MENTAL HEALTH PROBLEMS AND SYMPTOMS AMONG MALE ADOLESCENTS ATTENDING A TEEN HEALTH CLINIC.

Smith, Peggy B. ; Buzi, Ruth S. ; Weinman, Maxine L. 等

ABSTRACT

The purpose of this study was to examine the frequency and nature of mental health problems and symptoms among a group of 51 inner-city male adolescents attending a teen health clinic at a large county hospital in the southwestern part of the United States. They were administered a problem area checklist and a problem symptom checklist. The problem area checklist covered a range of mental health issues, including peer/friendship, relationship, and family problems; problems with money, time, and the law; substance use; and eating disorders. The problem symptom checklist queried participants about anger, nervousness, depression, fear, loneliness, suicide, aggression, and self-esteem. The results indicated that these young males experienced significant mental health problems and symptoms, such as relationship problems, problems with time and money, and symptoms of anger, depression, and aggression. Further, scared/afraid feelings correlated with five of the eight problem areas. The authors recommend investigatin g ways to target young males who present at such clinics in order to address their mental health problems and symptoms, as well as studying how their environment affects their overall health.

A number of epidemiological studies have reported prevalence rates ranging from 12% to 20% for psychiatric disorders among children and adolescents. For example, Roberts, Attkisson, and Rosenblatt (1998), in an international meta-analysis of 52 studies, reported a mean prevalence rate of 15.8%. Kazdin's (1992) review of studies from a number of countries estimated that between 17% and 22% of youth under 18 years of age experience emotional and behavioral problems.

In several studies, depression has been singled out. For example, a review of epidemiological studies of childhood and adolescent depression by Birmaher et al. (1996) found that the prevalence rates of depression range between 0.4% and 2.5% in children and between 0.4% and 8.3% in adolescents. The lifetime prevalence rate of Major Depressive Disorder (MDD) in adolescents has been estimated to range from 15% to 20%. Lewinsohn and Clarke's (1999) review also suggested that between 2% and 5% of the general adolescent population experiences MDD at any given point in time.

Studies have found gender differences in the presentation of mental disorders. Females tend to have more episodic problems, such as depression, and milder manifestation, such as nonaggressive conduct disorders, while males tend to have more aggressive conduct disorders (Bardone, Moffitt, Caspi, Dickson, Stanton, & Silva, 1998). A two-stage cross-sectional analysis of a random sample of a rural population found that females mainly demonstrated neuroses and manic-depressive psychosis, while males had higher rates of personality disorders, alcoholism, and antisocial conduct (Vazquez-Barquero et al., 1992). A national study of 1,400 children ages 5-17 attending U.S. schools, which assessed behavioral pathology using the Adjustment Scales for Children and Adolescents, found that males dominated in the prevalence of psychological maladjustment (McDermott, 1996). Males accounted for roughly 60% of aggressive-provocative, oppositional, and avoidant maladjustment, 70% of hyperactive maladjustment, and 75% of impulser idden aggression. Conversely, no significant female prevalence was detected for any type of major disorder. The Dunedin Multidisciplinary Health and Development Study, with a sample from a New Zealand birth cohort of 890 youths who were followed from ages 3 to 18 years, also documented gender differences. Boys appeared more vulnerable, and those from socially disadvantaged backgrounds in early childhood had an elevated risk of disorder at age 18 (Feehan, McGee, Williams, & Nada-Raja, 1995).

Research has indicated that depression in adolescence is associated with an increased risk of suicidal behavior. For adolescent boys this risk may rise if the depression is accompanied by conduct disorder and alcohol or other substance abuse (Shaffer & Craft, 1999). Some studies have also suggested that the onset of mental disorders peaks during adolescence (Frost, Reinherz, Pakiz-Camras, Giaconia, & Lefkowitz, 1999), and that the presence of such pathology during adolescence often persists and could predict future mental health problems. For example, a longitudinal study (from kindergarten through senior high school) of a cohort of 386 U.S. youths in a working-class community in the northeastern United States indicated that early risk factors help predict depressive symptomatology in late adolescence (Frost, Reinherz, Pakiz-Camras, Giaconia, & Lefkowitz, 1999). The aforementioned New Zealand study also found that a disorder at age 15 was a predictor of subsequent mental health problems (Feehan, McGee, Willi ams, & Nada-Raja, 1995).

Several stressors have been identified as contributing to mental disorders among adolescents. For example, Frost et al.'s (1999) longitudinal study of a community sample of 386 participants from age 5 to 18 found that symptomatology for males at age 18 was associated with family discord and lack of social support. Another longitudinal study of a sample of 1,222 respondents between 15 and 24 years of age in the Netherlands found that vocational and especially relationship stressors led to poor mental health among males and females (de Goede, Sprulit, Iedema, & Meeus, 1999). Early low socioeconomic status (SES) and disadvantage have also been found to have long-term effects on boys' mental health (Feehan, McGee, Williams, & NadaRaja, 1995).

The high prevalence of mental health problems among adolescent males and their potential persistence into adulthood underscore the benefits of early identification and treatment. However, it has been found that males, and especially adolescent males, are reluctant to use available medical services. Barriers include lack of knowledge on availability of services, and cultural beliefs which hold that seeking medical care is inappropriate masculine behavior. Yet, a study of 1,200 Dominicans who attended a young men's clinic in New York City found that clients utilized health services in order to also receive mental health attention (Armstrong et al., 1999). While 80% of the clients received medical counseling, 20% received mental health counseling. The researchers suggested that young men have a need, and are willing, to access such programs for a variety of mental and physical problems.

In keeping with these findings, it appears that it is important to address the mental health needs of male adolescents presenting for a variety of health services. In order to develop effective interventions, it is necessary to examine the specific needs of this group. Therefore, the purpose of the present study was to identify the frequency and nature of specific problems and symptoms among male adolescents presenting to a family planning clinic serving inner-city youth.

METHOD

Participants

A survey of mental health problems and symptoms was conducted at a teen health clinic located in a large county hospital in the southwestern United States. This clinic provides free comprehensive family planning and reproductive health services to indigent adolescents who reside in the inner city (parental consent is solicited but not required). Young males ranging in age from 16 to 30 years were recruited to participate in the study. These males attended the clinic by appointment or drop-in. Although this clinic serves adolescents under 21 years of age, males older than 21 who have adolescent sexual partners are still provided services.

Instruments

A standardized data collection form was used to record demographic information, school status, ethnicity, language preference, marital status, and age at first sexual activity. Through scaled items, participants were asked to indicate whether they had experienced any behavioral problems and symptoms. They completed a problem area checklist (eight items) and a problem symptom checklist (eight times). All items were rated on a 4-point scale: does not bother me at all (1), bothers me somewhat (2), bothers me a lot (3), bothers me all the time (4). The problem areas covered a range of mental health issues, including peer/friendship, relationship, and family problems; problems with money, time, and the law; substance use; and eating disorders. In terms of symptomatology, participants were queried about their emotions, including anger, nervousness, depression, fear, loneliness, suicide, aggression, and self-esteem.

Procedure

A clinic staff member distributed the questionnaires consecutively among all available participants during the course of their visit. (The Institutional Review Board of the affiliated medical school approved the study protocol.) The purpose of the study was explained, and informed consent was obtained before data were collected. A clinic staff member was available to clarify any questions. A few male adolescents required some assistance to complete the survey, and three adolescents declined to participate. The instrument was tailored to a seventh-grade reading level. Adolescents who did not speak English were not included in the study. On-site case management services were available to teenagers if any specific issues caine up as a result of the questions. The sample size reflected 20% of the adolescent males who attended the clinic in an 8-month period.

RESULTS

Fifty-one males completed the survey. Their mean age was 19.34 years (SD = 2.60; range = 16-30). There were 28 (54.9%) African-American, 14(27.5%) Hispanic, and 9 (17.6%) Caucasian patients. English was the primary language for 43 (83.4%), with 40 (78.4%) reporting that English was the language they spoke at home. Forty-six (92.0%) were single. A variety of living arrangements were reported. Seventeen (33.3%) lived in a single-parent household (mainly mothers), 11 (21.6%) lived with both parents, 5 (9.8%) lived with a girlfriend, 3 (5.9%) lived with grandparents, 4 (7.8%) lived with other relatives, 5 (9.8%) lived alone, 3 (5.9%) lived with a wife, and 3 (5.9%) lived with friends. Twenty-two (44.0%) were in school, with a range spanning 10th grade through high school as well as graduate equivalency degree (GED) programs and college. Of the 28 males who were not in school, 17 (60.7%) did not graduate from high school. Thirty-seven (72.5%) did not have any children, 11 (21.6%) were parents, and 3 (5.9%) had gir lfriends who were pregnant.

The mean age at first sexual activity was 14 years (range = 10-18). The mean number of sexual partners in the past year was 2.77 (SD = 1.90; range = 1-8). Fifteen (29.4%) had at least one sexually transmitted disease (STD). Of the 16 who reported STDs, 11 (68.8%) reported one STD, 4 (25.0%) reported two STDs, and 1 (6.3%) reported three STDs. Ten (20.4%) reported always using contraception in the past year, 34 (69.4%) reported sometimes using contraceptives, and 5 (10.2%) reported never using contraceptives. Forty-one (80.4%) used condoms.

The overall reliability for the eight problem areas was [alpha] = .80. The overall reliability for the problem symptoms was [alpha] = .89. The extent of the problem areas and symptoms (the frequency distributions by category) and the mean scores for each item are presented in Table 1. Of the eight problem areas, relationship problems, family problems, money problems, and time problems were perceived as most severe. Among the eight problem symptoms, the major symptoms reported were angry feelings, nervous/tense feelings, sad/depressed feelings, and aggressive feelings.

There were significant correlations between problem symptoms and problem areas (see Table 2). Using a stringent criteria of p = .001, it was found that scared/afraid feelings correlated with five of the eight problem areas, and angry feelings correlated with three problem areas. The highest correlation was between nervous/tense feelings and family problems. Additionally, family problems correlated with five of the eight problem symptoms. We also examined whether school status, presence of STDs, contraception, and number of partners could distinguish teens with mental health concerns. However, neither univariate nor multivariate analysis showed any significant effects.

DISCUSSION

The purpose of this study was to identify specific mental health problems and symptoms among male adolescents utilizing a family planning clinic. The findings confirmed that they experienced a variety of problems and symptoms. Over half reported problems with relationships, family, money, and time. Relationship and money problems had the highest severity levels. In terms of problem symptoms, over half reported angry feelings, and over two-fifths reported nervous/tense feelings, sad/depressed feelings, and aggressive feelings. The highest severity level was for angry feelings. Moreover, there were significant relationships between problems and symptoms. Specifically, family problems correlated with anger, nervousness, fear, isolation/loneliness, and aggressiveness. Anger manifested a high correlation with relationship problems and time problems, in addition to family problems. The young men also reported significant problems with afraid/scared feelings. These feelings significantly correlated with peer/friends hip, relationship, family, money, and time problems.

The findings of this study support the growing recognition in the literature on young people that many mental health symptoms are related to problems in such domains as relationships and family (Frost, Reinherz, Pakiz-Camras, Giaconia, & Lefkowitz, 1999; de Goede, Spruijt, ledema, & Meeus, 1999). A variety of studies have also shown that psychological distress, high-risk behaviors, and school performance are linked. Many youth come to school with a variety of complex emotional problems that interfere with their ability to succeed (Bronstein & Kelly, 1998; Gullotta & Noyes, 1995). Therefore, early intervention to prevent such conditions should be considered a major priority.

Many of the participants sought STD treatment or had experienced an STD during the past year. Linking reproductive health care to mental health care therefore can act as a safety net for inner-city youth. Reproductive health clinics can be an efficient vehicle for screening mental as well as physical health concerns for young males, who are not usually clients of preventive medicine services. This is especially relevant to our group of males, in that the majority were not in school, which has been identified as an effective mental health service site.

In reviewing the findings, it is logical to consider the individual and environmental contexts when assessing mental disorders. Many of the reported problems involved issues related to the family and community in which the male youths lived. The symptoms they described, such as anger and fear, could possibly be attributed to experiences of victimization and violence that are prevalent in the inner city. For example, a study of 221 African-American male youths living in low-income housing in Alabama found that over 79% had been victims of violence and 87% reported witnessing at least one violent act (Fitzpatrick, 1997). Therefore, understanding the environmental context may be important in the assessment of mental health issues.

The results of this study contribute to the literature in several ways. First, significant mental health problems and symptoms were found among adolescent males attending a teen health clinic. Therefore, it is recommended that this population be targeted at health sites in order to screen them for emotional problems and symptoms. Second, the findings suggest that there is also a need to address problems and symptoms that reflect the inner-city socioeconomic environment. Many inner-city youths experience a variety of complex social and economic problems, including violence. These problems are likely to affect teenagers' psychosocial health (Bronstein & Kelly, 1998). Therefore, the screening process must take into account the environment of these teens.

In sum, confidential family planning clinics can serve as a promising setting for the detection of mental health problems in male adolescents, who for a variety of reasons are unwilling or unable to access mental health services. In order for family planning clinics to advocate for the inclusion of mental health services for young men, more studies validating their mental health problems and symptoms need to be conducted.

This project was made possible by The Hogg Foundation for Mental Health and the Texas Department of Health.

Ruth S. Buzi, Baylor College of Medicine, Teen Health Clinic, Houston, Texas.

Maxine L. Weinman, Graduate School of Social Work, University of Houston, Texas.

Reprint requests to Peggy B. Smith, Teen Health Clinic, Baylor College of Medicine, One Baylor Plaza, Houston, Texas 77030. Electronic mail may be sent to peggys@bcm.tmc.edu.

REFERENCES

Armstrong, B., Cohall, A. T., Vaughan, R. D., McColvin, S., Tiezzi, L., & McCarthy, F. (1999). Involving men in reproductive health: The Young Men's Clinic. American Journal of Public Health, 89(6), 902-905.

Bardone, M. A., Moffitt, T. E., Caspi, A., Dickson, N., Stanton, W. R., & Silva, P. A. (1998). Adult physical health outcomes of adolescent girls with conduct disorder, depression, and anxiety. Journal of the American Academy of Child Psychiatry, 37(6), 594-601.

Birmaher, B., Ryan, N. D., Williamson, D. E., Brent, D. A., Kaufman, J., Dahl, R., Perel, J., & Nelson, B. (1996). Journal of the Academy of Child and Adolescent Psychiatry, 35(11), 1427-1439.

Bronstein, L. R., & Kelly, T. B. (1998). A multidimensional approach to evaluating school-linked services: A school of social work and county public school partnership. Social Work in Education, 20(3), 152-164.

de Goede, M., Spruijt, E., Iedema, J., & Meeus, W. (1999). How do vocational and relationship stressors and identity formation affect adolescent mental health? Journal of Adolescent Health, 25, 14-20.

Feehan, M., McGee, R., Williams, S. M., & Nada-Raja, S. (1995). Journal of the Academy of Child and Adolescent Psychiatry, 34(5), 670-679.

Fitzpatrick, K. M. (1997). Aggression and environmental risk among low income African-American youth. Journal of Adolescent Health, 21, 172-178.

Frost, A. K., Reinherz, H. Z., Pakiz-Camras, B., Giaconia, R., M., & Lefkowitz, E. S. (1999). Risk factors for depressive symptoms in late adolescence: A longitudinal community study. American Journal of Orthopsychiatry, 69(3), 370-381.

Gullotta, T. P., & Noyes, L. (1995). The changing paradigm of community health: The role of school-based health centers. Adolescence, 30(117), 107-115.

Kazdin, A. E. (1992). Child and adolescent dysfunction and paths toward maladjustment: Targets for intervention. Clinical Psychology Review, 12, 785-817.

Lewinsohn, P. M., & Clarke, G. N. (1999). Psychosocial treatments for adolescent depression. Clinical Psychology Review, 19(3), 329-342.

McDermott, P. A. (1996). A nationwide study of development and gender prevalence for psychopathology in childhood and adolescence. Journal of Abnormal Child Psychology, 24(1), 53-66.

Roberts, R. E., Attkisson, C. C., & Rosenblatt, A. (1998). Prevalence of psychopathology among children and adolescents. American Journal of Psychiatry, 155(6), 715-725.

Shaffer, D. L., & Craft, L. (1999). Methods of adolescent suicide prevention. Journal of Clinical Psychiatry, 60(Suppl. 2), 70-74.

Vazquez-Barquero, J. I., Diez Manrique, J. F., Munoz, J., Menendez Arango, J., Gaite, L., Herrera, S., & Der, G. J. (1992). Sex differences in mental illness: A community study of the influence of physical health and socio-demographic factors. Social Psychiatry and Psychiatric Epidemiology, 27, 62-68.

Table 1.
Mental Health Problems and Symptoms
 Does not bother Bothers me
Problem/Symptom me at all sometimes
Peer/Friendship Problems 37 (72.5%) 9 (17.6%)
 (M = 1.41, SD = 0.78)
Relationship Problems 19 (37.3%) 17 (33.3%)
(problems with boyfriend/
girlfriend, spouse, etc.)
 (M = 2.00, SD = 0.96)
Family Problems (problems with 24 (47.1%) 14 (27.5%)
family such as parents,
grandparents, siblings, aunts,
uncles, step-parents)
 (M = 1.94, SD = 1.10)
Money Problems 16 (31.4%) 14 (27.5%)
 (M = 2.31, SD = 1.14)
Time Problems (difficulty 23 (45.1%) 15 (29.4%)
managing school, work,
family responsibilities)
 (M = 1.94, SD = 1.07)
Problems With The Law 30 (58.8%) 12 (23.5%)
 (M = 1.65, SD = 0.91)
Problems Due To Alcohol/Drugs 44 (86.3%) 6 (11.8%)
 (M = 1.16, SD = 0.42)
Eating Problems 39 (76.5%) 9 (17.6%)
 (M = 1.33, SD = 0.71)
Angry Feelings 20 (39.2%) 19 (37.3%)
 (M = 1.92, SD = 0.93)
Nervous/Tense Feelings 28 (56.0%) 16 (32.0%)
 (M = 1.62, SD = 0.85)
Sad/Depressed Feelings 26 (52.0%) 12 (24.0%)
 (M = 1.82, SD = 1.02)
Scared/Afraid Feelings 36 (72.0%) 11 (22.0%)
 (M = 1.36, SD = 0.66)
Isolated/Lonely Feelings 33 (66.0%) 9 (18.0%)
 (M = 1.56, SD = 0.91)
Suicidal Feelings 45 (90.0%) 2 (4.0%)
 (M = 1.20, SD = 0.67)
Aggressive Feelings 28 (56.0%) 13 (26.0%)
 (M = 1.70, SD = 0.95)
Self-Esteem Issues 38 (76.0%) 7 (14.0%)
 (M = 1.40, SD = 0.83)
 Bothers Bothers me
Problem/Symptom me a lot all the time
Peer/Friendship Problems 3 (5.9%) 2 (3.9%)
 (M = 1.41. SD = 0.78)
Relationship Problems 11 (21.6%) 4 (7.8%)
(problems with boyfriend/
girlfriend, spouse, etc.)
 (M = 2.00, SD = 0.96)
Family Problems (problems with 5 (9.8%) 8 (15.7%)
family such as parents,
grandparents, siblings, aunts,
uncles, step-parents)
 (M = 1.94, SD = 1.10)
Money Problems 10 (19.6%) 11 (21.6%)
 (M = 2.31, SD = 1.14)
Time Problems (difficulty 6 (11.8%) 7 (13.7%)
managing school, work,
family responsibilities)
 (M = 1.94, SD = 1.07)
Problems With The Law 6 (11.8%) 3 (5.9%)
 (M = 1.65, SD = 0.91)
Problems Due To Alcohol/Drugs None 1 (2.0%)

 (M = 1.16, SD = 0.42)
Eating Problems 1 (2.0%) 2 (3.9%)
 (M = 1.33, SD = 0.71)
Angry Feelings 8 (15.7%) 4 (7.8%)
 (M = 1.92, SD = 0.93)
Nervous/Tense Feelings 3 (6.0%) 3 (6.0%)
 (M = 1.62, SD = 0.85)
Sad/Depressed Feelings 7 (14.0%) 5 (10.0%)
 (M = 1.82, SD = 1.02)
Scared/Afraid Feelings 2 (4.0%) 1 (2.0%)
 (M = 1.36, SD = 0.66)
Isolated/Lonely Feelings 5 (10.0%) 3 (6.0%)
 (M = 1.56, SD = 0.91)
Suicidal Feelings 1 (2.0%) 2 (4.0%)
 (M = 1.20, SD = 0.67)
Aggressive Feelings 5 (10.0%) 4 (8.0%)
 (M = 1.70, SD = 0.95)
Self-Esteem Issues 2 (4.0%) 3 (6.0%)
 (M = 1.40, SD = 0.83)
Table 2.
Correlations of Symptoms and Problems
Symptoms Angry Nervous/Tense Sad/Depressed Scared/Afraid
 Feelings Feelings Feelings Feelings
Problems
Peer/Friendship .606
Problems
Relationship .468 .503 .438
Problems
Family Problems .539 .619 .555
Money Problems .452
Time Problems .437 .551 .460
Symptoms Isolated/Lonely Aggressive
 Feelings Feelings
Problems
Peer/Friendship
Problems
Relationship
Problems
Family Problems .478 .444
Money Problems
Time Problems
Note. All correlations are significant at p [less than] .001