Eur Child Adolesc Psychiatry DOI 10.1007/s00787-015-0743-z
ORIGINAL CONTRIBUTION
Child and adolescent mental health problems in Tyva Republic, Russia, as possible risk factors for a high suicide rate Helena R. Slobodskaya1 · Nadezhda B. Semenova2
Received: 29 January 2015 / Accepted: 28 June 2015 © Springer-Verlag Berlin Heidelberg 2015
Abstract High rates of child mental health problems in the Russian Federation have recently been documented; the rates of youth suicide are among the highest in the world. Across the Russian regions, Republic of Tyva has one of the highest rates of child and adolescent suicide and the lowest life expectancy at birth. The aim of this study was to investigate the prevalence and associations of mental health problems in Native Tyvinian children and adolescents using internationally recognised measures and diagnoses. A two-stage, two-phase design involved selection of schools in five rural settlements in Western Tyva and two schools in the capital city followed by selection of Native Tyvinian children in grades 3–4 (ages 9–10) and 6–7 (ages 14–15). In the first phase, a screening measure of psychopathology, the Rutter Teacher Questionnaire, was obtained on 1048 children with a 97 % participation rate. In the second phase, more detailed psychiatric assessments were carried out for subgroups of screen-positive and screen-negative children. The prevalence of mental health problems was about 25 %, ranging from 40 % in adolescent boys from rural areas to 9 % in adolescent girls from the city. The patterning of disorders and risk factors were similar to those in other countries, rural areas were associated with an increased risk of psychopathology. The findings indicate that there is an urgent need for interventions to reduce risk
* Helena R. Slobodskaya [email protected] 1
Institute of Physiology and Basic Medicine, Novosibirsk State University, Timakova Str., 4, Novosibirsk 630117, Russia
2
Scientific Research Institute of Medical Problems of the North, Partizan Zheleznyak Str., 3G, Krasnoyarsk 660022, Russia
in this population and provide effective help for Tyvinian children and adolescents with mental health problems. Keywords Tyva · Children · Adolescents · Mental health · Epidemiology
Introduction High rates of child mental health problems in Russia have recently been documented: in a series of population-based studies from seven countries (Bangladesh, Brazil, Britain, India, Norway, Russia and Yemen) that have used the same measures of psychopathology, the prevalence of psychiatric disorders was highest among Russian children: 17.1 % of 7- to 14-year-olds [1]. A study of Russian child mental health showed that though the rates of disorders were higher than in other countries, there were few differences in type of disorder or key risk factors [2]. Emotional and behavioural disorders were the two most common categories, and the most significant risk factors were characteristics of the child and proximal family environment, such as parental mental health, alcoholism in the family and domestic violence. The high rates of child psychiatric disorders, together with the exposure to adversity, may lead to suicidal behaviour [3], and indeed the rates of youth suicide in the Russian Federation since the 1990s are among the highest in the world [4]. However, there is a 60-fold difference in the rate of youth suicide across the Russian regions, leading researchers to conclude that due to considerable geographic, socio-economic, cultural and ethnic heterogeneity, it is crucial to consider the regional specificity of Russian youth suicide [4]. The Republic of Tyva has one of the highest rates of child and adolescent suicide [5]: in 2008–2009, the suicide
13
mortality rate in adolescents was 106.9 per 100,000 compared to 20.1 per 100,000 in the Russian Federation and the global suicide rate of 7.4 per 100,000 [4, 6]. Tyva is located in the South of Eastern Siberia near the geographical centre of the Asian continent and has an area of 170.5 km2. The population of Tyva is 311,761, with 37 % living in Kyzyl, the capital of the Tyva Republic. More than 82 % of the population are Native Tyvins and more than 16 % are Russians [7]. Tyva has the highest birth rate in the Russian Federation, in 2012 it was 26.7 per 1000 population, twice as high as Russia’s birth rate (13.3 per 1000 population) [7]. Life expectancy at birth (55.5 for men and 66.9 for women in 2012) is the lowest in the Russian Federation. High mortality rates are due to external causes of death, such as accidents, homicide and suicide, related to alcohol and drug abuse [5, 8]. These statistical data suggest that Tyvinian children and adolescents may have a relatively high rate of mental disorder. However, to our knowledge, there are no studies that have estimated the prevalence of child mental health problems in the Republic of Tyva. Therefore, the aim of the present study was to investigate the rate of mental health problems in representative community samples of Native Tyvinian children and adolescents using standardised and internationally recognised measures and diagnoses.
Methods Participants and procedure The study was a two-stage, two-phase cross-sectional survey carried out in Western rural areas of Tyva and in Kyzyl, the capital city. Data collection took place between 2001 and 2007 as part of three expeditions organised by the Scientific Research Institute of Medical Problems of the North. Five settlements in five districts (kozhuuns) were selected in Western rural areas most densely populated by Native Tyvins, Chaa-Khol (Chaa-Kholsky kozhuun), Teeli (Bay-Tayginsky kozhuun), Chadan (Dzun-Khemchiksky kozhuun), Khandagayty (Ovyursky kozhuun) and Torgalyg (Ulug-Khemsky kozhuun). The population in the settlements varied from 3200 to 8800, up to 98.3 % were Tyvins speaking native language. Russian is taught in school as a second language from first grade onward. All schools in the settlements were approached to invite participation in the study. In Kyzyl, two schools were selected, a national college for Native Tyvinian children and a public school that enrolled both Native Tyvins and children of other ethnicities. All Native Tyvinian children in grades 3–4 (ages 9–10) and 6–7 (ages 14–15) were selected for investigation, excluding children who had been previously identified as
13
Eur Child Adolesc Psychiatry
showing significant psychiatric or neurological condition such as schizophrenia, epilepsy or mental retardation. In the first phase, all participants were assessed using teacher ratings of the Rutter Children’s Behaviour Questionnaire [9]. The aims and procedure of the study were explained to teachers and administrative staff of the participating schools. Teachers were provided with the Rutter Children’s Behaviour Questionnaire and had the opportunity to ask questions. Questionnaires were obtained on 1048 children (97 % of those selected), or 0.97 % of the general child population in Tyva. Of these 1048 children, 545 (52 %) were male and 503 (48 %) were female; 647 (62 %) were aged 9–10 and 401 (38 %) were aged 14–15; 705 (67 %) were from rural area and 343 (33 %) were from urban area. In the second phase, more detailed psychiatric assessments were carried out on all 9- to 10-year-old children; for 14–15-year-old children, psychiatric assessments were carried out on all children with scores above the cut-off (N = 101) and a random 20 % sample of those with scores below this value (N = 57). Measures The Rutter Teacher Questionnaire (RTQ, Scale B) [9] is a standardised screening measure of child mental health problems. The RTQ consists of 26 items covering the main conduct, emotional, and hyperactivity symptoms. Each item is rated on a three-point scale: scale: 0 = ‘does not apply’, 1 = ‘applies somewhat’, and 2 = ‘certainly applies’. The RTQ is scored by adding across all of the items to generate a total difficulties score. Conduct problems score is the sum of six items (destroys, fights, disobedient, tells lies, has stolen things, bullies) and emotional symptoms score is the sum of four items (worries, miserable, fearful, tears on arrival at school or has refused to come). The RTQ is used to categorise children as having, or not having, mental health problems according to whether their total difficulties score is equal to or greater than a standard cut-off score of 9. The type of mental health problems in children scoring above the cut-off is identified by the greater of the conduct problems and emotional symptoms scores. The RTQ has been widely used around the world and has proved valuable for the identification of psychiatrically disturbed children among epidemiological samples; it can also satisfactorily differentiate conduct and emotional disorders [10]. The Russian version has been used in previous studies of child mental health and adjustment [11, 12]. Psychiatric diagnosis A mental health specialist (NS) conducted a semi-structured psychiatric interview with children in the second stage of the study. An experienced paediatrician from the Republican clinic or a school nurse, both Native Tyvins, was present during the interview, helping to translate the questions and the answers. In addition,
Eur Child Adolesc Psychiatry
the data relating to the emotional state and behaviour of the children were obtained from medical records and reports from teachers. The psychiatric information was collected together and a judgment made about the presence and type of psychiatric disorder, if any, in the child according to ICD-10 [13].
settlements, age difference in conduct problems scores was insignificant. For emotional symptoms, both effects of gender, F(1,1046) = 29.76, p
ORIGINAL CONTRIBUTION
Child and adolescent mental health problems in Tyva Republic, Russia, as possible risk factors for a high suicide rate Helena R. Slobodskaya1 · Nadezhda B. Semenova2
Received: 29 January 2015 / Accepted: 28 June 2015 © Springer-Verlag Berlin Heidelberg 2015
Abstract High rates of child mental health problems in the Russian Federation have recently been documented; the rates of youth suicide are among the highest in the world. Across the Russian regions, Republic of Tyva has one of the highest rates of child and adolescent suicide and the lowest life expectancy at birth. The aim of this study was to investigate the prevalence and associations of mental health problems in Native Tyvinian children and adolescents using internationally recognised measures and diagnoses. A two-stage, two-phase design involved selection of schools in five rural settlements in Western Tyva and two schools in the capital city followed by selection of Native Tyvinian children in grades 3–4 (ages 9–10) and 6–7 (ages 14–15). In the first phase, a screening measure of psychopathology, the Rutter Teacher Questionnaire, was obtained on 1048 children with a 97 % participation rate. In the second phase, more detailed psychiatric assessments were carried out for subgroups of screen-positive and screen-negative children. The prevalence of mental health problems was about 25 %, ranging from 40 % in adolescent boys from rural areas to 9 % in adolescent girls from the city. The patterning of disorders and risk factors were similar to those in other countries, rural areas were associated with an increased risk of psychopathology. The findings indicate that there is an urgent need for interventions to reduce risk
* Helena R. Slobodskaya [email protected] 1
Institute of Physiology and Basic Medicine, Novosibirsk State University, Timakova Str., 4, Novosibirsk 630117, Russia
2
Scientific Research Institute of Medical Problems of the North, Partizan Zheleznyak Str., 3G, Krasnoyarsk 660022, Russia
in this population and provide effective help for Tyvinian children and adolescents with mental health problems. Keywords Tyva · Children · Adolescents · Mental health · Epidemiology
Introduction High rates of child mental health problems in Russia have recently been documented: in a series of population-based studies from seven countries (Bangladesh, Brazil, Britain, India, Norway, Russia and Yemen) that have used the same measures of psychopathology, the prevalence of psychiatric disorders was highest among Russian children: 17.1 % of 7- to 14-year-olds [1]. A study of Russian child mental health showed that though the rates of disorders were higher than in other countries, there were few differences in type of disorder or key risk factors [2]. Emotional and behavioural disorders were the two most common categories, and the most significant risk factors were characteristics of the child and proximal family environment, such as parental mental health, alcoholism in the family and domestic violence. The high rates of child psychiatric disorders, together with the exposure to adversity, may lead to suicidal behaviour [3], and indeed the rates of youth suicide in the Russian Federation since the 1990s are among the highest in the world [4]. However, there is a 60-fold difference in the rate of youth suicide across the Russian regions, leading researchers to conclude that due to considerable geographic, socio-economic, cultural and ethnic heterogeneity, it is crucial to consider the regional specificity of Russian youth suicide [4]. The Republic of Tyva has one of the highest rates of child and adolescent suicide [5]: in 2008–2009, the suicide
13
mortality rate in adolescents was 106.9 per 100,000 compared to 20.1 per 100,000 in the Russian Federation and the global suicide rate of 7.4 per 100,000 [4, 6]. Tyva is located in the South of Eastern Siberia near the geographical centre of the Asian continent and has an area of 170.5 km2. The population of Tyva is 311,761, with 37 % living in Kyzyl, the capital of the Tyva Republic. More than 82 % of the population are Native Tyvins and more than 16 % are Russians [7]. Tyva has the highest birth rate in the Russian Federation, in 2012 it was 26.7 per 1000 population, twice as high as Russia’s birth rate (13.3 per 1000 population) [7]. Life expectancy at birth (55.5 for men and 66.9 for women in 2012) is the lowest in the Russian Federation. High mortality rates are due to external causes of death, such as accidents, homicide and suicide, related to alcohol and drug abuse [5, 8]. These statistical data suggest that Tyvinian children and adolescents may have a relatively high rate of mental disorder. However, to our knowledge, there are no studies that have estimated the prevalence of child mental health problems in the Republic of Tyva. Therefore, the aim of the present study was to investigate the rate of mental health problems in representative community samples of Native Tyvinian children and adolescents using standardised and internationally recognised measures and diagnoses.
Methods Participants and procedure The study was a two-stage, two-phase cross-sectional survey carried out in Western rural areas of Tyva and in Kyzyl, the capital city. Data collection took place between 2001 and 2007 as part of three expeditions organised by the Scientific Research Institute of Medical Problems of the North. Five settlements in five districts (kozhuuns) were selected in Western rural areas most densely populated by Native Tyvins, Chaa-Khol (Chaa-Kholsky kozhuun), Teeli (Bay-Tayginsky kozhuun), Chadan (Dzun-Khemchiksky kozhuun), Khandagayty (Ovyursky kozhuun) and Torgalyg (Ulug-Khemsky kozhuun). The population in the settlements varied from 3200 to 8800, up to 98.3 % were Tyvins speaking native language. Russian is taught in school as a second language from first grade onward. All schools in the settlements were approached to invite participation in the study. In Kyzyl, two schools were selected, a national college for Native Tyvinian children and a public school that enrolled both Native Tyvins and children of other ethnicities. All Native Tyvinian children in grades 3–4 (ages 9–10) and 6–7 (ages 14–15) were selected for investigation, excluding children who had been previously identified as
13
Eur Child Adolesc Psychiatry
showing significant psychiatric or neurological condition such as schizophrenia, epilepsy or mental retardation. In the first phase, all participants were assessed using teacher ratings of the Rutter Children’s Behaviour Questionnaire [9]. The aims and procedure of the study were explained to teachers and administrative staff of the participating schools. Teachers were provided with the Rutter Children’s Behaviour Questionnaire and had the opportunity to ask questions. Questionnaires were obtained on 1048 children (97 % of those selected), or 0.97 % of the general child population in Tyva. Of these 1048 children, 545 (52 %) were male and 503 (48 %) were female; 647 (62 %) were aged 9–10 and 401 (38 %) were aged 14–15; 705 (67 %) were from rural area and 343 (33 %) were from urban area. In the second phase, more detailed psychiatric assessments were carried out on all 9- to 10-year-old children; for 14–15-year-old children, psychiatric assessments were carried out on all children with scores above the cut-off (N = 101) and a random 20 % sample of those with scores below this value (N = 57). Measures The Rutter Teacher Questionnaire (RTQ, Scale B) [9] is a standardised screening measure of child mental health problems. The RTQ consists of 26 items covering the main conduct, emotional, and hyperactivity symptoms. Each item is rated on a three-point scale: scale: 0 = ‘does not apply’, 1 = ‘applies somewhat’, and 2 = ‘certainly applies’. The RTQ is scored by adding across all of the items to generate a total difficulties score. Conduct problems score is the sum of six items (destroys, fights, disobedient, tells lies, has stolen things, bullies) and emotional symptoms score is the sum of four items (worries, miserable, fearful, tears on arrival at school or has refused to come). The RTQ is used to categorise children as having, or not having, mental health problems according to whether their total difficulties score is equal to or greater than a standard cut-off score of 9. The type of mental health problems in children scoring above the cut-off is identified by the greater of the conduct problems and emotional symptoms scores. The RTQ has been widely used around the world and has proved valuable for the identification of psychiatrically disturbed children among epidemiological samples; it can also satisfactorily differentiate conduct and emotional disorders [10]. The Russian version has been used in previous studies of child mental health and adjustment [11, 12]. Psychiatric diagnosis A mental health specialist (NS) conducted a semi-structured psychiatric interview with children in the second stage of the study. An experienced paediatrician from the Republican clinic or a school nurse, both Native Tyvins, was present during the interview, helping to translate the questions and the answers. In addition,
Eur Child Adolesc Psychiatry
the data relating to the emotional state and behaviour of the children were obtained from medical records and reports from teachers. The psychiatric information was collected together and a judgment made about the presence and type of psychiatric disorder, if any, in the child according to ICD-10 [13].
settlements, age difference in conduct problems scores was insignificant. For emotional symptoms, both effects of gender, F(1,1046) = 29.76, p
