Clinical Epidemiology and Global Health 9 (2021) 179–183

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Clinical Epidemiology and Global Health

journal homepage: www.elsevier.com/locate/cegh

Original article

An exploratory study of the prevalence of mental health symptoms among

girls living in 5 childcare institutions in Goa and Mumbai
Priyanka Halli a, b, *, Prachi Khandeparkar c, Suman Kanougiya a, d, Bernadette Pereira c
a
EmancipAction India Foundation, 7, Elysium Mansion, Walton Road, Colaba Causeway, Mumbai, 400001, India
b
University of British Columbia, 2329 West Mall, Vancouver, BC, V6T 1Z4, Canada
c
Sangath, 451 (168), Bhatkar Waddo, Socorro, Bardez, Porvorim, Goa, 403501, India
d
Tata Institute of Social Sciences, V.N. Purav Marg, Eden Gardens, Deonar, Mumbai, Maharashtra, 400088, India

A R T I C L E I N F O A B S T R A C T

Keywords: Background: India is home to 240 million adolescents and 170 million are vulnerable to or experiencing difficult
Mental health circumstances. The most vulnerable of these children are housed in the estimated 7800 nationwide childcare
Depression institutions (CCIs). Recent media reports have put a spotlight on these homes for a lack of mental health care as
Anxiety
well as neglect, sexual and physical abuse. In this paper, we sought to determine the prevalence and severity of
Community health
mental health symptoms of the girls living in CCIs.
Methods: This is a cross sectional study of N = 110 girls, age 11–18, living in 5 childcare institutions in Mumbai
and Goa. We gathered demographic information from the girls. For mental health screening we used: a) Strengths
and Difficulties Questionnaire (SDQ); b) Patient Health Questionnaire-9 (PHQ-9); and c) The Children’s Global
Assessment Scale (CGAS).
Results: On the PHQ, 17% of girls screened positively for moderate or severe level of depression and 40% re­
ported thoughts they would be better off dead or of hurting themselves. On the SDQ, 52% of the girls had a total
difficulty score above 20 suggesting that 52% need a referral to a child and adolescent mental health specialist
for treatment. In the regression model, family psychiatric history was significantly associated with depression.
Conclusion: Our findings reiterate a need for mental health care in CCIs in India.

1. Background death among older adolescent girls.2

The global population of adolescents, which the World Health Or­
ganization (WHO) defines as a person between age 10–19, exceeds one
billion. More than 90% of these youth live in low and middle-income
countries. India is home to about 240 million adolescents and it is
estimated that 170 million of India’s adolescents are vulnerable to or
experiencing difficult circumstances. These include orphans, aban­
doned, missing or run-away children, street children, children of sex
workers, abused and exploited children, children affected by HIV/AIDS,
children affected by natural calamities, and disabilities. India houses the
world’s largest number of sexually abused children.1
Among Indian adolescents, mental health disorders are on the rise.
Unlike most countries in the world, where suicide rates increase with
age, India is one of the few countries where the suicide rate among the
15–29 age group is more than three times the national average. This risk
is three times higher in girls and currently suicide is the leading cause of
Many of India’s most vulnerable girls who are deemed to be under
the care and protection of the Child Welfare Committee of India are
housed in the over 7800 registered, childcare institutions (CCIs) that are
managed by government or private trusts. Recent media reports have
put a spotlight on these homes after cases of sexual abuse in a home in
Bihar were uncovered.3 The National Commission for Protection of
Child Rights’ (NCPCR) did a subsequent social audit on shelter homes in
India and reported that out of the 2874 children homes investigated,
only 54 received positive reviews. In the same report, widespread
neglect, verbal and physical abuse were highlighted.
Girls living in childcare institutions often have multiple risk factors
for mental health disorders including losing a parent, poverty, childhood
abuse. The Juvenile Justice Care and Protection of Children Act (2000),
mandates mental health care for each girl residing in a childcare insti­
tution (CCI) and caregiving skills training to the staff. Unfortunately, the
Indian National Institute of Child development survey of 185 CCIs found

* Corresponding author. Royal Columbian Hospital, 330 E Columbia St, New Westminister, BC, V3L 3M2, Canada.
E-mail address: priyanka.halli1@fraserhealth.ca (P. Halli).

https://doi.org/10.1016/j.cegh.2020.08.011
Received 14 August 2020; Received in revised form 19 August 2020; Accepted 21 August 2020
Available online 29 August 2020
2213-3984/© 2020 The Authors. Published by Elsevier, a division of RELX India, Pvt. Ltd on behalf of INDIACLEN. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
P. Halli et al.
counselling and therapeutic services lacking in most of these homes.4
This may be because the entire mental health workforce in India,
comprising psychiatrists, psychologists, social workers and psychiatric
nurses stands at 7,000, while the actual requirement is 54,750.5
Despite all these vulnerabilities, there have been no published
studies which quantify the mental health symptoms prevalence rates
among adolescent girls living in CCIs in India. In this paper, we attempt
to quantify the prevalence and severity of the mental health needs of
girls living in five CCIs and determine whether they differ based on the
type of CCI.
2. Materials and methods
The study adapted a cross sectional design recruiting 110 girls
residing in five childcare institutions located within Mumbai and Goa in
India. The selection of childcare institutions for the study was purposive
and was based on the approvals from the local Child Welfare Commit­
tees (CWC) and the head of the childcare institutions (Superintendent).
We only included Childcare institutions where the girls remained in
residence for the entire academic year 2018–2019. The three CCIs in
Goa were Christian faith-based trusts, while in Mumbai, one CCI was a
government run home while the other CCI was run by a private trust and
all were registered with the government of India. All the girls among the
age group 11–18 years residing in these homes were eligible and were
approached to participate in the study.
The ethical approval for the study was obtained by the Institutional
Review Board at Sangath (Goa, India). The respective CCIs superinten­
dents’ provided written consent and the assent was obtained from the
eligible participants before the initiation of the study. The English
version of the participant information sheet, and consent form were used
in Goa as that was the dominant language among the girls. In Mumbai,
consent and data collection was obtained in the regional language,
Hindi.
A semi-structured sociodemographic questionnaire was used to
collect relevant information from participants which included age,
religion, caste, place of birth, parent’s occupation and education.
For the purpose of mental health screening, three tools were used: a)
Strengths and Difficulties Questionnaire (SDQ); b) Patient Health
Questionnaire-9 (PHQ-9); and c) The Children’s Global Assessment
Scale (CGAS). The CGAS assessments were conducted by a trained
psychiatrist and psychologist and the other two scales were conducted
by trained research staff.
In the SDQ, Youth self-report measure (YR1–11-17), emotional,
behavioural problems and prosocial behaviours were assessed. The SDQ
is a 25- item questionnaire that can be completed by 11–17 year olds to
screen for probable psychological distress. It has been validated in
developing countries (including India) with good validity indices.6,7 It is
scored using a Likert scale with the following scores; 0 = not true, 1 =
somewhat true and 2 = certainly true. The tool has 5 subscales
including: emotional symptoms, conduct problems, hyper­
activity/inattention, peer problems, and prosocial behaviour. A total
difficulties score ranges from 0 to 40, and is calculated by adding all the
subscales except the prosocial subscale. Each one point increase in the
total difficulties score corresponds with an increase in the risk of
developing a mental health disorder. The externalising score is the sum
of the conduct and hyperactivity scales. The internalising score is the
sum of the emotional and peer problems scales. A threshold score of 20
or greater is considered very high, suggesting that a referral to a child
and mental health specialist is required.8
A four-fold classification has been created using four categories (80%
‘close to average’, 10% ‘slightly above average, 5% ‘high’ and 5% ‘very
high’ for all scales except prosocial, which is 80% ‘close to average’,
10% ‘slightly lowered’, 5% ‘low’ and 5% ‘very low’).
The PHQ is a self-administered version of the PRIME-MD diagnostic
instrument for common mental disorders. The PHQ-9 is the depression
module, which scores each of the 9 DSM-IV criteria as “0” (not at all) to
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Clinical Epidemiology and Global Health 9 (2021) 179–183
“3” (nearly every day) and ranges from zero to 27. It also screens for
suicidal thoughts and attempts over a period of two weeks. Scores of 5,
10, 15, and 20 represent the thresholds for mild, moderate, moderately
severe, and severe depression, respectively. A threshold score of 10 or
greater has been indicative of depression in validation studies.9,10 The
PHQ-9 has been used with adolescents in India11 and showed acceptable
internal consistency (Cronbach’s α = 0⋅83).12
The CGAS is an adaptation of the Global Assessment Scale and was
designed to reflect the level of functioning for a child or adolescent
during a specified time period.13 The score (1–100) is based on a clini­
cian’s assessment of aspects related to a child’s psychological and social
functioning. The scores range from ‘extremely impaired’ (1-10) to ‘doing
very well’ (91–100).13 This scale was found to be reliable between cli­
nicians and across time with discriminant and concurrent validity.
The statistical analysis package STATA version 15 was used for the
analysis. The data was presented as descriptive statistics. The relation­
ships between the variables were explored using test of significance (t-
tests) and chi square tests.
3. Results
Data was collected from five different CCIs, two from Mumbai (N =
62) and three in Goa (N = 48). The total number of adolescent girls ages
11–18 years in the 5 homes was 110. The mean age of the girls was 14
(±2) years. About 61% were between 11 and 14 years and 39% between
15 and 18 years. The mean age in Mumbai (13.4) was lower than the
mean age in the Goa (14.4) homes. Overall, 23% (Mumbai 8%, Goa
15%) of girls had reported that they had not reached menarche. The chi-
square results indicated a statistically significant difference in menarche
between girls in Mumbai and Goa. The majority of girls were Hindu
(60%), followed by Christian (18%) and Muslim (12%) and 10% fol­
lowed other religions (e.g. Sikhism (1), Buddhism (9), Jainism (1)). In
Goa, the majority of girls identified as Christian. Muslim Girls were only
found in the government run home in Mumbai. The majority of girls
were born in Maharashtra (60%) and Goa (23%). The remaining 17%
were from the other parts of India i.e. Kolkata, Jharkhand, Bihar,
Madhya-Pradesh, Karnataka and Uttar Pradesh. 96% of the girls were
enrolled in school. 78% were between 6 and 10th grade and 12% were
between 2–5th grade, 5% had completed their 11th grade, and 1% were
pursuing an undergraduate degree. 87% of the girls had siblings and
32% of them identified as the eldest child. 52% of the girls reported that
they had visited with a family member within the last 12 months. About
10% reported never living with or visiting family. About 14% of the
girl’s entered the CCI in the current year. The main reason for admission
was having a single parent who was unable to properly care for the girl.
Other reasons included being an orphan, parents with mental or physical
health problems, mother working as a sex worker, parent with HIV,
family violence, child sexual abuse, human trafficking and poverty. 34%
of girls did not have a living father and about 10% of them did not have a
living mother. 23% of girls were orphans, 44% had a single parent and
33% had two parents.
The height and weight of the girls were recorded. The Asian BMI cut-
off suggested by WHO14 were used. Only 31% of the girls had a normal
BMI. 65% of the girls were found to be under-weight, while 3% were
over-weight and 1% pre-obese. There were no significant differences in
BMI between the two cities.
About 46% of the girls reported having a parent who suffered from a
psychiatric disorder including depression, suicide, substance abuse,
psychosis, anxiety and trauma. 37% reported substance abuse, mainly
by father, 7% depression, 6% suicide and 2% psychosis. About 5% of the
girls endorsed more than one psychiatric disorder in a parent.
Using the PHQ-9, 34% of girls screened negatively for depression,
49% screened positively for mild depression, and 17% screened posi­
tively for moderate or severe depression. The results from Chi-square
test showed no significant difference in depression between the Goa
and Mumbai sites (Fig. 1). Similarly, no significant difference was seen
P. Halli et al.
Fig. 1. Prevalence of depression (%) using the PHQ-9 in the CCIs in Mumbai and Goa.
in the government-run home versus the public-private home in Mumbai.
Table 1 shows the prevalence of suicidal thoughts. 27% of girls reported
feeling that they would be better off dead or had thoughts of hurting
themselves on several days over a 2 week span. 9% reported these
thoughts more than half the days and 4% reported having these thoughts
nearly every day. There was no significant difference between the two
cities. A family history of suicide was found to be significantly correlated
to reported thoughts of suicide.
The results from the CGAS (Fig. 2) indicated that 56% of girls had
some difficulty in a single area of functioning like home, school, or with
peers, but were generally functioning well. 39% had a variable level of
functioning with sporadic difficulties. About 1% of the girls had a major
impairment of functioning in several areas. The results from Chi-square
were not significantly different between the two cities.
Overall, 68% of girls reported high and very high emotional symp­
toms on the SDQ; almost half reported significant peer problems; 41%
reported symptoms of a conduct disorder and 16% reported hyperactive
symptoms. Meanwhile, 81% of the girls showed close to average pro­
social behaviour while 19% had lowered prosocial behaviour. More girls
in Goa (73%) reported very high emotional symptoms compared to girls
from Mumbai (44%), a statistically significant difference. However,
more girls in Mumbai reported very high hyperactivity symptoms (13%)
than from Goa (2%), also a significant difference. In the other subscales,
no statistically significant differences were found between girls living in
the two sites (Table 2).
About 52% of the girls had a total difficulty score above 20 (Table 3)
suggesting that 52% should be referred to an adolescent mental health
specialist for treatment. 62% of the girls in Goa and 43% of the girls in
Mumbai met this threshold, a statistically significant difference. A
family psychiatric history, family suicide history and family substance
abuse history were also found to be significantly correlated with a total
difficulties score of 20 and above.
4. Discussion
Despite the fact that 90% of the world’s adolescents live in low and
middle income countries (LMICs), only 10% of all adolescent mental
health research has been conducted in LMICs.15 Research among
vulnerable groups such as those living in childcare institutions has been
Table 1
Prevalence of suicidal thoughts (%) using the PHQ-9 in the CCIs in Mumbai and Goa.
PHQ-Suicide Category Overall (n ¼ 110)
n %
Not at all 66 60.00
Several days 30 27.27
More than half days 10 9.09
Nearly every day 4 3.64
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Clinical Epidemiology and Global Health 9 (2021) 179–183
particularly difficult to conduct. Research throughout the world has
shown that the societal costs of poor mental health can be reduced by
early intervention, and there is an ethical responsibility to the most
vulnerable young people, whose full developmental potential can be
thwarted by a lack of care.15 Poor mental health is strongly related to
lower educational achievements, substance abuse, violence, and poor
reproductive and sexual health.
This is one of the few studies in the published literature to examine
the prevalence of mental health symptoms among the most vulnerable
girls in India living in CCIs. The National Mental Health Survey of India
2015–2016 shows a 7.3% prevalence of all psychiatric morbidity among
13–17 years age group.16 In contrast, in the 5 childcare institutions we
studied, the PHQ suggested a 17% prevalence of moderate to severe
depression and the SDQ indicated that 52% of girls showed sufficient
difficulties to require a referral to a mental health specialist. In a similar
cross sectional study done in school going populations in Gujarat,
abnormal SDQ rates were between 12 and 14%.17 These results suggest a
higher prevalence of mental health disorders necessitating specialized
care amongst adolescent girls residing in these CCIs.
The discrepancy between the PHQ scores and SDQ total difficulties
scores may be because the SDQ picks up a wider variety of disorders
including anxiety, attention deficit hyperactivity disorder, conduct dis­
orders, and peer problems. The SDQ is also more specific to the
adolescent age group and may be more sensitive to adolescent diffi­
culties. Finally the SDQ asks about the last month of symptoms whereas
the PHQ asks about the last two weeks resulting in higher self-reported
symptoms.
Encouragingly, these girls also showed high prosocial scores sug­
gesting high resilience despite their vulnerabilities. Interventions in
these homes should not be solely illness-focused but also supportive of
further developing the girls’ inherent resilience.
Our hypothesis was that the girls living in private CCIs would have
better mental health. This hypothesis was not borne out in our results. In
fact, the girls had very similar mental health symptoms in all homes,
regardless of whether they were private, public or faith based suggesting
girls living in CCIs are vulnerable and have higher levels of mental
health symptoms than their adolescent, female counterparts living at
home.18 Socio demographic factors (other than a history of a psychiatric
disorder in a parent) do not appear to significantly add to the risk of
Mumbai (n ¼ 62) Goa (n ¼ 48) p-value (95% CI)
n % n % 0.172
37 59.68 29 60.42
14 22.58 16 33.33
7 11.29 3 6.25
4 6.45 0 0.00
P. Halli et al. Clinical Epidemiology and Global Health 9 (2021) 179–183

Fig. 2. Assessment of functioning (%) using the CGAS in the CCIs in Mumbai and Goa.

Table 2
Prevalence of Mental health symptoms and Prosocial Behaviour using the SDQ.
Sub-Domains Categories Overall (N = 110) Mumbai (N = 62) Goa (N = 48) p-value (95% CI)

n % n % n %

Emotional symptoms Close to average 29 26.36 22 35.48 7 14.58 0.012*

Slightly raised 6 5.45 3 4.84 3 6.25
High 13 11.82 10 16.13 3 6.25
Very high 62 56.36 27 43.55 35 72.92
Conduct problems Close to average 41 37.27 23 37.1 18 37.5 0.578
Slightly raised 24 21.82 15 24.19 9 18.75
High 17 15.45 11 17.74 6 12.5
Very high 28 25.45 13 20.97 15 31.25
Hyperactivity Close to average 69 62.73 42 67.74 27 56.25 0.013*
Slightly raised 23 20.91 7 11.29 16 33.33
High 9 8.18 5 8.06 4 8.33
Very high 9 8.18 8 12.9 1 2.08
Peer problems Close to average 41 37.27 18 29.03 23 47.92 0.125
Slightly raised 14 12.73 11 17.74 3 6.25
High 21 19.09 13 20.97 8 16.67
Very high 34 30.91 20 32.26 14 29.17
ProSocial behaviour Close to average 89 80.91 50 80.65 39 81.25 0.768
Slightly lowered 10 9.09 6 9.68 4 8.33
Low 7 6.36 3 4.84 4 8.33
Very low 4 3.64 3 4.84 1 2.08
Total difficulty Close to average 32 29.09 20 32.26 12 25 0.223
Slightly raised 6 5.45 4 6.45 2 4.17
High 15 13.64 11 17.74 4 8.33
Very high 57 51.82 27 43.55 30 62.5

*p < 0.05; **p < 0.01

long term mental health of the girls. Girls were screened at just one point
Table 3
of time, and adolescent self reporting can vary greatly, depending on the
Prevalence of Girls requiring Further Evaluation by a Mental Health Specialist.
events on that day. We recommend further longitudinal studies are
Total difficulty score cut-off 20 & above conducted. A third limitation is, due to data constraints, we conducted
Overall (N Mumbai (n Goa (n = p value 95% bivariate analysis and thus we can only infer relationships between the
= 110) = 62) 48) CI variables rather than prove causality. In addition, we used convenience
n % n % n % sampling to choose the five childcare institutions as we were only able to
Total difficulty less 53 48.18 35 56.45 18 37.5 0.049
conduct this survey in those homes we received approvals.
than 20 While it is, thus, premature to generalize from our findings, we
Total difficulty 20 & 57 51.82 27 43.55 30 62.5 believe they are sufficiently significant to support a broad, government
above mandated study to further assess the prevalence and nature of mental
*p < 0.05; **p < 0.01 health symptoms in all childcare institutions in India, as well as to
support investments to provide comprehensive access to mental health
depression symptoms. This suggests that one of the largest risks to these care support for all children residing in childcare institutions in India.
girls’ mental health is the fact that they are living in childcare in­
stitutions. Decisive government action is therefore required to make Declaration of competing interest
these homes safe places of therapeutic healing, rather than punitive
holding places that increase the risk of mental health disorders. To the best of our knowledge, the named authors have no conflict of
The strength of this study is it is one of the few studies available to interest, financial or otherwise.
give us insight into the mental health symptoms of girls living in CCIs.
A limitation of the study is that mental health assessments are based Acknowledgement
on self-report of participants and the sample is from only 5 childcare
institutions. There is a large degree of heterogeneity between CCIs. We acknowledge EmancipAction for their support of this study.
Another limitation is the study is cross sectional and may not reflect the

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P. Halli et al. Clinical Epidemiology and Global Health 9 (2021) 179–183

References 10 Gelaye B, Williams MA, Lemma S, et al. Validity of the patient health questionnaire-9
for depression screening and diagnosis in East Africa. Psychiatr Res. 2013;210(2):
653–661. https://doi.org/10.1016/j.psychres.2013.07.015.
1 Child Abuse: INDIA 2007 Ministry of Women and Child Development Government of
11 Shinde S, Weiss HA, Varghese B, et al. Promoting school climate and health outcomes
India.
with the SEHER multi-component secondary school intervention in Bihar, India: A
2 Kay M. Suicide is leading cause of death in young Indian women, finds international
cluster-randomised controlled trial. www.thelancet.com; 2018, 392.
study. BMJ. 2013;346:f1900. https://doi.org/10.1136/bmj.f1900.
12 Ganguly S, Samanta M, Roy P, Chatterjee S, Kaplan DW, Basu B. Patient health
3 Abuse of Children in India’s Institutions Reveals Nationwide Crisis Of Reform | |
questionnaire-9 as an effective tool for screening of depression among Indian
IndiaSpend.
adolescents. J Adolesc Health. 2013;52(5):546–551. https://doi.org/10.1016/j.
4 National Institute of Public Cooperation and Child Development. Data Base of Child
jadohealth.2012.09.012.
Care Institutions.
13 Shaffer D, Gould MS, Brasic J, et al. A children’s global assessment scale (CGAS).
5 Ministry of Health and Family Welfare. Annual Report to the People on Health
Arch Gen Psychiatr. 1983;40(11):1228. https://doi.org/10.1001/
Government of India Ministry of Health and Family Welfare. 2011.
archpsyc.1983.01790100074010.
6 Bele SD, Bodhare TN, Valsangkar S, Saraf A. An epidemiological study of emotional
14 Nishida C. Appropriate Body-Mass Index for Asian Populations and its Implications for
and behavioral disorders among children in an urban slum. Psychol Health Med. 2013;
Policy and Intervention Strategies. Vol 363. 2004.
18(2):233. https://doi.org/10.1080/13548506.2012.701751.
15 Kieling C, Baker-Henningham H, Belfer M, et al. Child and adolescent mental health
7 Bhola P, Sathyanarayanan V, Rekha DP, Daniel S, Thomas T. Assessment of self-
worldwide: Evidence for action. Lancet (London, England). 2011;378(9801):
reported emotional and behavioral difficulties among pre-university college students
1515–1525. https://doi.org/10.1016/S0140-6736(11)60827-1.
in Bangalore, India. Indian J Community Med. 2016;41(2):146–150. https://doi.org/
16 Murthy RS. National mental health survey of India 2015-2016. Indian J Psychiatr.
10.4103/0970-0218.177536.
2017;59(1):21–26. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_102_17.
8 SDQ | Youthinmind.
17 Nair S, Ganjiwale J, Kharod N, Varma J, Nimbalkar SM. Epidemiological survey of
9 Cholera R, Gaynes BN, Pence BW, et al. Validity of the patient health questionnaire-9
mental health in adolescent school children of Gujarat, India. BMJ Paediatr open.
to screen for depression in a high-HIV burden primary healthcare clinic in
2017;1(1), e000139. https://doi.org/10.1136/bmjpo-2017-000139.
Johannesburg, South Africa. J Affect Disord. 2014;167:160–166. https://doi.org/
18 Pillai A, Patel V, Cardozo P, Goodman R, Weiss HA, Andrew G. Non-traditional
10.1016/J.JAD.2014.06.003.
lifestyles and prevalence of mental disorders in adolescents in Goa, India. Br J
Psychiatry. 2008;192(1):45–51. https://doi.org/10.1192/bjp.bp.106.034223.

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