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National Health and Morbidity Survey 2019 Technical Report − Volume I 224 This page has been intentionally left blank.

Non-Communicable Diseases: Risk Factors and other Health Problems 225 Mental Health Problems of Children

National Health and Morbidity Survey 2019 Technical Report − Volume I 226 Mental Health Problems of Children Contributors to this section: Abdul Aziz Harith, Mohd Shaiful Azlan Kassim, Noor Ani Ahmad, Norhafizah Sahril, Sherina Mohd Sidik, Idayu Badilla Idris, Nurashikin Ibrahim, Nur Azna Mahmud, Nor Asiah Muhamad, Rimah Melati Ab. Ghani, Zamtira Seman Introduction World Health Organization (WHO) reported 10-20% of children and adults experience mental disorders. More surprising, 50% of mental health illnesses begin by the age of 14 and three-quarters by mid-20s [1]. Consequences of mental health severely influence the child’s development, their education, and potential to live fulfilling and productive lives [2]. Children with mental disorders face challenges with stigma, isolation and discrimination [3]. Mental health is defined as a state well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. The positive dimension of mental health is highlighted in World Health Organization’s (WHO) definition of health as contained in its constitution: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease infirmity” [4]. Child mental health is the complete well-being and optimal development of a child in the emotional, behavioral, social and cognitive domains [5]. Children’s mental health is often defined as different from adult mental health and more multifaceted because of the unique development milestones that children experience. Characteristics of the child for example, gender and genetics, are important determinants of a child’s well-being. However, child mental health also includes those conditions that directly affects or modify mental health, including aspects of a child’s family, community and broader society. The mental health problems in children may be reflected as difficulties in psychological and emotional development, social relationships and behavior. Children with good mental health are able to develop emotionally and cognitively, form effective social relationships with others, and cope with problems [6]. The “Report from the 2016 National Survey of Children’s Health (NSCH) in United States among 3 to 17 years old children found that 7.1% had anxiety, 7.4% had current behavioral / conduct problems, and 3.2% had current depression [7]. The prevalence of each disorder was higher with older age and child with poor health [7]. Findings from the previous Malaysia National Health and Morbidity Survey (NHMS 2015) using the Strength and Difficulties Questionnaire (SDQ) found that the prevalence of mental health among children aged 5 to 15 years old was 12.1% (95% CI: 11.0, 13.4) and it was higher among males [12.4% (95% CI: 10.8, 14.1)] compared to females [11.9% (95% CI: 10.3, 13.6)] [8]. It was also found that children in the younger age (5-9 years old) had higher prevalence mental health problems compared to the older age group (10-15 years old) [8]. Objectives General objective To determine the prevalence of mental health problems among children age 5 to 15 years in Malaysia. Specific Objectives

  1. To determine the prevalence of emotional problem among children age 5 to 15 years in Malaysia
  2. To determine the prevalence of conduct problem among children age 5 to 15 years in Malaysia
  3. To determine the prevalence of hyperactivity problem among children age 5 to 15 years in Malaysia
  4. To determine the prevalence of peer problem among children age 5 to 15 years in Malaysia
  5. To determine the prevalence of pro-social skills among children age 5 to 15 years in Malaysia Methods The Strength and Difficulties Questionnaires (SDQ) is a brief behavioural screening questionnaire. This instrument has been used in 2015 and repeated in 2019. The information on mental health among children age 5 to 15 years were required from their parents or guardian. The SDQ comprises 25 items comprising 5 scales of 5 items which were emotional problems scale, conduct problems scales, hyperactivity problem scales, peer problem scales and pro-social scales. Informants answered the questionnaires using Likert-Scales. It scored the scale up to the pro rata if it completed if at least 3 items. Each problem scores comprises five items with a score range of 0-10.

Non-Communicable Diseases: Risk Factors and other Health Problems 227 The SDQ scores for each scale were categorized as follows: SDQ Scale Categories Normal Abnormal Emotional Problems Scores 0-3 4-10 Conduct Problem Scores 0-2 3-10 Hyperactivity Problem Scores 0-5 6-10 Peer Problem Scores 0-2 3-10 Pro-Social Scores 6-10 0-5 We consider a child to having mental health problems if total difficulties score was 14 or more. Total Difficulties Scores generated by adding the scores from all the scales except the pro-social scale. The resultant score ranged from 0 to 40 and counted as missing if one of the four component scores was missing. The Total Difficulties Scores for SDQ scores were categorized as follows: Scale Categories Normal Abnormal Total Difficulties Scores 0-13 14-40 Findings About 3185 out of a total of 3226 children aged 5 to 15 years old responded in this study (response rate: 98.7%). The overall prevalence of mental health problems among children was 7.9% (95% CI: 6.56, 9.38). The prevalence was highest in Perak [19.0% (95% CI: 11.19, 30.35)], followed by Perlis [14.9% (95% CI: 8.90, 23.93)] and Sarawak [14.1% (95% CI: 9.56, 20.25)]. Children from rural areas had higher prevalence of mental health problems as compared to those from urban areas [8.8% (95% CI: 6.68, 11.54) vs 7.5% (95% CI: 5.96, 9.39)]. By sex, mental health problems were higher among females than males [8.4% (95% CI: 6.65, 10.67) vs 7.3% (95% CI: 5.58, 9.38)]. Older children (10-15 years) showed higher prevalence of mental health problems [9.5% (95% CI: 7.58, 11.77)], as compared to younger children (5-9 years) [5.9% (95% CI: 4.60, 7.47)]. By household income, those with lower income (RM1,000-RM1,999) and (less than RM1,000) showed higher prevalence of mental health problems respectively [11.9% (95% CI: 8.49, 16.35)] and [10.1% (95% CI: 6.55, 15.38)]. Those who at B40 income group showed highest prevalence of mental health problems [8.8% (95% CI: 7.27, 10.70)].

By domains, peer problems had the highest prevalence, which increased from 32.5% in NHMS 2015 to 42.9% in NHMS 2019. Conduct, emotional and hyperactivity problems showed reduction in prevalence from NHMS 2015 to NHMS 2019; from 16.7% to 15.9%, 15.7% to 8.3% and 4.6% to 2.3% respectively. There is an improvement in the prevalence of pro-social skills from 11.2% in NHMS 2015 to 27.7% in the current survey (NHMS 2019). Conclusion This survey found that children who were at risk of mental health problems were those who were in the older age group (10-15 years old), female, and from rural areas. Children with lower household income showed higher prevalence of having mental health problems. However, the findings were only significant for age group. It was noted that the highest type of mental health problems were peer problems followed by conduct problems and emotional problems. Recommendations Special programs in managing stress among older children need to be emphasized in the school system. Trained preschool and school teachers need to be empowered and trained for early detection of mental health problems among children. Respective agencies involved with education and welfare of children should acknowledge these problems for subsequent action. Table 16.1: Mental Health (Children) Trend in Malaysia 2015 2019 Mental Health 12.1 7.9 Emotional Health 15.7 8.3 Conduct Problem 16.7 15.9 Hyperactivity Problem 4.6 2.3 Peer Problem 32.5 42.9 Pro-Social Skills 11.2 27.7 References

  1. World Health Organization. Web page on Mental Health; Child and adolescent mental health. https:/ /www.who.int/mental_health/maternal- child/ child_adolescent/ en/
  2. Sheehan R. Mental Illness in Children: Childhood Illness and Supporting the Family. Brain Sci. 2017; 7(8):97. Published 2017 Aug 8. doi:10.3390/ brainsci7080097
  3. Nich Gould. Mental Health Social Work in Context: Student social work. First edition published by Routledge 2010. | ISBN 9781138905672 (hbk).
  4. WHO: Mental health: a state of wellbeing.Geneva: World Health Organization;2014. www.who.int/features/factfiles/mental_health/ en/
  5. Child Mental Health. Melanie Barwick, Diana Urajnik. http:/ /www.britannica. com/topic/ child-mental-health.
  6. Reem M.Ghandour, StephenJ.Blumberg Prevalence and treatment of depression, anxiety and conduct problems in US Children.The Journal of Pediatrics.Volume 206, March 2019;256-267. http:/ / doi.org/10.1016/j. peds.2018.09.021
  7. Perou R, Bitsko RH, Blumberg SJ, Pastor P , Ghandour RM, Gfroerer JC, Hedden SL, Crosby AE, Visser SN, Schieve LA, Parks SE, Hall JE, Brody D, Simile CM, Thompson WW, Baio J, Avenevoli S, Kogan MD, Huang LN. Mental health surveillance among children – United States, 2005—2011. MMWR 2013;62(Suppl; May 16, 2013):1-35.
  8. Institute for Public Health. National Health Morbidity Survey 2015 Report. Url: http:/ /www.moh.gov.my/moh/resources/nhmsreport2015vol2.pdf
  9. Idris IB, Barlow J, Dolan A, Surat, S. The reliability and validity of the Malay parent-report version of the strengths and difficulties questionnaire. Malays J Med Sci. 2019;26(1):125–137. https:/ / doi.org/10.21315/mjms2019.26.1.12. National Health and Morbidity Survey 2019 Technical Report − Volume I 228 Table 16.2: Prevalence of Mental Health Problems Among Children Aged 5 - 15 Years in Malaysia by Socio-Demographic Characteristics (n=3,185) Sociodemographic Characteristics Count Estimated Population Prevalence (%) 95% CI Lower Upper MALAYSIA 251 424,017 7.9 6.56 9.38 State Johor 10 28,015 4.7* 2.32 9.44 Kedah 10 21,222 5.8* 2.61 12.21 Kelantan 14 23,564 6.1* 3.04 11.78 Melaka 11 8,675 6.6* 3.42 12.29 Negeri Sembilan 12 15,399 5.1* 2.51 10.08 Pahang 11 16,894 5.9* 2.67 12.68 Pulau Pinang 7 8,346 3.5* 0.78 14.46 Perak 23 66,292 19.0 11.19 30.35 Perlis 19 5,929 14.9 8.90 23.93 Selangor 16 41,458 4.1 2.34 6.94 Terengganu 25 25,655 10.1 6.53 15.21 Sabah 35 81,015 11.9 7.73 17.87 Sarawak 25 65,838 14.1 9.56 20.25 WP Kuala Lumpur 6 12,795 5.3* 2.00 13.08 WP Labuan 16 1,686 10.3* 5.61 18.10 WP Putrajaya 11 1,234 5.1* 2.71 9.38 Location Urban 146 295,867 7.5 5.96 9.39 Rural 105 128,150 8.8 6.68 11.54 Sex Male 123 195,827 7.3 5.58 9.38 Female 128 228,190 8.4 6.65 10.67 Age Group (Years) 5-9 100 142,691 5.9 4.60 7.47 10-15 151 281,325 9.5 7.58 11.77 Ethnicity Malaya 178 270,053 7.8 6.30 9.60 Chinese 11 24,851 3.1* 1.30 7.30 Indian 8 19,425 7.3* 3.30 15.30 Bumiputera Sabah 27 45,897 10.7 6.30 17.70 Bumiputera Sarawak 18 39,194 14.3 8.60 22.70 Others 9 24,597 14.3* 5.70 31.40 Household Income Group Less than RM 1,000 29 60,709 10.1 6.55 15.38 RM 1,000 - RM 1,999 64 116,482 11.9 8.49 16.35 RM 2,000 - RM 3,999 78 131,035 7.6 5.93 9.74 RM 4,000 - RM 5,999 43 67,199 7.6 5.07 11.22 RM 6,000 - RM 7,999 15 23,348 4.5* 1.69 11.33 RM 8,000 - RM 9,999 10 15,468 5.7* 2.63 12.08 RM 10,000 and above 12 9,776 2.3* 0.81 6.36 Sociodemographic Characteristics Count Estimated Population Prevalence (%) 95% CI Lower Upper Household Income Quintile Quintile 1 55 102,919 9.9 7.19 13.49 Quintile 2 62 117,884 11.7 8.36 16.16 Quintile 3 45 72,337 6.6 4.66 9.16 Quintile 4 52 82,285 7.0 4.88 9.98 Quintile 5 37 48,592 4.5* 2.47 8.06 Household Income Category Bottom 40% 178 307,881 8.8 7.27 10.70 Middle 40% 56 97,428 6.6 4.38 9.94 Top 20% 17 18,707 4.2* 1.97 8.59 *Prevalence with high RSE, interpret with caution a - Malay includes Orang Asli
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