adolescents are examined, the overall quality of life is above average.

The mean difficulty score was found abnormally determined. According to this result, they stated that they experienced a lot of emotional–behavioral problems.

When we look at the relationship between PedsQL and SDQ subscale scores of the adolescents in this study conducted to determine the difficulties and quality of life of adolescents in school age, positive, significant correlations were found in almost all subscales.

In line with these results, it is recommended to inform the students in the adolescent period about the possible difficulties of life; to increase the studies in this regard to better understand the situations that affect their quality of life negatively; to provide professional support for their relations with parents, teachers, and peers, considering the excessive difficulties they experience affect their quality of life negatively due to the characteristics of the period they are in; and also to provide training for parents and teachers to ensure them recognize the early indications of the problems, at home and school, before they emerge.

Footnotes

Authors’ note

This article was based on the master’s degree thesis of Ayla Hendekçi under the supervision of Sonay Bilgin. This study was presented as oral presentation at the 32nd Euro Nursing and Medicare Summit in Paris 2017, France.

Authorship statement

SB designed the study, collected the data, analyzed the data, and prepared the manuscript. AH guided article in the whole process from designing to writing. SB reviewed articles and extracted data. AH reviewed articles and extracted data. All listed authors meet the authorship criteria and that all authors are in agreement with the content of the manuscript.

Acknowledgements

The authors would like to thank all schools and families for participation. They acknowledge the contributions of workers taking part in the study.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Sonay Bilgin

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