*Author for correspondence: Ms. Anokhi Mehra, Headstart Educational Academy, Bangalore 562125, email id: Anokhi.mehra@gmail.com
Key words: adolescence, mental health, wellbeing, stress, survey, youth, India
Background
Adolescence can be a vulnerable period and in fact, up to 50% of behavioural, psychological and mental problems have their onset during this developmental phase.[1] According to a recent National Mental Health Survey report[2], 7.3% of 13-19-year-olds in India suffer from some kind of mental health disorder. Both boys and girls were found to be equally vulnerable and rates were higher in urban areas. The number of affected adolescents is shocking; nearly 9.8 million of young Indians aged between 13-17 years require mental health care. What is even more worrying, is that this figure does not include those young people who may not have a diagnosable psychiatric disorder but are experiencing stress and emotional difficulties.
In order to reach out to and help adolescents, it is important to understand the different types of stressful situations and emotional difficulties that they experience, which do not necessarily classify as a mental health disorder according to psychiatric classification systems such as ICD and DSM. Such information can help plan the components of school-based mental health programs. School-based programs have the potential to promote wellbeing through early intervention in areas of stress experienced by adolescents. [3]
An online survey was designed to collect and assess adolescents’ views on mental health and wellbeing, factors that cause stress, their willingness and attitude towards seeking help, and the books and movies adolescents read or watch that are sources of information about mental health. This was hosted on Instagram as this social media platform is being increasingly used by young people. In a recent survey [4] of American teenagers’ use of social media, Instagram came in second only to YouTube, while the popularity of Facebook has declined Similarly, the YouGov-Mint Millennial survey conducted in India [5] indicated that Instagram was the most popular network for the younger generation. With adolescents in India spending increasing amounts of time on social media, this online platform presented an opportunity to access this demographic.
This survey was planned and conducted during an internship at White Swan Foundation for Mental Health, Bangalore, India, from during 25th April – 30th May 2018. White Swan Foundation for Mental Health is a not-for-profit organisation that aims to provide accurate information in the area of mental health, both through an online portal and through programmes in the community. This survey was planned to gather insights to facilitate the writing of well-informed articles that reflect the concerns of adolescents, as well as in developing content for teacher training programmes.
Methods
Sample: The sample consisted of 122 adolescents aged between 13 and 19 years who responded to an online survey. The majority of respondents were girls; 74 girls, 41 boys and 7 respondents who did not indicate their gender. None of the respondents selected the ‘Other’ category provided as a response option. The sampling technique used was convenience sampling.
Survey Design: The online survey consisted of eight questions and was planned as a very brief assessment of adolescents’ views on mental health and wellbeing. It also aimed at assessing their willingness and attitude towards seeking help, and the books and movies adolescents read or watch that are sources of information about mental health. The questions and response options were developed based on a review of select research on adolescent stress and wellbeing, interviews with three clinical psychologists and one psychiatrist involved in child and adolescent mental health services and discussions between the two authors. The first two questions asked respondents to indicate their age and gender. There were two questions on domains of stress; the first inquired about the most common area of stress experienced by adolescents, and the second required respondents to select all areas of stress experienced personally. In answering the next question, respondents indicated their choice of confidant for sharing emotional problems/feelings, from a list of options provided. The next question focused on whether respondents would be comfortable meeting a counsellor, and a range of response options were provided. Finally, respondents were asked whether they had read any books or watched any movies with a positive message about mental health and wellbeing, and were asked to share any two names.
Procedure: The online survey was hosted on SurveyMonkey.com and the link to this anonymous survey was shared via Instagram. The instructions specified that respondents must be between the ages of 13 and 19. Responses were collected from 21st – 27th May, 2018. The survey was designed to be very brief and typically took about three minutes to complete.
Analysis
The median, mean, and standard deviation were calculated for the age of the survey participants. The frequencies and percentages were computed for the responses to the other questions.
Results
There were 122 respondents, both boys and girls, aged between 13 and 19 years. One respondent indicated her age as 11 years. It is possible that this age may have been a typographical error as the age range for eligibility to participate in the survey was clearly stated. The survey was anonymous so it was impossible to verify the age of the participant; therefore, this response was removed from the data before analysis, and the sample size was brought down to 122. Among the 122 respondents, the majority of respondents were female; 74 girls, 41 boys and 7 respondents who did not indicate their gender. The median age was 16 years (M=15.58 years, SD=1.60).
Figure 1 indicates the frequency of responses to the question about the most prominent area of stress experienced by adolescents.
Figure 1: Most frequent domain of stress experienced by adolescents
The results (Figure 1) indicated that 55.74% of respondents perceived that studies and academics were most stressful for adolescents. Friends and social life was the domain reported as causing the most stress for adolescents by 23.77% of the respondents. This was followed by stress associated with family issues (10.66%). Other areas that causes stress include romantic relationships (3.28%), trauma, abuse or loss of a close person (2.46%), and physical health problems (1.64%). Three of the respondents (2.46%) selected the ‘other’ option for this question. They specified the following responses; “fear of not fitting in”, “a combination of all these, can’t be absolutes”, “all of the above”. None of the respondents marked financial issues as the primary cause of stress.
Figure 2 indicates the frequency of the responses to all areas of stress each respondent had experienced.
Figure 2: Multiple domains of stress experienced by survey respondents
Studies and academics were selected as an area of stress by almost 90% of the respondents (89.34%). More than 50% of the respondents had experienced difficulties in relationships (with friends, family) and social life). Family issues caused stress for 41.80% of the adolescents who participated in the survey. Stress associated with romantic relationships was reported by 21.31% of the adolescents. Other stressors included trauma or loss (11.48%), physical health problems (9.84%), and financial problems (6.56%). Six participants marked the ‘other’ option. Two of them indicated that they had experienced no specific or significant stress. Of the other four, three gave the following responses; “body image issues”, “self-esteem issues”, and “sexuality being accepted”.
Table 1 indicates the frequency of responses to the question about the choice of confidant for adolescents’ emotional problems and stress.
| Choice of confidant | N | % |
| Close friends | 66 | 54.10 |
| Mother | 32 | 26.23 |
| Counsellor/ Therapist | 11 | 9.02 |
| Other* | 6 | 4.92 |
| Other family members | 5 | 4.10 |
| Father | 2 | 1.64 |
| Teachers | 0 | 0.00 |
* “Other (please specify) category: Five respondents indicated “nobody” while one mentioned “girlfriend”
Table 1: Choice of confidant for teenagers’ emotional problems and stress
Among the respondents, 54.10% said that they would talk to close friends about any emotional problems they experience. In this survey, 26.23% of adolescents said they would be most comfortable speaking to their mothers. In contrast, only 1.64% preferred sharing their emotional problems with their fathers. Counsellors were the preferred confidant for 9.02% of the respondents. A small proportion of adolescents (4.10%) reported feeling most comfortable confiding in other family members such as siblings or grandparents. The results indicated that none of the respondents marked teachers as their first choice of confidant. Of the six respondents who selected the ‘other’ category, five were unwilling to confide in anyone, while one mentioned “girlfriend”.
The next survey question examined adolescents’ perceptions about meeting a counsellor for their emotional problems. When adolescents were asked if they would be okay to talk to a counsellor, only 18.18% categorically said that they would not. Almost 1/3rd were on the fence and indicated ‘maybe’ (30.58%), while 28.10% of the adolescents were agreeable to meeting a counsellor for help. A proportion of adolescents were willing to meet a counsellor, but only in the context of having a diagnosable mental health condition (23.14%). One participant did not answer this question.
The survey results indicated that 50% of adolescents had read books or watched movies with a positive message about mental health. The respondents, who reported having read books or watched movies on this theme, mentioned a wide variety of books and movies/ TV shows. The four most frequently reported books were: ‘Turtles all the way down’ by John Green, ‘All the bright places’ by Jennifer Niven, ‘My Heart and Other Black Holes’ by Jasmine Warga, and ‘Made you up’ by Francesca Zappia. The six most frequently reported movies/ TV Shows were: ‘13 Reasons Why’, ‘Taare Zameen Par’ (Hindi), ‘The Perks of Being a Wallflower’, ‘Dear Zindagi’ (Hindi), ‘Girl, Interrupted’, and ‘To the Bone.’
Discussion
The findings provided a snapshot of domains of stress experienced by adolescents and the patterns of their help-seeking attitudes. Social media provided a platform for adolescents to respond to a series of questions prepared by a peer. These factors could have positively influenced the response rate, with 122 responses in a one week time-period.
Knowing what adolescents are most stressed about can help in the planning and implementation of programs to reduce stress and enhance wellbeing among adolescents. One of the key findings was that academic stress and pressures was the most prominent type of stress experienced by adolescents. In an extensive study based in Ireland,[6] 227 adolescents, aged 12-18, who took part in consultations and workshops. The results showed that academics was second most prominent area of stress reported by these adolescents. The prominence of school-related stress was also reported in a survey of 13-17 year-old adolescents, by the American Psychological Association. [7] High rates of academic stress were prominent among high school adolescents in India as well. [8] Any attempt to address issues of adolescent stress by reaching out to young people should focus on this area very closely. While adolescents must learn coping methods and strategies, parents, teachers, educational institutions and systems also need to work towards reducing this experience of academic stress.
The results indicated that that adolescents actually experienced multiple areas of stress. Other prominent areas of stress included issues relating to friends/ social life and family. Though the numbers were lower, there were still some adolescents who reported experiencing stress because of romantic relationships, trauma/loss, abuse and financial and physical health problems. These are also areas that need to be addressed when trying to lessen stress experienced by adolescents.
Since the preferred primary support system seems to be close friends, efforts need to be made to educate adolescents and create awareness, so that they provide help and support to each other. Peer support programs to improve student mental health have been described by Coleman, Sykes, & Groom. [9] In this survey, 26.23% of adolescents said they would be most comfortable speaking to their mothers. In contrast, only 1.64% preferred sharing their emotional problems with their fathers. This pattern shows us that it would be unwise to club both mother and father into one category of ‘parents’. Any initiatives to encourage adolescents to share their problems with others should keep this in mind. Interestingly, 9.02% of adolescents would reach out to a counsellor/therapist first, for help with their emotional issues.
It was very encouraging that 28.10% of adolescents said that they would be comfortable talking to a counsellor. Another large group of adolescents felt that seeking help from a counsellor would be okay only if there was a diagnosable mental health condition. This shows that for some, this help-seeking option may be seen as acceptable only under certain conditions. Research has shown that adolescents are reticent about sharing their problems and reluctant about seeking help.[10] Mental health professionals must speak to adolescents and find out what their internal and external barriers are, and understand adolescents’ reasons for ambivalence about seeing a therapist/counsellor.
The books which were most commonly read by respondents covered a wide range of mental health conditions. As the protagonists of most of these books are adolescents, adolescents have some awareness of how mental health issues impact people of their age group. However, none of the books reported were by Indian authors or set in an Indian context. So, adolescents are exposed to a very ‘foreign’ view on mental health and treatment and acceptance of mental illnesses.
‘Turtles all the way down’ by John Green is a recent book that talks about a 16-year-old girl, Aza Holmes, and her struggles with multiple anxiety disorders. ‘All the bright places’ by Jennifer Niven is a story of a friendship that develops between two 16-year-olds who are both experiencing thoughts of suicide. ‘My Heart and Other Black Holes’ by Jasmine Warga also deals with suicide and depression, and the troubling issue of a ‘suicide pact.’ The protagonist connects with a troubled teenage boy and together they struggle through their shared issues. ‘Made you up’ by Francesca Zappia describes how a teenage girl copes with the challenges of schizophrenia, a diagnosis she received when she was just a child. Perhaps the most informative (and therefore the most potentially misleading or inaccurate) of all the books mentioned, ‘Made you up’ details the specific symptoms, medications, and coping mechanisms related to schizophrenia.
The most common movies and TV shows reported by respondents included both Indian and Western films, showing a slightly broader perspective on mental health. ‘Taare Zameen Par’ has the message that “every child is special.” A perceptive teacher reaches out to a child with specific learning disability and helps him to develop his potential and self-esteem. ‘The Perks of Being a Wallflower’ is a coming of age movie which highlights the importance of friendships in helping a clinically depressed young student who has just been discharged from a mental health care institution. ‘Dear Zindagi’ features a young woman discontented with life and troubled by difficult childhood memories. The plot is centred on her therapy sessions with a psychologist and is a positive story of personal growth and change. ‘Girl, Interrupted’ is a powerful movie is about a teenage girl who has been diagnosed with borderline personality disorder and her stay in a psychiatric care facility. The film ‘To the Bone’ sheds light on 20 year old Ellen’s journey of recovery from anorexia nervosa. The most frequently mentioned and perhaps the most controversial on this list, was the popular television show 13 Reasons Why. This television show has been criticised by mental health professionals for its graphic content, its inaccurate representation of suicide and its causes, and violation of guidelines for safe media reporting of suicide content.[11] Since adolescents are a vulnerable and impressionable group, experts have expressed concerns about the potential for ‘copycat’ suicides.[12] At least some of the books and movies mentioned by adolescents are partly inaccurate, or have a controversial and not wholly positive message.
This survey does have some limitations in its design. The fact that the data collection was done through social media, i.e. Instagram, would have limited the demographic of the sample obtained. It is relatively accurate to assume that respondents were educated, urban, and English speaking. Thus, the results of the survey cannot be generalised to the adolescent Indian population. Additionally, the participants were unevenly distributed across age and gender, with more girls than boys. If a more equitable distribution of participants had been achieved, then the differences in domains of stress across developmental stage and gender could have been assessed. As in any survey, social desirability could have influenced the responses. The data obtained from this brief survey was largely quantitative in nature.
The questions of the survey themselves also had a number of limitations. Suggestions from the respondents themselves included increasing the number of options in areas of stress (e.g. peer pressure, bullying, difficulties managing overuse of social media/technology, sexuality, body image, self-esteem issues and ‘no stress’). In the question related to choice of confidant, options of ‘nobody’ and ‘significant other/romantic partner’ could be added. Involving other young people and meeting in small interactive groups could help in developing a more comprehensive survey for future research.
One of the major strengths of this survey was that respondents found it non-intrusive, quick and easy to complete and the online option provided a degree of anonymity. Another positive aspect was the information gained about books and movies that are popular among urban adolescents in India. Adolescents get some of their information about mental health through books and movies and this is encouraging. This also presents some concerns about adolescents having misinformed opinions about mental health from some of these sources. There is a need for providing accurate and positive information through these channels that are accessed by adolescents. The findings provide information for use in training programs for teachers and counsellors working with adolescents. Programs for the promotion of youth mental health can incorporate some of these findings related to areas of stress and choice of confidants.
Conclusions
This brief exploratory survey provided a preliminary understanding of how urban adolescents experience stress, and their attitudes towards finding and receiving support from others. Involving other young people and meeting in small interactive groups could help in developing a more comprehensive survey for future research. The inclusion of a qualitative perspective via interviews and interaction with respondents can provide an in-depth understanding of adolescents’ experiences of stress. Given the results of this survey, barriers to help seeking among adolescents could be explored, with a special focus on the reasons behind those barriers, and possible ways to facilitate their removal.
Acknowledgements
Dr. Neena David, Dr. Nithya Poornima, Dr. Prabha Chandra and Dr. Chetna Duggal for sharing their views and experiences about youth mental health, which helped in planning the survey. Mr. Manoj Chandran for the opportunity to do an internship at the White Swan Foundation for Mental Health and to work on the development of the survey.
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