1. Background
First epidemiological studies on psychiatry problems in children and adolescents were performed in the mid-60s in England (1). Since then, most advanced countries have conducted similar studies to find out the prevalence and risk factors for psychiatric disorders in children and adolescents (2-4). There are many factors such as the social, cultural, political, and economic status of the family, genetics, lifestyle, etc. which may affect the physical and mental health of children and adolescents (5). A recent review of the degree of behavioral, mental, or emotional disorders among children in developing countries reported that the prevalence of psychiatric disorders in children and adolescents living in large cities in these countries is 10% - 20%, equal to or somewhat higher than the rates of developed countries (6). Other studies conducted in India, Colombia, Philippines, and Sudan surveyed the population attending in primary health service centers and reported a prevalence of 12% - 29% for childhood psychiatric disorders (5), and prevalence of 3% - 11% for psychiatric disorders in children and adolescents in Ethiopia (7), Sudan (8) and India (9), Beijing, (10) and Hong Kong (11). These studies also considered various emotional and behavioral disorders, developmental delay, psychosis, epilepsy, or behavioral disorders, and mental retardation. Also, some studies reported prevalence as high as 70% for these disorders (12).
Kohgiloyeh and Boyer-Ahmad province is located in the southwest of Iran, with a population of about 700000, and it is estimated that children and adolescents compose at least 10% - 15% of its population (13). Many of these children and adolescents may suffer from behavioral and emotional disorders and may require more health care services and facilities. Unfortunately, there is no accurate statistic on the prevalence of childhood and adolescent psychiatric disorders in the subjected province, and the available information are limited to regional studies (13-18). Also, as mentioned above, one of the important factors which may affect children’s and adolescents’ mental health is the lifestyle and many studies that highlighted its influential effect in this kind of disorder (19-22). So, a lot of studies are needed to address this issue, to examine different aspects of lifestyle, and to investigate their impacts on psychiatric disorders of children and adolescents in this area.
2. Objectives
The current study aimed to epidemiologically assess the effects of lifestyle on psychiatric disorders among children and adolescents living in Kohgiloyeh and Boyer-Ahmad, considering different lifestyle variables. The results of such a study can provide useful and valuable information to the mental health authorities and decision-makers to provide proper planning and appropriate distribution of facilities, to take the basic steps to prevent and treat these disorders in the country.
3. Methods
3.1. Study Design and Sampling
The current research is an example of a well-designed provincial study in Iran. Since few studies have assessed the impact of lifestyle-related factors on childhood and adolescent psychiatric disorders, this cross-sectional study was conducted between 2016 - 2017 in Kohgiloyeh and Boyer-Ahmad Province (Iran) to fill the gap. Participants were randomly selected using the multi-stage stratified cluster random sampling method among the 6 - 18-year-old population living in urban and rural areas of the province. 170 clusters of houses were randomly selected based on postal codes in both rural and urban areas, and in each cluster, 6 children and adolescents were randomly selected within equal blocks of gender and age groups (6 - 9 years, 10 - 14 years, and 15 - 18 years). Then, about 1000 children and adolescents were selected. The research team tried to address the potential sources of bias in the design of the study, from the very beginning to the end. At the design stage, it was tried to decrease the selection bias by using multistage cluster sampling and stratified random sampling methods. Also, it was tried to distribute the main confounders, such as age and gender, evenly in each cluster. Individuals who decided to not participate in the study, and questionnaires that contained confused answers were excluded. The demographic data such as age, gender, location, race, and religion of all participants are presented in
Table 1.Demographic Information of the Participants in This Study
| Variables an classifications | Total | |
|---|---|---|
| Frequency | Percent | |
| Gender | ||
| Boy (male) | 496 | 49.6 |
| Girl (Female) | 505 | 50.5 |
| Unknown | - | - |
| Age group | ||
| 6-9 | 321 | 32.1 |
| 10-14 | 386 | 38.6 |
| 15-18 | 294 | 29.4 |
| No response | - | - |
| Location | ||
| City | 520 | 52.0 |
| Village | 481 | 48.1 |
| No response | - | - |
| Race or nation | ||
| Fars | 7 | 0.7 |
| Turk | 8 | 0.8 |
| Kurd | 1 | 0.1 |
| Lor | 975 | 97.5 |
| Others | 4 | 0.4 |
| No response | 6 | 0.6 |
| Religion | ||
| Shia | 993 | 99.8 |
| Sunnis | 2 | 0.2 |
| Other religions | - | - |
| No response | 6 | 0.6 |
| Whole sample | 1001 | 100 |
3.2. Kiddie-Sads-Present and Lifetime Questionnaire
A complete, reliable Persian version of Kiddie-Sads-Present and Lifetime (K-SADS-PL) was instructed and adopted of its original one by participating clinical psychologists (23). The K-SADS-PL questionnaire is a semi-structured interview designed to evaluate the current episodes of mental illness in children and adolescents (aged 6 - 18) based on DSM (Diagnostic and Statistical Manual of Mental Disorders)-III-R and DSM-IV. K-SADS-PL includes three main parts: introductory interview (demographic, health, and other background information), screen interview (82 symptoms related to 20 diagnostic areas), and five diagnostic supplements: (1) affective disorders (major depression, dysthymia, mania, hypomania); (2) psychotic disorders; (3) anxiety disorders (social phobia, agoraphobia, specific phobia, obsessive-compulsive disorder, separation anxiety disorder, generalized anxiety disorder, panic disorder, posttraumatic stress disorder); (4) disruptive behavioral disorders (attention deficit hyperactivity disorder/ADHD, conduct disorder, oppositional defiant disorder); and (5) substance abuse, tic disorders, eating disorders, and elimination disorders (enuresis, encopresis). (24). This semi-structured interview contains multiple questions with a space for accountability and has been developed to specify more signs. This diagnostic tool reveals information about the current diagnosis and signs of the past years. Also, this questionnaire was completed by parents following the interview with the children. It worth noting that the K-SADS-PL questionnaire requires filling in the following sections: (1) a prior non-structured interview; (2) a diagnostic screening interview; (3) a supplementary checklist; (4) a diagnostic attachment; (5) a checklist of diagnostic summaries throughout life; and (6) the overall assessment of the child (Children's Global Assessment Scale [C-GAS]).
3.3. Lifestyle Questionnaire (LSQ)
The lifestyle questionnaire is used to measure physical health, exercise and fitness, control weight and nutrition, disease prevention, psychological health, spiritual well-being, social health, drug avoidance, prevention of accidents, and environmental health. We used a well-designed lifestyle questionnaire, which was developed by Lali and colleagues (25) with a reliability coefficient of 0.91 and a correlation coefficient of 0.58. Also, the Cronbach's alpha of the questionnaire was proven to be 0.087 for different scales. Based on the results obtained from the analysis of the factors using the principal components analysis method, 10 factors with a higher value than one were extracted, which all altogether were determining 22.46% of the total variance of the whole lifestyle. These results confirmed the validity of the lifestyle questionnaire as a multidimensional tool for assessing and measuring lifestyle.
3.4. Ethics
All participants were contributed voluntarily. Written informed consent was taken from each participant or parent of adolescents less than 16 years. The Ministerial Committee for Medical and Health Research Ethics approved the protocol of the present study (ethics code: IR.NIMAD.REC.1395.001).
3.5. Analysis
Fisher and Chi-square tests were used to statistically analyze the data. Analyses were performed using SPSS version 16.0, and a P values < 0.05 was assumed as statistically significant.
4. Results
4.1. The Association Between Lifestyle and Psychiatric Disorders in Children and Adolescents
According to the results, it is obvious that the variables related to lifestyle could significantly affect the children and adolescent psychiatric disorders. The statistical analysis showed no significant correlation between sport activities and well-being with psychiatric disorders in the subjected group (P = 0.057). Also, 9 (out of 10) variables related to the lifestyle were significantly correlated with the prevalence and incidence of psychiatric disorders of children and adolescents. The exact P values for each factors were (physical health, P = 0.007), (sport activities and well-being, P = 0.057), (weight control and nutrition, P = 0.001), (prevention of diseases, P = 0.04), (mental health-cognitive, P = 0.05 ), (spiritual health, P = 0.008), (social health, P = 0.05), (drug avoidance, P = 0.001), (accident prevention, P = 0.02), and (environmental health, P = 0.001). Detailed data are presented in Table 2. Ultimately, by putting all results together, it became obvious that lifestyle has a significant role in children and adolescent disorders. Also, it has to be mentioned that the most populated subgroups in our classification were ‘normal lifestyle’ and ‘below normal lifestyle’ groups (Table 2 and Figure 1). The cut points to diagnose the disorder were performed according to the KSADS instruction for a lifetime and current diagnoses, which were the cutting points of the criteria mentioned in DSM by APA.
Table 2.Relationship Between Family Lifestyle and Psychiatric Disorder in Children and Adolescents Using Chi-Square and Fisher Tests
| Disorders | Lifestyle | P Value | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Bad | Below the Standard Limit | Normal | Good | ||||||
| Frequency | Percent | Frequency | Percent | Frequency | Percent | Frequency | Percent | ||
| Physical health | 0.007 | ||||||||
| No psychiatric disorder | 37 | 3.7 | 402 | 40.2 | 325 | 32.5 | 32 | 3.2 | |
| With psychiatric disorders | 2 | 0.2 | 93 | 9.3 | 93 | 9.3 | 16 | 1.6 | |
| Sports and well-being | 0.057 | ||||||||
| No psychiatric disorder | 6 | 0.6 | 437 | 43.7 | 323 | 32.3 | 30 | 3 | |
| With psychiatric disorders | 2 | 0.2 | 91 | 9.1 | 99 | 9.9 | 12 | 1.2 | |
| Weight control and nutrition | 0.001 | ||||||||
| No psychiatric disorder | 43 | 4.3 | 202 | 20.2 | 502 | 50.2 | 49 | 4.9 | |
| With psychiatric disorders | 6 | 0.6 | 80 | 8 | 99 | 9.9 | 19 | 1.9 | |
| Prevention of diseases | 0.04 | ||||||||
| No psychiatric disorder | - | - | 201 | 20.1 | 487 | 48.7 | 108 | 10.8 | |
| With psychiatric disorders | - | - | 49 | 4.9 | 113 | 11.3 | 42 | 4.2 | |
| Mental health-cognitive | 0.05 | ||||||||
| No psychiatric disorder | 0 | 0 | 223 | 22.3 | 445 | 44.5 | 128 | 12.8 | |
| With psychiatric disorders | 1 | 0.1 | 54 | 5.4 | 104 | 10.4 | 45 | 4.5 | |
| Spiritual health | 0.008 | ||||||||
| No psychiatric disorder | 1 | 0.1 | 235 | 23.5 | 351 | 35.1 | 209 | 20.9 | |
| With psychiatric disorders | 0 | 0 | 56 | 5.6 | 71 | 7.1 | 77 | 7.7 | |
| Social health | 0.005 | ||||||||
| No psychiatric disorder | - | - | 227 | 22.7 | 416 | 41.6 | 153 | 15.3 | |
| With psychiatric disorders | - | - | 55 | 5.5 | 89 | 8.9 | 60 | 6 | |
| Drug avoidance | 0.001 | ||||||||
| No psychiatric disorder | 8 | 0.8 | 233 | 23.3 | 334 | 33.4 | 221 | 22.1 | |
| With psychiatric disorders | 7 | 0.7 | 54 | 5.4 | 57 | 5.7 | 86 | 8.6 | |
| Accident prevention | 0.02 | ||||||||
| No psychiatric disorder | 1 | 0.1 | 262 | 26.2 | 365 | 36.5 | 168 | 16.8 | |
| With psychiatric disorders | 0 | 0 | 61 | 6.1 | 80 | 8 | 63 | 6.3 | |
| Environmental health | 0.001 | ||||||||
| No psychiatric disorder | 1 | 0.1 | 244 | 24.4 | 433 | 43.3 | 118 | 11.8 | |
| With psychiatric disorders | 0 | 0 | 54 | 5.4 | 87 | 8.7 | 63 | 6.3 | |
| The whole lifestyle | 0.005 | ||||||||
| No psychiatric disorder | - | - | 228 | 22.8 | 532 | 53.3 | 35 | 3.5 | |
| With psychiatric disorders | - | - | 55 | 5.5 | 128 | 12.8 | 21 | 2.1 | |
Figure 1.
Average score of lifestyle dimensions of families
4.2. Descriptive Information of the Variable Related to Lifestyle and Their Association with Mental Disorders in Children and Adolescents
According to Table 3 and Figure 2, it is clear that all investigated variables may individually or partially be associated with psychiatric disorders. However, it may be concluded that, if a number of these variables come together in a bad manner, they can synergistically affect children and adolescent mental health and cause mental disorders.
Table 3.Descriptive Information of the Components of the Lifestyle of Families in Terms of Disorder Status (Total Psychiatry) in Provincial Sample
| Variable/Grouping | Mean | SD | P Value |
|---|---|---|---|
| Physical health | 0.007 | ||
| No disorder | 12.41 | 3.83 | |
| With disorder | 13.39 | 4.10 | |
| Sports and well-being | 0.003 | ||
| No disorder | 10.53 | 3.48 | |
| With disorder | 11.26 | 3.71 | |
| Weight control and nutrition | 0.125 | ||
| No disorder | 11.70 | 3.86 | |
| With disorder | 11.53 | 4.07 | |
| Prevention of diseases | 0.006 | ||
| No disorder | 13.10 | 3.54 | |
| With disorder | 13.94 | 4.08 | |
| Mental health-cognitive | 0.115 | ||
| No disorder | 13.10 | 3.95 | |
| With disorder | 13.61 | 4.21 | |
| Spiritual health | 0.028 | ||
| No disorder | 11.88 | 3.64 | |
| With disorder | 12.57 | 3.85 | |
| Social health | 0.009 | ||
| No disorder | 13.13 | 3.91 | |
| With disorder | 14.09 | 4.43 | |
| Drug avoidance | 0.038 | ||
| No disorder | 11.91 | 3.56 | |
| With disorder | 12.34 | 4.20 | |
| Accident prevention | 0.005 | ||
| No disorder | 15.15 | 4.58 | |
| With disorder | 16.35 | 5.09 | |
| Environmental health | 0.001 | ||
| No disorder | 13.09 | 3.98 | |
| With disorder | 14.29 | 4.37 |
Figure 2.
Comparative diagram of family lifestyle and lacking or disruptive psychiatric disorders in children and adolescents
5. Discussion
Most mental health disorders emerge during adolescence, and it has been revealed that about 20% of the world’s children and adolescents suffer from mental disorders or problems (26). Studies have reported various prevalence of psychiatric disorders in children and adolescents worldwide (15, 27). In Iran, few studies have reported a heterogeneous frequency of these psychiatric disorders, ranging from 10% to 30% in different areas (14, 15).
Many studies have reported that psychiatric disorders are associated with different factors such as the social, political, economic status of family, poor lifestyle, and adverse outcomes (5), but few studies have directly compared these characteristics in children and adolescent with psychiatric disorders to those in the general population. This cross-sectional study aimed to investigate the epidemiological associations of lifestyle variables of children and adolescent concerning psychiatric disorders and to assess physical health, physical activity and well-being, weight control and nutrition, prevention of diseases, mental health-cognitive, spiritual health, social health, drug avoidance, prevention of accidents and environmental health as important factors that affect the prevalence of psychiatric disorders in Kohgiloyeh and Boyer-Ahmad province in Iran. Also, we assessed the frequency of these 10 lifestyle-related variables in children and adolescents with psychiatric disorders compared to those without psychiatric disorders. We assumed that these 10 lifestyle-related variables can both influence and be influenced by mental health problems. Besides, by gaining an in-depth knowledge of their association with mental disorders in children and adolescents, they can be early detected, modified, prevented, and (finally) better treated.
To investigated the association between lifestyle-related variables and psychiatric disorders among children and adolescents, we divided the participants into three groups based on age, gender, location, race, and nationality along with religion (Table 1). We assessed the coherence of 10 different lifestyle-related variables with children and adolescent psychiatric disorders (Table 2). Interestingly, the results showed that 9 (out of 10) lifestyle-related variables were significantly correlated with psychiatric disorders in children and adolescents. However, the association of sports and well-being was not statistically significant with this kind of disorder, but the results showed that this factor was highly associated with psychiatric disorders in children and adolescents. It seems to be in line with the results of other studies that reported children or adolescents who suffer from mental disorders have less activity, which may exacerbate their problems (28). Few studies have shown that lifestyle significantly affects adolescents with obsessive-compulsive disorder (19, 29). Also, another study has shown that the association between lifestyle and children’s obsessive-compulsive disorder is reciprocal (19). Based on the results, most of the participants were in the ‘Normal Lifestyle group’ (Figure 1), and we could conclude that in this group, lifestyle has more significant importance in the incidence of psychiatric disorders. Also, according to the findings, each of 10 studied variables had an individual and relative effect on children and adolescent psychiatric disorders (Figure 2), and probably when a bunch of these variables simultaneously come together in a bad manner, they may cause psychiatric disorder or even exacerbate the situation. We found that the 10 lifestyle-related variables are directly associate with the children and adolescent psychiatric disorders and should be considered in future studies.
5.1. Conclusion
According to the results, different lifestyle-related variables were significantly related to children’s and adolescent’s psychiatric disorders. However, this study has some limitations which should be considered in future studies to put a spotlight on other factors that may be associated with lifestyle and psychiatric disorders.
