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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 38  |  Issue : 3  |  Page : 287-292

Design and delivery of a need-based mental health promotion program for shelter-home adolescents


Department of Psychology, The Maharaja Sayajirao University of Baroda, Vadodara, Gujarat, India

Date of Submission21-Jun-2020
Date of Decision28-Dec-2020
Date of Acceptance03-Jan-2021
Date of Web Publication17-Feb-2022

Correspondence Address:
Ms. Parisha Jijina
Department of Psychology, Faculty of Education and Psychology, The Maharaja Sayajirao University of Baroda, Lokmanya Tilak Road, Vadodara - 390 002, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_170_20

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  Abstract 


Background: India has a large population of adolescents living in shelter homes. However, there is a scarcity of empirical literature on mental health promotion programs developed to suit their unique needs. Aim: The aim of this research was to design a need-based mental health promotion program for runaway and homeless adolescents living in a shelter home in Vadodara, India. Methods: To gain a holistic understanding into their mental health issues and felt needs, semi-structured interviews were conducted with these adolescents along with key stakeholders such as their care takers, counselors, and teachers. The key needs identified pertained to issues related to academics, reduction of substance abuse, anger management, and emotional regulation. On the basis of identified needs, a training program of 13 sessions was developed using indigenous technique of Yoga and techniques from literature of subjective well-being and life skills. Total sample included 35 male adolescents from 12 to 18 years of age. Participants were randomly divided into experimental group (n = 19) and control group (n = 16). Pre- and post-intervention assessment was performed using Academic Stress Scale, State Trait Anxiety Scale, Children and Adolescent Mindfulness Measure, and Children Depression Inventory. Results: The results indicated that trait anxiety was significantly reduced, and there was a significant increase in mindfulness in the intervention group. However, there was no significant improvement in depression and academic stress. Discussion: The observations from this study are detailed to sensitize researchers toward the design and delivery of mental health promotion programs for institutionalized youth.

Keywords: Adolescent well-being, institutionalized adolescents, shelter-home


How to cite this article:
Soni J, Jijina P. Design and delivery of a need-based mental health promotion program for shelter-home adolescents. Indian J Soc Psychiatry 2022;38:287-92

How to cite this URL:
Soni J, Jijina P. Design and delivery of a need-based mental health promotion program for shelter-home adolescents. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 Oct 3];38:287-92. Available from: https://www.indjsp.org/text.asp?2022/38/3/287/337868




  Introduction Top


Adolescence is a pivotal time to help teenagers navigate risks and vulnerabilities, and investing in their well-being is fundamental to discontinuing the intergenerational transmission of poverty and discrimination.[1] A substantial number of children and adolescents in India are out of the protective net of family and get institutionalized as abandoned, runaways, or children in conflict with the law. These children and adolescents have greater exposure to adverse experiences such as abandonment, violence,[2] and are often at risk for physical and sexual abuse.[3] Various organizations in India provide institutional care to the children who are orphans and even children with a single surviving parent who is unable to provide for the child due to poverty.[4]

In a recent report, 2018, by the Ministry of Child and Women Development, Government of India, the number of Children in Need of Care and Protection has been found to be 370,227[5] and include children who are orphan, abandoned, surrendered, sexually abused, victim of child pornography, trafficked, and victims of child marriage. Many studies from India report the psychological problems of children in institutionalized care. The prevalence of behavioral problems was found to be at a high rate of 56% among institutionalized street children in Tiruchirappalli;[6] among orphan adolescents, 7.5% were at risk for attention deficit hyperactivity disorder in Mangalore;[7] and 47.06% of the orphans were in the clinical range category of socioemotional behavior problems in Dharwad.[8] A study in Tamil Nadu reported 35% prevalence of depression among institutionalized children.[9] Subclinical mild depression was found in 19.3% of institutionalized children in Andhra Pradesh.[10] Substance abuse has also been indicated in institutionalized children in India with respect to nicotine, alcohol, and misuse of inhalants.[11]

Very often, the materialistic aspect of care food, medical care, and shelter is regarded as more significant than the psychological needs of the children.[12] There is a scarcity of empirical literature on mental health promotion programs developed to suit the unique needs of children and adolescents in shelter homes. Thus, the major objectives of the study are as follows:

  1. To understand the psychosocial needs and issues of the adolescents living in shelter home from the various stakeholders as it has implications in developing intervention components that have a high degree of receptivity and perceived utility
  2. Based on the above, to design and deliver a mental health promotion program for shelter home adolescents amalgamating techniques from life skills and well-being literature and including indigenous techniques such as yoga and pranayama.



  Methods Top


The study setting

The study was conducted in a Shelter Home for the Young at Risk located in Vadodara, Gujarat. The shelter home was founded on May 24, 2001, with the objective to provide shelter to the male children and youth living on the railway platforms and on the streets.

Sample for need assessment

Total sample size for need assessment was ten respondents, which includes five male adolescents living in the shelter home since the last 1 year. Five stakeholders who were in regular contact with the adolescents were interviewed which included the father of the shelter home, two social workers, the in-house teacher of the adolescents, and the manager of the shelter home.

Sample for Intervention

The total sample for intervention consisted of 35 male adolescents living in shelter home in the age group of 12–18 years. Inclusion criterion for selecting the sample for intervention was the duration of staying in current shelter home for at least 1 year. The adolescents were randomly divided into experimental and control groups. The experimental group consisted of 19 adolescent boys whose average age was 14.52 years. Total sample size of control group was 16 adolescent boys whose average age was 14.56 years.

Measures

State trait anxiety inventory for children

It was developed by Spielberger. The inventory consists of twenty statements and comprises two scales which is state scale measuring situation-specific anxiety and trait anxiety.[13] For the current study, only trait anxiety scale was utilized.

Child and adolescent mindfulness measure

Greco et al. developed this scale. It consists of ten statements to be rated on a 5-point Likert scale.[14]

Children's Depression Inventory 2-Short Version

Kovacs (2014) constructed this inventory of 12 items assessing depressive symptoms to be rated on a three-point Likert scale.[15]

Problem questionnaire

This scale is developed by Seiffge-Krenke and comprises seven stress domains.[16] For this study, only the items from school domain have been utilized.

Ethical considerations and procedure

This study was presented before and approved by the Departmental Research Committee. Consent was obtained from the administrator of the shelter home for conducting the study, and assent of all the participants of the study was undertaken. For Phase 1, need assessment was undertaken, and based on the findings from the interviews, key areas were identified, and an intervention program was designed. The intervention was sent to two experts who had expertise in both yoga and psychology, their feedback was incorporated, and necessary changes were made.

For Phase 2, the adolescents were randomly assigned to experimental and control group. Assessment was conducted with the above tools. During each session, behavioral observation was done, and notes were taken. Feedback was also undertaken of the intervention group.

Design of the mental health promotion module

Target areas of the intervention, in line with the qualitative findings were:

  • Focus on concentration, memory, and study habits
  • Inculcating empathy and dealing with bullying
  • Relationship skills
  • Assertiveness training and anger management
  • Relaxation training
  • Understanding common cognitive distortions
  • Identifying one's strengths and increasing self-esteem
  • Dealing with peer pressure and substance abuse psychoeducation.


The intervention module was designed amalgamating techniques from Yoga and techniques from the psychological literature. Yoga as an indigenous technique has been found effective in reducing depressive symptoms, anxiety, and aggression in children in orphanages.[17] Furthermore, indigenous breathing techniques such as Anulom vilom were inculcated in the module. Each session lasted for 1.5 h and consisted of two parts. In the first part, the children were taught yoga for 30 min and the remaining 60 min were for the psychological intervention.

The first author is a certified yoga teacher and conducted the intervention sessions. The techniques from psychological literature were taken from authentic sources such as the manuals published from National Institute of Mental Health and Neurological Sciences by Vrunda[18] and Bharat and Kumar[19] on adolescents' life skills and mental health promotion and Stallard[20] cognitive behavioral therapy (CBT) workbook for children.

Data analysis

Thematic analysis by Braun and Clarke[21] was utilized to analyze the interview data. Paired Sample t-test analysis using SPSS (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp) was used to calculate the significance of difference between mean scores in the pre- and post-training conditions. Feedback received post the intervention has also been incorporated in the findings.


  Findings: Needs assessment Top


Based on the analyses of the interviews, five major themes emerged as shown in [Figure 1] below. The themes and subthemes are further elaborated below.
Figure 1: Themes and subthemes related to psychosocial needs of adolescents in shelter home

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Family of origin issues

The findings from the interviews revealed a host of family of origin issues as seen in the subthemes below.

Parental issues

There were children in the shelter home who has single parents, but they cannot afford raising children. There are adolescents whose both parents have died. There is a positive history of mental illness in few parents.

Traumatic events

These children were found living in bus station, railway station, slum areas, and street in dire conditions. A case was mentioned, wherein the child's father had passed away, and the uncle used to sexually abuse the mother in front of him. Another case was reported by social worker, wherein the child and mother were sleeping on the footpath and a car rammed into the mother killing her instantly.

Behavioral issues

The findings from the interviews revealed a host of behavioral problems.

Bullying

All the adolescent participants shared their experience of bullying, wherein others tease them, use swear words, and use offensive language.

Truancy and theft

Truancy or running away from the shelter home was reported by the stakeholders. As one elaborated.

These children who don't have parents, when they face a problem or do not like anything, be it at home, school, or railway station, they simply run away from that…

Four of the stakeholders reported that the children have the habit of stealing. The children were found to steal other children's belongings, go through the lockers of others, and at times even steal the belongings of the shelter home.

Emotional problems

Anger issues

All the adolescents reported having frequent and uncontrollable anger outbursts. The reasons perceived by them for anger outburst were lack of support from others, feeling of loneliness, and on being teased by others.

Lack of attachment toward others

The stakeholders reported that the children and adolescents in the shelter home are not able to form secure attachments with others. As one interviewee elaborated,

The children believe that people are not going to stay in their life, so what is the point of getting emotional for them.

Perceived absence of affection

During the interviews, the adolescents reported that they do not have anybody close to share their concerns with. In another excerpt, it was mentioned that:

Kabhi kabhi mujhe mere mummy-pappa ki yaad aati hai to kuch karne ka mann nahi hota, me pada rehta hu.(When I miss my parents, I don't feel like doing anything, I just keep lying down).

The stakeholders reported that, due to their background, the younger children crave for love and attention from others.

Low self-esteem

Stakeholders and adolescents both reported issues of low self-esteem. An adolescent reported that “Mein mere liye kuch bhi sochta hu uska ulta hi hota hai” (Whatever I plan for myself, it never works out). One of the stakeholders reported.

Poor performance in school or tests, makes the adolescents feel they cannot achieve.

Academic difficulties

Gaining admission in school at later age

This subtheme explains the difficulty faced by children who gained admission in school at later age in higher grades. An employee described this problem in detail which is as follows:

Children have skipped lower grades because they were old to join the lower grades due to which they face difficulties in understanding the basic concepts.

Lack of interest in education

The adolescents reported that most of the times they do not understand what is taught at school, which leads to boredom and so they do not like to study. The stakeholders perceived that the children were not much interested in educating themselves as they believed that even without an education they survived on the streets or railway station, through various means such as begging, doing odd jobs, and hence they may feel less motivated to study.

Concentration difficulties

Nine out of ten interviewees reported concentration difficulties in academics. An adolescent reported that “padhai karta hu to bohot saare vichar aate hai” (When I am studying, I am having too many thoughts in my mind).

Substance abuse

Use of tobacco and inhalants

In the shelter home tobacco is the most consumed substance in the form of cigarettes or sopari (betel nuts). Stakeholders also reported the use of inhalants by adolescents which is extremely addictive and have a high relapse rate. One of the stakeholders reported a case, wherein ten of the boys were sent on a fully funded treatment to a deaddiction center in Lonavala. He reported that, within 5 weeks, the boys escaped from the center and came back to Baroda. Thus, adherence to treatment for drug abuse was reported as low.

Based on the above findings from the interviews of the psychosocial issues of the adolescents, a mental health promotion module consisting of 13 sessions was designed.

Assessment of the intervention

Normality assumption was checked, and subsequently, paired t-test was used to calculate the significance difference between mean scores in the pre- and posttraining conditions as shown in [Table 1]. Adolescents in the control group would at times attend the intervention sessions in spite of the interventionist's multiple requests to not attend the sessions. Hence, the control group was considered void and was not included in the post-intervention assessment.
Table 1: Pre-post intervention assessment

Click here to view


As seen in [Table 1], the results indicate that trait anxiety was significantly reduced, and there was significant increase in mindfulness in the intervention group. However, there was no significant improvement in depression and academic stress. The observations from this study are further detailed below to sensitize researchers toward the design and delivery of mental health promotion programs for institutionalized youth.

Feedback taken from the adolescents

At the end of the intervention, feedback was taken from the adolescents (n = 19) regarding the utility of the program as shown in [Table 2].
Table 2: Feedback obtained from participants

Click here to view


Thus, findings from [Table 2] indicate that the promotion program has a high degree of perceived utility in the target population. The behavioral observations of the interventionist and the difficulties faced by her are further detailed in the discussion.


  Discussion Top


The interviews indicated that the children who are living in shelter home have faced traumatic history in family of origin. They have many behavioral issues such as indulgence in theft, truancy, and bullying. Past studies have indicated that bullying increases the risk mental health problems and reduces self-esteem and self-efficacy.[22] Studies have indicated that being abandoned and loss of parental care can cause multiple psychological problems such as stress, anxiety, depression, lack of self-confidence, helplessness, and hopelessness.[23],[24]

The findings from the interviews indicated that there is evidence of substance abuse in adolescents currently living in shelter home. As the rapport developed, in the later sessions, it was mentioned by a few of the adolescents that they consume substances such as marijuana and tobacco. Research on street children in India suggests the use of correction fluid, petrol, and glues which are cheap and easily available.[25],[26]

Based on the identification of above psychosocial needs, an intervention program was undertaken using yoga as an indigenous method and subjective well-being and life skills. Analysis of the posttraining assessment reveals that there is a significant reduction in anxiety and an increase in mindfulness. However, there was no significant effect on the academic stress and depressive symptoms of the shelter home adolescents. Since these adolescents have faced multiple and severe traumatic experiences and life situations, individualized therapy or counseling may be better equipped for the depressive symptoms which are rooted in severe traumatic experiences. Furthermore, individualized coaching may be better suited for management of academic difficulties as these children have very weak basic concepts and gain late admission to school.

The mental health promotion program designed in this study integrated techniques from both yoga and psychological literature. Integration of indigenous methods such as yoga along with psychological techniques may have increased utility and acceptability in the Indian context. Research study in the Indian context revealed that 1-h daily yoga practice, potentially reduced anxiety and improves self-esteem of orphanage adolescents.[17]

The interventionist observations are noted below which can aid researchers planning to conduct similar researchers in this specific population.

It was observed that most of the adolescents found it very difficult to identify their strengths. Many participants found it very difficult to write good things about themselves and good things about the future. Researchers may note to positively reinforce the child wherever possible and to work on the children's self-esteem.

During group discussion of vignettes for continuing education, it was revealed that some adolescents believe that if there is too much of pressure you cannot handle then either run away from that place or should give up their lives. Most common cognitive distortions in adolescents were over generalization and focusing only on the negative. Hence, future researchers may consider adaptive strategies for the same. The most difficult sessions for the researcher were the ones on the very basic CBT as the adolescents found it hard to grasp the concepts. It was attempted to make it as simple as possible, but it was challenging for the researcher. Furthermore, it was very difficult for the researcher to restrict the children from the control group to not come for the sessions.

The sessions which the adolescents participated most enthusiastically according to the researcher's observations were the ones on yoga. Adolescents were usually little fidgety, but in the sessions, in which they practiced breathing techniques, it was observed that they were calmer and less restless. This suggests that psychological training programs can be integrated successfully with indigenous mind–body techniques such as yoga and can be explored by future studies.

It is hoped that the observations from this study may be utilized to sensitize researchers toward the design and delivery of mental health promotion programs for institutionalized children and adolescents in the Indian context.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
United Nations Children's Fund (UNICEF). Adolescence an Opportunity. Available from: https://www.unicef.org/sowc2011/pdfs/SOWC2011MainReport_EN_02092011.pdf. [Last accessed on 2020 Apr 20].  Back to cited text no. 1
    
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Sinha A, Lombe M, Saltzman LY, Whetten K, Whetten R, Positive Outcomes for Orphans Research Team. Exploring factors associated with educational outcomes for orphan and abandoned children in India. Glob Soc Welf 2016;3:23-32.  Back to cited text no. 3
    
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Padmaja G, Sushma B, Agarwal S. Psychosocial problems and wellbeing in institutionalized and non-institutionalized children. J Humanit Soc Sci 2014;19:59-64.  Back to cited text no. 4
    
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Ministry of Child & Women Development, Government of India. The Report of the Committee for Analysing Data of Mapping & Review Exercise of Child Care Institutions under the JJ Act. Available from: https://wcd.nic.in/sites/default/files/CIF%20Report%201_0_0.pdf. [Last acessed on 2020 Apr 2020].  Back to cited text no. 5
    
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Kovacs M. Children's Depression Inventory (CDI and CDI 2). Hoboken, NJ, USA: John Wiley & Sons, Inc., (2014), Available from 10.1002/9781118625392.wbecp419.  Back to cited text no. 15
    
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Tejvani R, Metri KG, Agrawal J, Nagendra HR. Effect of yoga on anxiety, depression and self-esteem in orphanage residents: A pilot study. Ayu 2016;37:22-5.  Back to cited text no. 17
[PUBMED]  [Full text]  
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Vrunda MN. Promotion of Mental Health and Well-Being of Adolescents in Schools. Bengaluru: National Institute of Mental Health and Neuro Sciences; 2014.  Back to cited text no. 18
    
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Bharath S, Kumar KV. Empowering Adolescents Using Life Skills for Psychosocial Competence- Level 3, Life Skills Educator's Activity Manual. Bengaluru: National Institute of Mental Health and Neuro Sciences; 2014.  Back to cited text no. 19
    
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Stallard P. Think Good-Feel Good, A Cognitive Behaviour Therapy Workbook for Children and Young People. England: John Willey & Sons Ltd.; 2004.  Back to cited text no. 20
    
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O'Moore M, Kirkham C. Self-esteem and its relationship to bullying behaviour. Aggressive Journal: Official Journal of the International Society for Research on Aggression 2001;27:269-83.  Back to cited text no. 22
    
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Tadesse S, Dereje F, Belay M. Psychosocial wellbeing of orphan and vulnerable children at orphanages in Gondar Town, North West Ethiopia. J Public Health Epidemiol 2014;6:293-301.  Back to cited text no. 23
    
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Killian B, Durrheim K. Psychological distress in orphan, vulnerable children and non-vulnerable children in high prevalence HIV/AIDS communities. J Psychol Afr 2008;18:421-9.  Back to cited text no. 24
    
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Gaidhane AM, Syed Zahiruddin Q, Waghmare L, Shanbhag S, Zodpey S, Joharapurkar SR. Substance abuse among street children in Mumbai. Vulnerable Child Youth Stud 2008;3:42-51.  Back to cited text no. 25
    
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