Title : Parental Knowledge and Educational Intervention on Behavioural Disorders in Pre-school Children

 Parental Knowledge and Educational Intervention on Behavioural Disorders in Pre-school Children in Kolkata

Abstract

Parents need to know the common behavioural disorders and their prevention in order to detect deviations early and promote healthy childhood. A prospective interventional study was con-ducted to assess the impact of an educational intervention on the awareness of behavioural disorders among the mothers of pre-school children attending child guidance clinic in a tertiary care hospital in Kolkata, India. Knowledge of 50 mothers of children between 3 to 6 years of age was assessed before and one week after the educational intervention by administration of a pre-validated questionnaire and analysed with inferential statistics like paired t test. The pre-test scores of parents on knowledge of behavioural problem of children did not vary significantly with age of the child, birth order of child, type of the family, educational background of parents and behavioural disorder of child. There was a significant improvement in post-test score (17.26 ± 4.11) over pre-test score (8.28 ± 4.54) which was statistically significant (p-value 4.494e-12 <0.0001). This study establishes the significance of educating parents on behavioural disorders in children and reflects the need for sustained structured educational services for parents to improve mental health of the children in a developing nation like India.

 

Children are the precious possession of parents, future of mankind and asset of a nation. A healthy child makes a society healthy and prosperous. From birth to adulthood a child passes through phases of physical, mental and social development. The emotional needs are considered as emotional food for healthy behaviour. The children are dependent on their parents, so parents are responsible for fulfillment of the emotional needs. They should have opportunity for development of independence, trust, confidence and self respect. Any disruption in mental or emotional development can lead to behavioural disorders in children. Review of re-cent studies on mental health problems among school going children showed prevalence rate varying from 6.33 percent to 43.1 percent in Indian context (Prakash et al, 2008).

Children may suffer from wide range of behavioural problems such as psychosocial disorder, conduct disorder, eating disorder, attention deficit hyper activity disorders, adjustment disorder, disruptive behavior, sleep disorder, elimination disorder and in extreme cases depression, anxiety and sub-stance abuse. According to Malhotra (2005), common disorders in India are enuresis, ADHD, learning dis-order, conduct disorders etc.

Children less than 15 years of age constitute approximately one third of the world’s population and between 5-15 percent are affected by persistent socially handicapping behavioural disorders. According to Malhotra (1992), 80 percent of world’s children live in developing countries where mental health services are meagre or non-existent.

Children too feel unhappy, anxious, fearful and angry. They may lack concentration, be forgetful, impulsive, have difficulty in controlling anger and fight. They may have difficulty in getting their mind off certain thoughts; may suffer unexplained headache, stomachache, anorexia, insomnia; may have trouble in maintaining friendships or dealing with people and may feel like hurting themselves or others. These are not uncommon scenarios. They all indicate that all is not well with the child. Most parents, teachers and other adults are not sensitive to pick up these subtle forms of behavioural indications. It is only when the problem becomes severe and disabling that some attention is paid to the child. In early stages it is much easier and simpler to intervene and push the developmental trajectories into a healthier and adaptive course. Studies regarding parental knowledge on behavioural problems are very few and no evidential data was found from Eastern India.

So it is necessary to assess the level of aware-ness of parents regarding behavioural disorders in children. This study was conducted to assess the baseline knowledge of parents of preschool children attending child guidance clinic in a tertiary care hospital in Kolkata and to find out the effectiveness of an educational intervention on their knowledge with an aim to strengthen mental health of children in India.

Review of Literature

Gupta I (2001) conducted a study to determine the prevalence of behavioural problem in 957 school children of Ludhiana, India. The result showed that 45.6 percent of the children had behavioural problems, of which 36.5 percent had significant problems. Con-duct disorders (5.4%) hyperkinetic syndrome (12.9%) scholastic under achievement (17%) and enuresis (20.3%) were detected to be the main problems in children. The study concluded that behavioural deviance does exist in our children.

In a school-based cross-sectional study by Pathak et al (2011) to explore the prevalence and patterns of behavioural and emotional problems in adolescents, stratified random sampling was done and 1150 adolescents in 12 to 18 years age group in grades 7 to 12 in 10 co-educational schools from Chandigarh were assessed using Youth Self-Report questionnaire. Family stressors were assessed using a pre-tested 23-item questionnaire. Prevalence of behavioural and emotional problems in adolescents was found to be 30 percent, with girls exceeding boys in all age groups. Internalising syndrome was the most common (28.6%) psychiatric problem. Stepwise regression analysis showed that a perceived lack of emotional proximity to mother had the highest odds (3.489) followed by addiction in father (2.642) and marital discord in parents (1.402). These data suggested urgency in establishing a school-based mental health service.

Sharma & Kaur (2014) conducted a quasi-experimental study in Ludhiana to assess the effect of structured teaching programme on knowledge of mothers regarding behavioural problems in children. Sample of 60 mothers were chosen by purposive sampling technique; 30 mothers were kept in experimental group and 30 in control group. Findings revealed that majority of mothers (50%) in both control and experimental group had average pre-test knowledge regarding behavioural problems in children. Maxi-mum mothers (66.66%) obtained below average post-test knowledge score in control group whereas maxi-mum mothers (93.33%) obtained excellent post-test knowledge score in experimental group. Education and type of family were found to be significantly related with knowledge of mothers regarding behavioural problems in children.

A study by Karl F Riem et al (2009) to assess the mother’s knowledge regarding reinforcement for behavioural problems of infants, toddlers, and preschoolers among 583 mothers with children aged 59 months or younger showed the need for parent education programmes regarding reinforcement for behavioural problems to help parents manage their children. The study concluded that knowledge regarding reinforcement will change the attitude of mothers towards behavioural problems.

Objectives

1.      To assess the knowledge on behavioral problems of pre-school children among parents before and after educational intervention

2.      To assess the effectiveness of educational intervention on the knowledge of parents of pre-school children

3.      To associate the pre-test knowledge score with selected background variables.

Methodology

It was a prospective interventional study using dedicated hours of teaching on behavioural disorders to investigate the level of awareness regarding child-hood behavioral problems among parents after for-mal approval from the institution. Pre-experimental research design was adopted. Informed consent was obtained from the participants before including in the study.

A questionnaire was developed to assess the knowledge before and after an educational intervention. It consisted of two parts: Part A containing items on background information and part B containing questions on knowledge on behavioural problems. Part B consisted of 25 questions. Knowledge questions focused mainly on causes, various types of behavioural problems, their features, treatment and prevention. Content validity was evaluated by various subject experts, including the consultant clinical child psychologists. Reliability was assessed by test-retest method applied on 10 randomly selected parents attending paediatric outdoor. The reliability score of Cronbach’s alpha was 0.87 implying good re-liability. A teaching module was prepared and validated by the consultant paediatrician and senior paediatric nursing faculty to conduct the teaching programme.

 

Fifty parents were selected from child guidance clinic of a tertiary care hospital in Kolkata using non-probability convenient sampling method. Questionnaires were administered to all the parents at the beginning of the programme to assess their knowledge followed by a dedicated two hour teaching programme by a set of assigned teachers. After 7 days the questionnaire was re-administered on their next follow-up visit.

 

 

The filled-in questionnaires were analysed by descriptive and inferential statistics using statistical software R. Score 1 was assigned to the correct answers and zero was assigned to wrong answers. Test statistic Analysis of Variance was used for study of association of pre-test knowledge score with selected demographic variables Effectiveness of the educational intervention was analysed using one sided (greater than type) paired t test. One-sided Pearson’s chi-squared test statistic (greater than type) was used to assess the impact of educational intervention to the parents and proportion of parents attempting correct alternatives in selected questions.

Results

Half of the parents of pre-school children attending child guidance clinic in Peerless Hospitex Hospital & Research Centre, Kolkata was administered questionnaire and teaching given. The observed demo-graphics and characteristics of the respondents are depicted in Table 1; 48 percent of the children were 4 years old. 70 percent of the children attending out-door was first born child. Majority (72%) of the parents were having education above higher secondary level.

Pre-test scores of parents on knowledge of behavioral problem of children did not vary significantly with age of the child (p=0.5488, > 0.05); birth order of child (p=0.93, > 0.05); type of the family (p=0.1873, > 0.05); educational background of parents (p=0.6364,

A 0.05) and history of behavioral disorder of child (p=0.9971, > 0.05).

Pre-test scores and post-test scores were measured on a total of 25 score points on knowledge of Parents regarding behavioral problems of pre-school children attending a clinic. There was a significant improvement in post-test score (17.26 ± 4.11) over pre-test score (8.28 ± 4.54) with p-value 4.494e-12, < 0.0001. Pre-test and post-test knowledge scores are demonstrated in Fig 1.

 

There is a significant impact of teaching to the parents and proportion of parents attempting correct alternatives are significantly higher in the post-training score compared to pre training score for all Questions except No. 20 & 22 i.e. questions regarding meaning of school phobia and meaning of autism. Table 2 shows the question wise impact on knowledge score of parents after the educational intervention. Knowledge score on management of temper tantrum increased from 26 percent to 70 percent which is a significant change. Knowledge on management of enuresis also showed significant improvement (32% to 68%) after the teaching. Parents showed less improvement of knowledge in areas like school phobia (72% to 86%) and autism (14% to 28%).

 

 

Table -2 Question-wise knowledge score of parents in pre-test and post-test

 

 

Discussion

Various studies have been done on behavioural dis-orders of children but very few are done on impact of educational intervention on parents regarding behavioural disorders in children. This study emphasises the need for increasing parental awareness to prevent the behavioural disorders in children. Ellen C. Perrin et al (2014) conducted a randomised clinical trial in Greater Boston area to investigate the effectiveness of parent-training delivered to parents of toddlers in paediatric primary care settings and greater improvement was observed in intervention group (p<0.05). The present study also reflected significant changes in the knowledge score after the educational intervention.

Bele SD et al (2013) showed that 22.43 percent children had an abnormal score on at least one do-main of strength and difficulties questionnaire and also indicated that male gender (odds ratio / OR=5.51), under-nutrition (OR=2.74), low socioeconomic status (OR=3.73), nuclear family (OR=1.89), working status of the mother, younger age of the mother at the birth of the child, disciplinary method, financial problem at home, conflicts in family (OR=7.29), and depression among mother (OR=3.95) were significant predictors. There was also a significant impact on educational performance (p=0.008) and parents had little awareness regarding the condition. The present study established that age of the child, birth or-der of the child and educational back-ground of the parents has no significant influence on knowledge of parents. But educational intervention is required to protect our children for developing behavioural problems.

BhagyaLakshmi (2012) identified in her study conducted in south India that 19 percent parents had adequate knowledge, 47 percent had moderate knowledge and 34 percent had inadequate knowledge on

behavioural problems of teenage boys. She further suggested that adequate knowledge to parents will helps to reduce the behavioural problems among teenage boys. Our study not only assessed the knowledge of parents of preschool children but also provided educational intervention and established a positive impact.

A similar study by Shubhangi S. Dumbray (2014) revealed that in pre-test, majority i.e. 86.7 percent of the subjects had poor knowledge and 13.3 percent of them had average knowledge which improved after a structured planned teaching with majority i.e. 71.7 percent having good knowledge and 28.3 percent having average knowledge in post test. Our study also reflects similar findings emphasising the need for improving parental education services.

The study identified significant knowledge improvement in areas like temper tantrum, enuresis, thumb sucking and pica etc. but less improvement was seen in more complex problems such as school phobia and autism. These special areas need to be emphasised for early detection and management. This was supported by a study done by Hartley, Sigan L etal (2013) to examine parental attributions for child behaviour problems in 63 married couples of children and adolescents (aged 3-20 years) with autism spectrum disorders (ASDs) and identified that parents tended to attribute the behavior problems of their child/adolescent with an ASD.

 

Limitations

The study is not a multi-centric study and it is time-bound in nature. However, the present study strongly suggests that educational intervention is necessary for parents to improve parenting style and detect behavioural deviations in their children.

 

Recommendations

·         A similar study can be undertaken in a Govt. hospital or community.

·         A similar study can be done on larger sample size.

·      A study can be done to assess the effectiveness of other teaching strategies like video-assisted teaching on knowledge of parents on behavioural disorders among pre-school children.

·         Information booklet can be developed on behavioural disorder among children.

 

Conclusion

This study proves the urgent need of educating parents regarding behavioural disorders to reduce the burden of behavioural problems in children. Structured education is required in community setting, outpatient department to improve the mental health in children

 

References

1.            Prakash Jyoti, Mitra AK, Prabhu HRA. Child and behaviour: A school based study. Delhi Psychiatry Journal 2008; 11(1): 79-82.

2.    Malhotra S. Mental Health in Childhood and Adolescence: Global Agenda. In: Mental Disorders in Children and Ado-lescents – Need and Strategies for Intervention. N. Delhi; CBS Publishers and Distributions: 2005

3.     Malhortra S. Needs and Priorities. In: Child Mental Health in India. MacMillan India Limited: 1992

4.    Gupta I, Verma M, Gupta V. Prevalence of behavioural prob-lems in school going children. Indian Journal of Pediatrics 2001; 68(4):323-26 

5.    Pathak Rambha, Sharma RC, Parvan UC et al. Behavioural and emotional problems in school going adolescents. Australas Med J 2011; 4(1): 15-21

6.    Sharma Pawan, Kaur Jagjeet. A study to assess the ef-fect of structured teaching programme on knowledge re-garding behavioral problems in children among moth-ers. International Journal of Nursing Care 2014; 2(2): 14-19.

7.     Riem Karl F, Adams Roderick E. Assessment of mothers’ concerns about infants, toddlers, and preschoolers on behavioural problems. Infant Mental Health Journal 2009; (1): 56-66 

8.  Ellen C Perrin, R Christopher Sheldrick, Jannette M McMenamy, Brandi S. Henson, Alice S Carter. Improving parenting skills for families of young children in pediatric settings. A randomized clinical trial. JAMA Pediatrics 2014; January; 168 )

9.     Bele SD, Bodhare TN, Valsangkar S, Saraf A. An epidemio-logical study of emotional and behavioral disorders among children in an urban slum. Psychol Health Med 2013; 18(2): 223-32.

10. Bhagya Lakshmi M. Assessment of the knowledge of par-ents on behavioral problems of teenage boys. IJPRBS 2012; 1(4): 215-21

11. Shubhangi S Dumbray, Shubhada Kale, Arpana Jadhav & Neetu PV. Effectiveness of structured teaching programme on knowledge of mothers regarding behavioural problems in children (1-12 years). Asian Journal of Multidisciplinary Studies 2014; November; 2(11)

 

12. Hartley Sigan L, Schaidle Emily M, Burnson Cynthia F. Pa-rental attributions for the behavior problems of children and adolescents with autism spectrum disorders. Journal of Developmental & Behavioral Pediatrics 2013 November / December; 34 (9): 651-60.

 

Authors: Panchali Datta (Pal)1, A Kundu2

(The authors are: 1. PhD Scholar (WBUHS) & Associate Professor, Peerless College of Nursing, Kolkata, and 2. Guest Faculty, University of Calcutta, Kolkata).)

 

Source: TNAI-Journal