Introduction

According to the World Health Organization, there are 1.2 billion adolescents worldwide, 90% of whom live in low- and middle-income countries (LMICs) [1]. Generally, LMICs have a younger population than high-income countries; in Nepal, adolescents make up about 20% of the total population [2]. Adolescence is a transition period between childhood and adulthood which is characterized by many physical, psychological, and behavioral changes and adaptation processes. These changes can be emotionally distressing and affect personal well-being, productivity, and quality of life [3, 4].

Globally, one in seven 10-19-year-olds experiences a mental disorder, accounting for 13% of the global burden of disease in this age group [1]. A recent systematic review that examined common mental disorders in adolescents using the General Health Questionnaire (GHQ-12), reported a global prevalence of common mental disorders in adolescents of 25% and 31%, using the GHQ-12 cut-off points 4 and 3, respectively [5]. Further, it has been found that about half of all lifetimes mental health problems start during adolescence [6].

Mental health problems in children and adolescents include several types of emotional and behavioral disorders, i.e., disruptive disorders, depression, anxiety, and pervasive developmental disorders characterized as either “internalizing” (such as depression and anxiety) or “externalizing” (disruptive behaviors such as conduct disorders and attention-deficit/hyperactivity disorder). Emotional and behavioral problems (EBPs) with their related disorders have significant negative impacts on the individual, the family, and society. Despite the relevance of these problems as a leading cause of disability, their long-lasting effects throughout life and impact on the surroundings, the mental health needs of adolescents are often neglected. This is especially true in LMICs, possibly due to limited financial resources and a lack of trained mental health professionals [7, 8]. If adolescent mental health is not addressed, ill health may extend into adulthood, limiting people’s opportunities to lead fulfilling lives. Hence, adolescent mental health is a growing public health concern worldwide and should be of particular concern to LMICs [1].

Although the prevalence of mental health disorders in adolescence may be high globally, the prevalence varies across countries and cultures. One reason is that prevalence estimates may vary according to the measurement tools that are used in different studies. Screening instruments that measure EBPs in children and adolescents are commonly used to indicate the prevalence of mental health disorders. For example, scores on the Achenbach System of Empirically Based Assessments (ASEBA) instruments are significantly associated with DSM-5 diagnostic categories, and ASEBA scores can be directly related to DSM-5 diagnostic categories by using the DSM-oriented scales for scoring ASEBA forms[9]. Generally, screening instruments may yield a higher prevalence compared to diagnostic tools [10, 11].

Studies on adolescents’ self-reported EBPs are still sparse, especially from LMICs. Few scientific studies have been published on self-reported mental health problems among adolescents in Nepal, except for some smaller studies from different schools and/or from particular geographic areas [12]. The studies reported different prevalences (15%– 30%) and suggested that Nepali adolescents had more internalizing problems than externalizing problems [13, 14]. Recently, the Nepal Health Research Council (NHRC) conducted a national mental health survey with 5888 participants using the “Mini International Neuropsychiatric Interview” as an instrument. This survey yielded a prevalence of mental disorders in adolescents aged 13–17 years of 5.2% [15]. In 2021, a larger epidemiological study of parent-reported EBPs in Nepali children aged 6–18 years was published. This study used the Child Behavior Checklist (CBCL) as an assessment instrument and reported a prevalence of parent-reported EBPs of 18.3% [16].

Age and gender have been found to influence EBPs in studies from around the world. Internalizing problems tend to increase with age, whereas externalizing problems tend to decrease [17, 18]. Across cultures, studies show that girls tend to score higher than boys on internalizing problems, whereas boys tend to score higher on externalizing problems [17, 19–22]. However, more studies from LMICs are warranted to confirm whether these countries follow the same patterns as more developed countries. Further, it has been shown that the magnitude of EBPs and the relative magnitude of internalizing problems versus externalizing problems in adolescents may vary across countries and ethnic groups, suggesting that the impact of culture should be considered when assessing EBPs, especially in the less examined LMICs [18, 23].

Studies have demonstrated a positive relationship between negative/traumatic life events and mental health problems [24–28]. The prevalence of negative life events differs across countries, living environments, and social contexts and may partially explain the cross-cultural variation found in adolescents’ EBPs.

Physical illness, including chronic medical conditions that require long-term treatment, can increase the risk of EBPs [29, 30]. Young people with such illnesses are more likely to have higher levels of both internalizing and externalizing problems [31–36]. This may be due to a perceived lack of control over the illness and its symptoms, restrictions to participate in positive activities, and side effects of treatments. Additionally, symptoms of physical illness, such as pain, may lead to elevated problem scores [37].

Factors that are found to be negatively associated with EBPs include child competencies such as academic performance. Studies have reported a positive relationship between mental health and academic achievement [38], whereas mental health problems have been found to have a negative impact [39, 40]. Students with poorer academic performance have reported more EBPs [4, 41].

The present study is part of a larger epidemiological study published on EBPs in Nepali schoolchildren aged 6–18 years [16]. The aims of the present study were to assess the prevalence, magnitude, and types of self-reported EBPs in Nepali adolescents aged 11–18 years and to explore possible gender and age differences. As family correlates of child EBPs had already been examined [42], the present study further aimed to explore the associations between self-reported EBPs and adolescents’ factors such as academic performance, physical illness, and the impact of negative/traumatic life events.

Materials and methods

Results

Reliability analysis of the Nepali version of the Youth Self Report

Cronbach’s alpha for the YSR was found to be within the acceptable range, with values above 0.7 for all syndrome scales except the Withdrawn/Depressed and Social Problems scales, which had a somewhat lower level. We also calculated the correlations between each syndrome scale and each of its subitems, which revealed weak to strong associations according to Cohen’s classification [47, 48]. For the Anxious/Depressed scale, items like “fears at school”, “perfectionism”, and “thoughts about suicide” were weakly correlated, whereas items such as “nervous or tense”, “afraid of certain animals, situations or places”, and “worries” were strongly correlated. For the Withdrawn/Depressed scale, the items “enjoys little” and “withdrawn” had the weakest correlation, and “sadness” had the strongest correlation. For Somatic Complaints, the item “eye problem” was moderately correlated, and “nausea” was strongly correlated. For Rule-Breaking Behavior, “use of alcohol” had the weakest correlation, and the item related to “lies and cheating” had the highest correlation, though it was still moderate. For Aggressive Behavior, “demanding attention” had the weakest correlation, and the item related to “stubbornness” had the strongest correlation. For Thought Problems, “harms self” had the weakest correlation, and “having strange ideas” had the strongest correlation. For Attention Problems, “acting young for his/her age” had the weakest correlation, and “inattentiveness” was most strongly correlated. For Social Problems, “preference for younger children” had the weakest correlation, and other items were moderately correlated (Table 1).

Download:

• PNG
  larger image
• TIFF
  original image

Table 1. Internal consistency of the Youth Self Report (YSR) for Nepali adolescents (N = 1904).

https://doi.org/10.1371/journal.pone.0287305.t001

Background information

The mean age of the adolescents was 14.5 years (standard deviation, SD = 1.78). Most of the participants were from the Middle hills and Terai regions and from semi-urban areas. Father’s occupation was mostly farming, and most mothers were housewives. A considerable number of fathers were migrant workers (16%). Most fathers had a secondary school education (53%), whereas mothers had a lower level of education. About 11% of the adolescents had at least one illiterate parent. About half of the participants belonged to the higher Hindu caste groups, whereas 36% were from ethnic/ indigenous minorities. Less than 10% of the adolescents had been affected by negative/traumatic life events in the past 12 months, and most of them (89%) had no reported chronic physical illness/disabilities (Table 2).

Download:

• PNG
  larger image
• TIFF
  original image

Table 2. Distribution of selected background variables (N = 1904).

https://doi.org/10.1371/journal.pone.0287305.t002

Prevalence of emotional and behavioral problems

The prevalence of self-reported EBPs was calculated according to the YSR manual, i.e., based on American cut-off points indicating “normal”, “borderline” and “clinical” range of problems [44]. Prevalence of Total Problems was found to be 14.2%; 15.6% for boys and 12.9% for girls. Relatively more adolescents scored in the clinical range on Internalizing Problems (24.0%) than on Externalizing Problems (7.4%) (Table 3).

Download:

• PNG
  larger image
• TIFF
  original image

Table 3. Prevalence of emotional and behavioral problems in Nepali adolescents by gender.

https://doi.org/10.1371/journal.pone.0287305.t003

Magnitude of emotional and behavioral problems by gender in Nepali adolescents

Boys scored significantly higher than girls on Externalizing Problems and Rule-Breaking Behavior. Girls scored significantly higher than boys on Internalizing Problems, Anxious/Depressed, and Somatic Complaints. However, there was no gender difference in the magnitude of Total Problems. The Hedges’ g ranged from −0.29 to 0.28, indicating small effect sizes for gender comparisons according to Cohen [47] (Table 4).

Download:

• PNG
  larger image
• TIFF
  original image

Table 4. Youth Self Report mean scale scores in Nepali adolescents by gender (N = 1904).

https://doi.org/10.1371/journal.pone.0287305.t004

Mean item scores

The highest mean item scores were found for items that fall into the following syndrome scales: Anxious/Depressed, Withdrawn/Depressed, Somatic Complaints, Social Problems, Thought Problems, and Rule-Breaking Behavior (Table 5).

Download:

• PNG
  larger image
• TIFF
  original image

Table 5. Items with the highest mean scores in Nepali adolescents (N = 1904).

https://doi.org/10.1371/journal.pone.0287305.t005

Correlates of self-reported emotional and behavioral problems

For Total Problems, the variance accounted by the control variables was 1.7% (R² = 0.017). The variance increased to 3.7% (R² = 0.037) after adding the adolescent factors. For Internalizing Problems, the variance accounted by the control variables was 2.2% (R² = 0.022), which increased to 5.1% (R² = 0.051) after adding the adolescent factors. For Externalizing Problems, the variance increased from 1.5% (R² = 0.015) to 3.8% (R² = 0.038) after adding the adolescent factors. When all the control variables and the adolescent factors were simultaneously entered into the model, the child’s age was positively correlated with Externalizing Problems. The female gender was strongly associated with Internalizing Problems, i.e., girls scored higher than boys, whereas the male gender was more strongly associated with Externalizing Problems, i.e., boys scored higher than girls. Further, chronic physical illness/disabilities and child experience of negative/traumatic life events were positively correlated with Total Problems, Internalizing Problems, and Externalizing Problems. Academic performance was negatively correlated with Total Problems. However, all effect sizes were small, with partial eta squares less than 0.02 (Table 6).

Download:

• PNG
  larger image
• TIFF
  original image

Table 6. Correlates of self-reported emotional and behavioral problems in Nepali adolescents.

https://doi.org/10.1371/journal.pone.0287305.t006

Discussion

The study assessed the prevalence, magnitude, and type of self-reported EBPs among school-going adolescents in 16 different districts of Nepal. In addition, correlates of self-reported EBPs, such as age, gender, academic performance, chronic physical illness/disabilities, and negative/traumatic life events, were explored.

Earlier, different norm groups (high, medium, and low) were constructed for the YSR. These were based on the omnicultural mean of 36.67 (SD = 6.23) that was found in a large, epidemiological study by averaging the Total Problems scores of 34 cultures [21]. Later, Nepal was placed in the highest rank based on results from a former study of adolescents residing in the Western development region of Nepal [13]. However, the present study showed a mean Total Problems score of 39.27 (SD = 24.16) which suggests that Nepal should be placed among the medium-scoring countries since the mean score lied within one SD of the omnicultural mean. The difference in mean scores between the two Nepali studies might be related to methodological issues such as smaller sample size and limited geographic area in the earlier study [13].

In the present study, the prevalence of self-reported EBPs among Nepali adolescents was 14.2%. This prevalence is higher than the mean prevalence of self-reported mental health problems for adolescents in LMICs described in an earlier review [49]. It should be noted that the higher prevalence might be due to methodological issues. Studies using screening instruments are likely to overestimate the prevalence rates compared to studies using validated diagnostic interviews or rates based on diagnostic criteria [10, 50]. However, our finding is within the range of prevalence found in some previous Nepali studies [13, 14, 51–55].

As in other studies that used the YSR in South Asia [13, 14, 20], the prevalence of internalizing problems was much higher than that of externalizing problems (24.0% vs. 7.4%). This finding has also been reported in studies from other parts of the world, e.g., Europe [19] and Africa [56]. Further, our finding is in line with a recent American study suggesting a trend of increasing internalizing symptoms and decreasing externalizing symptoms among adolescents during the last decennium [57]. The finding of higher internalizing problems relative to externalizing problems in countries like Nepal could also be explained by the cultural sanction and cultural facilitation model described by Weisz et al. [58]. “Cultural facilitation” refers to a cluster of behaviors encouraged by a culture, whereas “cultural sanction” refers to a cluster of behaviors that are verbally disapproved, negatively sanctioned, or punished by that culture. Asian cultures tend to deemphasize verbal expression of aggression, acts of physical aggression, and rule-breaking behavior in children and adolescents (i.e., cultural sanction) which might facilitate the occurrence of internalizing problems [59]. Additionally, the value placed on family connectedness in Asian cultures is associated with a greater tolerance for Internalizing Problems (i.e., cultural facilitation) and a lower tolerance for Externalizing Problems [60]. Other studies have demonstrated that ratings of EBPs differ between countries. For example, in a cross-cultural study, Japanese adolescents reported a lower rate of externalizing behaviors (Rule-Breaking and Aggressive Behaviors) than adolescents from Greece, Russia, and Sweden [61]. However, cultural differences might be only one of several reasons for the differences in internalizing versus externalizing problems. Biological factors such as genes and sex hormones also impact the expression of symptoms, especially in adolescence [62, 63]. For instance, the male hormone, testosterone, is found to be associated with aggressive, rule-breaking behaviors [64]. However, to examine the biological aspect of adolescent behaviors was beyond the scope of the present study.

In our study, the prevalence of internalizing problems in boys was 28.7% compared to 19.3% in girls. This higher prevalence for boys should be regarded with caution as the prevalence estimates were based on American norms, and we cannot conclude that Nepali children’s problems were categorized according to relevant cut-offs. When we examined the mean scores (raw scores), girls had a higher mean score of Internalizing Problems than boys (15.30 versus 13.21). Our findings of gender differences in the magnitude (means) of self-reported EBPs converge with findings from a comprehensive, international meta-analytic review [65]; and with findings from other international studies [13, 17–20, 66]. Previous studies have suggested that girls’ tendency to internalize problems is mostly related to their daily hassles and the parent-child relationship [67], and to gender-specific coping patterns, such as girls’ increased tendency to ruminate when compared to boys [68]. The same explanations might apply to Nepali girls, along with the impact of other, additional factors such as cultural norms. For example, Nepali boys and girls are expected to behave differently. Girls are expected to engage in household chores, communicate through expressions of fearfulness, and remain silent. To protect girls’ marriage prospects, local cultural practices provide girls with less cultural space to behave in a disruptive manner [69]. Our finding that boys had higher scores on Rule-Breaking Behavior than girls is consistent with a previous Nepali study [13]. A possible explanation could be that boys spend more time outside of the home and are expected to show their masculinity by confronting fearful situations while limiting their emotional expression [69]. More studies on gender-related patterns in adolescents’ EBPs are warranted across cultures, especially from less investigated LMICs like Nepal.

We found that Externalizing Problems seemed to rise with increasing age, whereas Total Problems and Internalizing Problems did not. This finding is consistent with a previous study [19], but contrasts with most of the international literature which has suggested that older adolescents report more Total Problems and Internalizing Problems [18, 21] and less Aggressive Behavior [17]. Our finding might be due to a lack of culturally appropriate norms with which to compare the types of problems. Owing to the small effect sizes, these finding needs replication, and future studies are needed to verify the results.

The single items with the highest mean scores in our study, were self-criticism, fearfulness, inability to experience pleasure, too much dependency on adults, sleep problems, and headaches. These are somewhat different from the items that were most frequently reported in a previous international study that compared ratings of EBPs on the YSR in general population samples from 24 different countries [18]. However, one item, item no 32: “Have to be perfect”, was found to have a high mean score in both studies. Most of the frequently reported items in our study were related to somatic problems and to anxiety and depressive problems which might be due to the cultural expression of distress in Nepali culture. Items related to the use of drugs such as alcohol or tobacco, were among the least reported, which might be due to underreporting. Indeed, adolescents might want to keep any drug use a secret, given the taboo of substance use in Nepali society [70].

In accordance with other studies, negative/traumatic life events were positively associated with EBPs [25, 28, 51, 71]. The reason for increased EBPs among adolescents suffering from traumatic life events could be related to the stress and difficulty of coping with such events. In LMICs, like in Nepal, this association needs to be further explored considering the challenging socio-political contexts, the poverty and economic adversities, and the frequency of natural disasters that many children and adolescents in these countries must endure, and which might make them more vulnerable to mental health problems.

An important risk factor for mental health problems during adolescence is the presence of chronic physical illness/disabilities [72]. Consistent with the international literature [29–33], we found a positive association between physical illness and self-reported EBPs in Nepali adolescents. The fact that adolescents with chronic physical illness/disabilities are more likely to suffer from EBPs implicates the necessity to offer mental health assessments and treatment to adolescents with physical illnesses.

Further, we found that academic performance was negatively correlated with self-reported EBPs in our Nepali adolescents. The finding is consistent with the international literature [4, 38–40]. It seems that EBPs in adolescents not only cause pain and distress but also negatively influence their academic performance [73]. However, we cannot conclude whether EBPs lead to poor performance or vice-versa. It may even be a self-reinforcing circle. It should be mentioned that in Nepal, adolescents with poor academic performance are likely to be treated unfavorably and physically punished both at home and school, as this may be considered the best way to discipline a child and help him/her perform better [74]. This response may lead the adolescent to develop feelings of guilt, fear, violation, loss of control, and low self-esteem, which in turn could lead to more dysfunctional behavior. One explanation for the negative association between academic performance and self-reported EBPs might be the specific negative effect of attention problems on academic performance [41, 75]. Regardless of the explanation, early identification of adolescents’ EBPs and timely intervention are recommended to improve academic attainment.

Conclusion

This study focuses on the prevalence, magnitude, and type of self-reported EBPs among school-going adolescents in Nepal and explores possible correlates. It helps to narrow the knowledge gap in the existing literature about adolescents’ EBPs in LMICs and demonstrates that in a country like Nepal, many adolescents are likely to suffer from various types of mental health problems that need attention. Further, it highlights the importance of adolescent factors that might be associated with EBPs. Given the scarcity of data on adolescents’ EBPs in Nepal, our study might provide useful information to researchers, clinicians, and policymakers alike and may be particularly useful in preventive mental health work.

Supporting information

Acknowledgments

We are grateful to all participating Nepali adolescents and their teachers, and to the team of data enumerators and supervisors for making this study possible. Further, we would like to extend our gratitude to Dr. Arun Raj Kunwar and his child and adolescent psychiatry team at Kanti Children’s Hospital, Kathmandu, for their support.