Negative Mental Health Symptoms and Their Causes in Secondary School Students (A Case Study in Hanoi)

Dang Bich Thuy*

Abstract: The mental health of secondary school students and associated problems in school have been topics of interest in recent research on children. In 2019, the Institute for Family and Gender Studies (IFGS) led a case study in Hanoi with the aim of exploring the current mental health related issues of secondary school students. According to this study, a relatively high rate of these students struggle with mental health disorders, the most prevalent of which is attention deficit hyperactivity disorder (ADHD). This is followed by emotional disorders which exhibit evidence of anxiety, depression and, especially, suicidal thoughts. Personal conduct problems and difficulties in relationships with peers are also recognised as common among the study’s sample of school students. The main causes of these negative mental health symptoms are related to the stress associated with academic pressure, school bullying, tensions in relationships with peers and teachers, family conflicts and parents’ behaviours toward their children. This paper aims to share the key findings of the study. The study findings and a number of comments included in this article are developed based on the contents presented by the author in the study’s full report.

Key words: Child, Adolescents, Secondary School, Student, Mental Health.

1. Introduction and Background

Secondary school students (grades 6-9) are at the early stage of adolescence. At this age, they are vulnerable to both physical and mental health problems. Mental health risks faced by secondary school students not only stem from academic stress, but also are largely related to psychophysiological changes during puberty, problems with peers, conflicts with parents, distresses related to family problems such as household discord and poverty. The prevalence of negative mental health symptoms among secondary school students and the complication of various other factors simultaneously influencing their mental health in different ways have raised public concern and researchers’ interest.

Currently, approximately 20% of adolescents globally experience challenging mental health conditions (WHO, 2019). Up to now, there has been no national survey on children and adolescents’ mental health in Vietnam; however, new knowledge of mental health related issues among Vietnamese adolescents was sought in the first Survey and Assessment of Vietnamese Youth (SAVY) in 2003, and the SAVY second round in 2008. In addition to these two national SAVY surveys, existing sample studies and thematic research also provide insights into a number of issues and various dimensions of mental health among Vietnamese youth. Accordingly, the situation of the mental health of children and adolescents raises concerns in terms of the prevalence of significant problems, from common negative symptoms to more alarming problems related to depression and suicide.

SAVY 1 found that 2.8% of the total respondents reported that they had attempted self-harm behaviours, and this rate was doubled in SAVY 2 (7.5%). Notably, the percentages were highest for 14-17 year old males (10.9% in rural areas and 10.6% in urban areas). According to SAVY 2, the proportion of respondents who had thought about suicide was 4.1%, a 0.5 percentage point increase from that of SAVY 1 (3.4%). What is noteworthy is that both SAVY studies revealed a higher percentage of female adolescents having suicidal ideation. Specifically, in SAVY 1, the rate of female adolescents having suicidal thoughts was 6.6% of the 14-17 year old girls, and 7.8% of the 18-21 year old girls. According to SAVY 2, the percentage of young females who had thought about suicide also exceeded the average of the total sample, and doubled the percentage of that of young males (5.9% versus 2.3%). Of note here is that the rate for urban 14-17 year old girls was the highest (9.6%), while the rural rate for the same age group of girls was 6.5% (MOH et. al, 2005; NCPFP et. al, 2010). Meanwhile, with the addition of more mental health indicators, SAVY 2 discovered a relatively high rate (21.3%) of youth who had previously felt hopeless about the future (NCPFP et. al, 2010).

A number of studies in Vietnam have provided evidence suggesting that mental health is an issue of concern in child and adolescent populations. The prevalence of mental health problems range from 8% to 29% for children and adolescents, with varying rates across provinces and by gender (Samuels et. al, 2017, as cited by Dang Bich Thuy, 2019). A study funded by the U.S. National Institute of Health (NIH) and conducted by Vanderbilt University (U.S.A.) and Vietnam National University, Hanoi in 2013 found that 10.7% of adolescents between 12 and 16 years of age were faced with mental health problems (Dang Hoang Minh et. al, 2013).[1] A study by Samuels et. al (2017) commissioned by UNICEF, with a sample of 402 secondary and high school children, suggested a relatively high proportion of children having negative mental health symptoms. As many as 19.7% of the school children respondents showed signs of emotional disorders, followed by attention deficit hyperactive disorder (ADHD) at 8.5%; 7.5% of the respondents had conduct problems and 7.0% experienced peer problems.

A study by Tran Thi Huyen (2019) of depression and anxiety among secondary school students indicated that the rates of the sampled students[2] at risk of depression and anxiety stood at 16.14% and 16.58%, respectively. Nguyen Thi Minh Thu et. al (2019) also provided statistics that reflected a number of concerning issues regarding depression among high school students, particularly, challenges in responding to depression symptoms among the students. A large proportion (5%) of the students in the sample[3] showed obvious signs of depression, but three fourths of these students were not provided with treatment in a timely manner.

In the context of the mental health problems of children becoming more and more prevalent and complex, and largely associated with problems in school, in 2019, the IFGS led a case study in Hanoi of secondary school students. They are at an age of rigorous psychophysiological changes and highly vulnerable to their surrounding environments. The study was carried out in order to explore current mental health problems faced by secondary school students, and provide more updated knowledge of their prevalence and underlying causes.

2. Methodology

The literature review was used to explore related mental health problems of secondary school students, and the primary data collection was carried out using quantitative and qualitative surveys. The quantitative survey was done with a sample of 381 students from a secondary school based in Hanoi city, with representatives from all the four grades (6^th to 9^th grades), of which 52.5% were boys and 47.5% were girls. A range of qualitative data methods were used including in-depth interviews (IDIs) with four students, focus-group discussions (FGDs) with four groups of students recruited from different grades and classes, and key informant interviews (KIIs) with two teachers.

The quantitative data collection utilised the self-reported Strengths and Difficulties Questionnaire (SDQ) scale for children, in order to identify the prevalence of negative mental health symptoms among the students. The data were entered into Epidata software using the double entry method, and then crosschecked to detect any potential errors. After that, the data were transferred to the SPSS software to be processed and analysed following the instructions on SDQ scale scoring and analysis. To determine negative mental health symptoms among the secondary school students, the study utilises methods of descriptive statistics (frequency distribution), and the calculation of mean and total scores of SDQ scales.

Cronbach’s Alpha is also used to test the reliability and intercorrelation between observed variables in the scales. One-way analysis of variance (one-way ANOVA) is applied to test the null hypothesis that the sample groups are drawn from populations with the same mean values, with a 5% probability of error (which means 95% reliability). Based on the instructions for Interpreting Symptom Scores and Defining “Caseness” from Symptom Score,[4] the cut-off point of the SDQ Total Difficulties Score (0-40) in this Study is set at 15, with scores of 0-15 being considered “Normal”; scores of 16-19 being “Borderline”; and 20-40 being “Abnormal”.

Regarding the qualitative study component, a set of guides for children’s FGDs and IDIs and teachers’ KIIs were developed based on the study’s goals and requirements. All of the interviews were recorded and transcribed for the purpose of data analysis.

3. Some Definitions in the Study

Within the scope of this small-scaled study, which focuses on common negative mental health symptoms among secondary school students, not all aspects of mental health are covered, such as subjective well-being, self-efficacy, the ability to cope with the normal stresses of life and the ability to work productively as often mentioned in many definitions of mental health.

The opposite of experiencing mental well-being is having mental health problems, also understood as mental disorders, or abnormal mental states and behaviours, and also called mental and behavioural disorders. However, it is extremely difficult to draw a clear and accurate definition of mental and behavioural disorders, because although there are relatively common norms shared across different societies, each society has their own distinct norms and rules. A behaviour considered normal in one society might be abnormal in another, and thus normal is difficult to determine (WHO, 2001; Dang Hoang Minh et. al, 2013. Cited by Dang Bich Thuy, 2019).

According to Dang Hoang Minh et. al (2013), mental disorders, also called psychological disorders, mental illnesses, or mental health problems, are mental, behavioural or emotional patterns that cause significant distress or self-destruction, which seriously affect aspects of a person’s life such as work, family or sociable life, or cause danger to other people or the community. Mental disorders could also be considered feelings of misery experienced by an individual. A person might feel in agony, unhappy, tired, exhausted, or losing interest in normal activities and life. These conditions are usually seen in patients with depression and anxiety. A recent study by Samuels et. al (2017) mentions some mental health problems faced by children, including mental disorders diagnosed in childhood, delayed mental development, ADHD, anxiety disorder, post-traumatic stress disorder (PTSD), depression, mood disorder, substance abuse, personality disorders and stress.

Within the scope of this study, the phrase negative mental health symptoms is used to refer to symptoms of mild mental and behavioural disorders, which do not include severe mental disorders and symptoms of chronic mental illnesses (such as schizophrenia, intellectual disability and dementia). The negative mental health symptoms among the school children within the scope of this study are considered based on the emotional and behavioural aspects of ???? as self-reported by the children, including issues related to emotional and conduct problems, ADHD, peer problems and prosocial behaviours. Specifically:

(1) Emotional problems: Including symptoms related to mood disorders such as anxiety, sadness and insecurity. which are often the causes of depression and suicide, as well as somatic problems such as headaches, loss of appetite, sleep loss, poor sleep and nightmares.

(2) Conduct problems: Symptoms relate to behavioural or conduct disorders such as getting angry, being violent or aggressive towards peers, bullying, playing truant from school or refusing to do homework.

(3) Hyperactivity/Inattention: Symptoms relate to developmental disorders among school children, including overactive behaviours accompanied by reduced attention, which affects their learning ability and relationships with other people.

(4) Peer problems: Symptoms are of loneliness, lack of willingness to make friends with peers, and withdrawal from social relationships (early signs of depression).

(5) Prosocial behaviours: Negative mental health symptoms related to antisocial behaviours could be understood as lack of interest, or indifference towards others, lack of willingness to help and share with peers and other people.

4. Key Findings

In order to provide an overall picture of the prevalence of negative mental health symptoms among secondary school students, this section shall present the findings drawn from the data analysis based on the instructions for Interpreting Symptom Scores and Defining “Caseness” from Total Difficulty Scores. The next section shall describe findings related to the frequencies of negative mental health symptoms categorised under the five groups of problems as mentioned above.

4.1. Prevalence of mental health problems based on symptom scores – caseness and total difficulty scores

The study’s data analysis results (as shown in Table 1) recognise hyperactivity/inattention as the most prevalent mental health problem among the secondary school students. The rate of students having hyperactivity issues within the abnormal band was 15%, which was a concerning problem. With the highest mean score (4.17, SD = 2.14) among the four types of problems, this ‘abnormal’ score is twice as high as that of the peer problem scale, and is significantly higher than that of the conduct problem scale.

The second prevalent negative mental health symptoms after hyperactivity/inattention are those of emotional problems. According to the total difficulty scores, the rate of secondary school students scoring ‘Abnormal’ in the emotional problem scale is 12.1%, with a mean score of 3.3 (SD = 2.45); this ‘Abnormal’ score is considerably higher than that on the peer problem scale. This implies difficulties faced by secondary school students during the adolescence period, accompanied by significant emotional changes could potentially lead to mental health risks.

Table 1. Total Difficulty Scores and Caseness

In terms of conduct problems, the percentage of students scoring ‘Abnormal’ stood at 10.8%. Similar to with peer problems, it is notable that the rate of students having ‘borderline’ conduct problems is higher than that of the other problems (15.5%). This indicates that a number of students are on the threshold of facing difficulties in their ability to develop and control behaviours in their relationships with peers and other people.

The rate of students experiencing ‘Abnormal’ peer problems in this study is only 7.3%. However, most noteworthy in the study sample is that the percentage of students scoring ‘Borderline’ in the peer problems scale is 1.5 to 4 times higher than that of other problems (30.2% as opposed to 7.1%-15% of other problems), which shows that a large proportion of students are on the verge of experiencing difficulties in their ability to develop social relationships at this stage when they are beginning to expand their social circles.

With regards to prosocial behaviours, the study found that the majority of the students in the sample had positive social relationships (75.9% scored ‘Normal’), with 13.4% in the ‘Borderline’ band and 10.8% in the ‘Abnormal’ band, and a mean score of 6.69 (SD = 1.98). This is the most positive mental health aspect of the students as compared to the other aspects mentioned above. In other words, the prevalence of negative mental health symptoms among the sampled secondary school students was the lowest in terms of prosocial behaviours.

Considering the student’s grades and gender, analysis of Total Difficulty Scores resulted in differences between students of different grades and gender (See Table 2). Overall, the students in the higher grades appear to face more difficulties across the problems. The rates of 8^th and 9^th graders with total difficulty scores within ‘Abnormal’ and “Borderline’ bands are more or less twice as high as those of lower grade students (19.6% in the ‘Abnormal’ band and 26.8% in the ‘Borderline’ band). These rates among the 9^th graders are 11.9% and 23.8%, respectively. Such numbers among the 6^th and 7^th graders are significantly lower (as shown in Table 8). Of interest here is that there is almost no substantial difference in the total Difficulty Scores between boys and girls. Specifically, the rate of girls facing problems is just higher than that of boys by a tiny margin (13.9% versus 13.69%), and there is no difference in the ‘borderline’ band.

Table 2. Total Difficulty Scores by Grades and Gender

 (Statistical significance: *p<0,05; **p<0,01)

As such, a preliminary conclusion that could be drawn from the Total Difficulty Scores is that the most prevalent mental health problem among the sampled secondary school students is hyperactivity/inattention, followed by emotional problems. Meanwhile, conduct problems and peer problems also have relatively high prevalence, especially in the ‘borderline’ band. Although this is only the finding of a case study, it brings attention to the mental health problems currently faced by school children, and the need for more in-depth studies. Considering different grades, in general, students from higher grades are more likely than others to face difficulties from mental health problems. At the same time, there is no significant difference between male and female students in terms of total difficulty scores., When considering each group of problems separately, though, the survey resulted in a number of differences between boys and girls, which shall be presented in the next section.

4.2. Prevalence of negative mental health symptoms exhibited by secondary school students, by specific groups of problems

This section shall discuss the negative mental health symptoms usually experienced by secondary school students based on the study’s data analysis across the five groups of problems: (1) Emotional problems; (2) Conduct problems; (3) Hyperactivity and inattention; (4) Peer problems; and (5) Prosocial behaviours.

Emotional problems

The data analysis showed that a sizeable proportion of secondary school students in the sample were experiencing negative emotional symptoms such as anxiety, sadness, fear, upset, and lack of self-confidence. The rates of students selecting the “Certainly True” response to emotional problems’ Items range from 7.9% to 23.6%. Notably, more than a quarter of all the children (23.6%) felt nervous in new situations or lost confidence easily; 13.6% reported “I have many fears; I’m easily scared.” These symptoms could potentially lead to negative mental health risks. More than a third of the students in the survey sample admitted it was “Somewhat True” when asked about the emotional problems they were experiencing (with percentages ranging from 33.7% to 39.6%). Specifically, 33.7% of the respondents answered “Somewhat True” to the Item related to negative physical symptoms such as headaches, stomach-aches or sickness; 39.6% reported that they worried a lot; 34.7% often felt unhappy, down-hearted or tearful; and 39.6% answered “Somewhat True” to the Item “I am nervous in new situations. I easily lose confidence” and 34.6% to the Item “I have many fears; I am easily scared”.

Considering the Symptom Scores by students’ grades and gender, it was found that the rates of students having ‘Abnormal’ emotional problems are highest among the 8^th and 9^th graders. 10.2% of the 6^th graders and 6.2% of the 7^th graders faced ‘abnormal’ emotional problems, whereas such rates among the 8^th and 9^th graders were remarkably higher, at 15.2% and 16.7%, in that order. The study also discovered that more girls were experiencing ‘Abnormal’ problems than the boys, doubling the percentage of boys experiencing the same level of problems (16.6% versus 8%). This suggests the necessity of studying the factors driving such a high rate of girls facing emotional problems in schools. In addition, the high percentages of students reporting emotional difficulties such as sadness, nervousness and downheartedness as mentioned above call for attention from schools and families, because these emotions are likely to lead to depression in the absence of early intervention.

Table 3. School Children’s Responses to Emotional Problems (%)

Conduct problems and disorders

Within this study sample, the percentage of children having behavioural problems is quite high (as presented in Table 4); the most common symptoms include getting angry and losing ones temper easily, a lack of self-control or refusing to do as one is told. More than a fifth (25.2%) of the children responded “Certainly True” to the Item “ I get very angry and often lose my temper”, and more than a third (32.7%) to the Item “I usually do as I am told.” Similarly, the numbers of students selecting the “Somewhat True” response to these two items were relatively high, 39.5% and 62.0%, respectively.

Although the number of children having symptoms of conduct disorders such as fighting, bullying (making other people do what one wants), being accused of lying or taking other people’s things only made up a small proportion, ranging from 0.8% to 5%, if we take into consideration the shares of participants who reported “Somewhat True” to items related to dishonesty and cheating such as “lying or cheating” (17.7%) and “take things that are not mine” (10.3%), these rates need to be taken into consideration, and recognised by the families and school, in order to apply appropriate measures in a timely manner, before these signs become a number of students’ personality traits.

Table 4. School Students’ Assessments of Conduct/Behavioural Problems (%)

Considering the percentages by grade and gender, the survey’s symptom scores show that the rate of students having ‘Abnormal’ behavioural problems is highest among the 8^th graders (16.1%), followed by the 6^th graders (10.2%), 9^th graders (9.5%) and lastly, 7^th graders (6.2%). However, if we look at the ‘borderline’ students, the rates range from 14-17% across all four grades, with no significant differences between the grades. This implies that, unlike emotional problems, behavioural problems require close attention across all age groups. Moreover, it is noteworthy that the percentage of boys having abnormal behavioural problems is almost double that of the girls (14.5% versus 6.6%).

The data analysis mentioned above allows for an initial conclusion that the rate of students having behavioural problems in this survey is quite high, the most common symptoms include getting angry and losing their temper easily, showing a lack of self-control, or not doing as one is told. Only a very small proportion of the students affirmed that they were not incited by other people to do things, which indicates a very low degree of self-control among the sample students. This is worrying because secondary school-aged children are easily influenced by their peers to engage in high-risk behaviours, including substance abuse, violence and other deviant behaviours. The difference between the boys and the girls regarding taking part in abnormal behaviours is to be noted, as the boys’ rate is double of that of the girls’. This is in direct contrast with emotional problems numbers, with twice as many girls reporting abnormal emotional difficulties compared to the boys, as pointed out in the emotional problems section.

Hyperactivity/inattention

The data surveyed by this study provides evidence that hyperactivity and inattention symptoms are quite common among the students (See Table 5). About two-thirds of the students in the sample reported problems or symptoms of hyperactivity and inattention.

As many as 20.2% of the children selected the “Certainly True” response and 43.8% chose “Somewhat True” to the Item “I am restless, cannot stay still for long;” 24.6% answered “Certainly True” and 28.0% “Somewhat True” to the Item “I am constantly fidgeting or squirming;” and 22.4% responded “Certainly True” and 50.8% “Somewhat True” to the Item “I am easily distracted, find it difficult to concentrate.” At the same time, the percentage of students having good attention and ability to complete tasks effectively is quite low. A considerable number of students more or less faced hyperactivity and inattention problems, coupled with a very low proportion of students affirming having good attention skills. This is something that the family and school need to pay attention to, because these symptoms of distraction and difficulties paying attention as reported by the children shall not only affect their performance in school, but also potentially lead to behavioural disorders in their interactions with other people.

Table 5. School Students’ Assessments on Hyperactivity/Inattention (%)

Note: *The scores have been reversed according to SDQ scoring instructions.

With regards to the symptom scores of different grades, the percentages of students with abnormal hyperactivity/inattention problems are highest in 8^th and 9^th graders (15.2% and 20.2%, respectively), whereas these rates of the 6^th and 7^th graders stood around 13%. Furthermore, male students showed a lower rate of abnormal hyperactivity/inattention problems than female students (13.0% as compared to 17.1%).

Based on the data analysis above, it is arguable that hyperactivity/inattention is a common negative mental health symptom among the study’s sample, and it is also the most prevalent negative mental health dimension compared to the four other dimensions analysed by this study. Of note here is that as many as two-thirds of the students in the sample experienced problems or showed symptoms of hyperactivity/inattention, especially such symptoms as “being easily distracted” and “difficulties in concentrating”. Signs of hyperactivity/ inattention tend to be more prevalent among 8^th and 9^th graders, and more male students reported abnormal symptoms than female students. However, there is a need for larger scaled studies, and potentially more specific scales for hyperactivity/inattention symptoms so as to draw representative and more accurate conclusions which reflect the actual situation of this negative mental health symptom among school children at the present. Those responsible for the children will then be able to come up with appropriate warnings and prompt interventions, contributing to reducing negative impacts on children’s academic performance and relationships.

Peer problems

The study findings suggest that a significant portion of the students were rather solitary: They only had one or a few good friends; they were not liked by other children their age, so they preferred hanging out with adults; and some of them were even victims of bullying by their peers (as can be seen from Table 6). 9% of the children chose the “Certainly True” response and 32.4% chose “Somewhat True” to the statement “I am usually on my own. I generally play alone or keep to myself.” 9.1% answered “Certainly True” and 19.8 % answered “Somewhat True” to the Item “I have one good friend or more.”

The number of students who felt that they were respected and liked by peers was rather small. Only 13.9% and 63.2% of the students responded “Certainly True” and “Somewhat True” to the Item “Other people my age generally like me”, while more than one-fifth of the children selected the “Not True” response to this statement, which means they themselves thought that they were certainly not liked by their peers. Only about a third (32.6%) of the survey participants thought that they had good relationships with other people their age. Over one-third of the students considered themselves victims or at risk of being victims of bullying by peers. 8.5% of the children answered “Certainly True” and 27.8% answered “Somewhat True” to the statement “Other children or young people pick on me or bully me.” These findings suggest that it is necessary to pay attention to the current problem of violence in schools.

Table 6. School Children’s Assessment of Peer Problems (%)

Note: * The scores have been reversed according to SDQ scoring instructions

Looking at the symptoms scores across grades and gender, the percentage of students having abnormal peer problems is highest among the 8^th graders (11.6%), considerably higher than those of other grades (which are around 6%). No difference is observed between male and female students.

As a result, it can be concluded that a considerable portion of the students tend to keep to themselves, avoiding social contact, while only a small percentage of the students in the sample were certain that they were respected and liked by their peers. These are concerning negative mental health symptoms among school children, which signal risks of loneliness.

Prosocial behaviours

Negative social behaviours include a lack of interest in or indifference towards other people, lack of willingness to help and share with peers and other people. This study found that only a tiny proportion of the students chose the “Not True” response to all of the statements, while the majority of the secondary students in the sample demonstrated prosocial attitudes and care towards other people (See Table 7).

Based on the symptom scores, no significant differences were noticed between the different grades or genders with regards to abnormal behaviours (which reflect negative symptoms of social and peer relationships). However, the rate of students who reported ‘Borderline’ behaviours is remarkably higher among the 7^th graders (16.5%) and 8^th graders (15.2%), as opposed to the 9^th graders (8.3%). Meanwhile, there is almost no difference between the rates of male and female students across all the three bands of ‘Normal’, ‘Borderline’ and ‘Abnormal.’

As such, the study findings show that of all the five mental health domains analysed, this is the domain where the students reported the fewest negative symptoms, and although there are differences between different grades, no clear differences are found between male and female students.

           Table 7. School Children’s Assessment of Prosocial Behaviours (%)

In line with the quantitative data analysis results, the qualitative study component also provided evidence of negative mental health symptoms related to emotional disorders, behavioural disorders, hyperactivity/inattention and difficulties in relationships with peers and the feelings of loneliness and downheartedness. Particularly, some study participants even reported that they used to have suicidal ideation, or felt “bored, not wanting to live anymore,”, “wanted to die,” or was in an “anxious” state, or could not explain their emotions and somatic problems. For example “it was like restlessness, but… I don’t know how to describe it”… A number of negative mental health symptoms regarding emotional problems, difficulties in relationships with other people, autism, hyperactivity/inattention, and behavioural disorders have been reported by the students and teachers participating in the study, as quoted below (Box 1).

Differences in negative mental health symptoms are also observed for different grades in the qualitative study. While secondary school students are at the age of adolescence, experiencing many psychophysiological changes, which lead to negative mental health symptoms, especially in romantic relationships with other children of the opposite sex; they are also burdened by academic pressure. The stress is most commonly experienced by students in the 9^th grade, the final year of the secondary school, who have to face the high school entrance exam at the end of the school year.

4.3. Causes of negative mental health symptoms among secondary school students

The underlying causes of negative mental health symptoms among secondary school students can be examined across various dimensions and from different perspectives; however, within the scope of this paper, and the data collected by a small scaled study with a number of limitations, this section shall only provide a concise discussion of a number of key and most common causes reported by the students and teachers who participated in this Study.

Causes related to academic pressure

Academic pressure and school marks are important causes of negative mental health symptoms among students. All of the FGDs, IDIs and KIIs provided evidence of symptoms of anxiety and stress related to academic pressure, especially before and during exams. In addition, there are feelings of boredom and lack of interest in a number of subjects that require learning by heart, and literature is described as “boring”, “make me feel sleepy” by the students. The feeling of anxiousness in school is also associated with “uncompleted homework”, “pressure when studying difficult subjects” and “headaches” [the students often cited the subject of English as a pressure point]. Academic pressure comes from students themselves as well as teachers and parents, as mentioned in some FGD and IDI quotes below:

The problems most frequently cited by the students regarding stress and pressure related to being in school include “have not done my homework” [15-minute or full period tests], “Nervous when tests are returned”, “during review of the previous lesson” [lessons to be learnt by heart], “when called up to recite previous lessons”, “full-period tests” (excerpts from FGDs and IDIs with students). The pressure from the need to get good marks or not understanding the lessons, and the stress before and during tests and exams are often mentioned by students and teachers alike. One student, when asked about what she most worried about in school, shared her thoughts: “I think that the marks… the pressure of studying is a bit too much” (IDI, female student, 7^th grade). A teacher also commented that students were often most stressed out during exams, “…the most stressful is during exams, preparation of exams, when teachers assign a lot of homework. Because during exam periods, the workload will certainly be increased… usually weaker students are more afraid…” (KII, head teacher); “If I don’t understand the lesson, if I feel it’s a bit difficult, I might feel pressure” (IDI, female student, 8^th grade). “Many times, I have finished studying the lessons, but when I have to take exams, all the words are lost. I was that scared”. “It’s like it was so much pressure that all the words get jammed, I can’t keep calm” [during tests]; “I forget this subject and that subject”, “I was hurrying to finish in time, after a while I felt too stressful, I reviewed my answers and realized that I forgot this thing, and then I was afraid that the teacher would see that and give me a bad mark. Or after a test, if I compare my answers to other classmates and find differences, I will be afraid that I will get a bad mark” (FGD, female student, grade 6).

 The stress caused by academic and exam pressure also stems from the fierce competition of entrance exams, as reported by a teacher. “Because in the past, the competition to get into high schools was less intense, the probability of not making it to public schools or top schools was lower. But nowadays, the competition has increased, and the pressure of getting into [good] schools has become greater. That’s why both parents and children feel that way.” (KII, head teacher).

Causes related to relationships in school

This study provides evidence of the linkage between negative mental health symptoms among secondary school students and their relationships with peers, including school bullying and relationships with teachers.

Interviews and discussions with the students revealed that many of their negative symptoms of mental health have their roots in various conflicts, disagreements and complicated relationships with their peers. The students often mentioned negative feelings such as anxiety, sadness, annoyance due to “being talked behind my back”, “being jealous of each other”, “hating each other”, “talking behind one’s back”, “misunderstanding”, “insulting [each other] on Face[book].” Some students shared their feelings: “Sad, mostly because of little things like a classmate talks bad about another classmate… mostly it’s about emotions,” “I’m just afraid that people talk behind each other’s back and hate each other,” “students nowadays, not everyone is genuine friends with each other, it’s like best friends talk behind each other’s back” (IDI, female student, grade 9); “When they disagree… they’re annoyed at each other, threaten each other, mock each other,” “[they] call for their friends to gang up… cursing at, threatening [others]” (FGD, female students, grade 8).

Violence among school children and school bullying are also causes of negative mental health symptoms among students. The quantitative data, though it did not support exploring the causes related to school violence, did discover that more than one third of the school children considered themselves victims or at risk of being bullied by their peers. 8.5% of the students responded “Certainly True” and 27.8% responded “Somewhat True” to the Item “Other children or young people pick on me or bully me.” At the same time, the qualitative data also confirmed negative symptoms of mental health stemming from school violence. The children participating in the study described feelings such as “scared”, “worried”, “afraid when going to school”, “sad”, “quite scary”. One student who was frequently bullied reported that he was usually worried when he went to school, and the experience of being locked up in the toilet always came back to haunt him: “… I was locked up in the toilet… I was afraid that the door was locked forever and could never be opened. The scariest was when I was calling for help but no one heard me…”, “my schoolbag was always hidden from me, sometimes even thrown to other classrooms for no reason…”, “the whole week, through all the five periods” … “They did that when the teacher was not paying attention, and I was also being busy studying, or when I was eating or playing, they would take [my bag]”; “I’m sad because I don’t want to talk to anybody any more…” (IDI, male student, grade 8).

In their relationships with teachers, negative emotions often result from being wrongfully scolded by teachers, or bearing school punishments such as standing in a corner facing the wall, repeatedly writing down the lesson text or cleaning up. The qualitative data showed that students’ negative emotions such as anger, resentment or protest originated from “being punished by teachers” when making mistakes such as not doing homework, chatting in class, or not following school regulations. Some children felt that the fact that they did not dare argue with the teachers when they were “wrongfully criticised” also created feelings of “upset”, “resigned… because the teacher is always right,” “in general, the teacher is always right, if she’s wrong, see clause 1 [the former clause]” (FGD, male students, grade 7). The students also shared feelings of annoyance and stress with teachers’ academic requirements: “[I’m] annoyed when the teacher keeps pushing me to review the lessons”, “[we] were taking a Technology test in the afternoon, but the teacher forced [us] to study maths in the morning”; “learn four literature paragraphs to answer the teacher’s questions, three full pages” (FGD, male students, grade 7).

Causes from family related issues

Qualitative data unveiled that many negative mental health symptoms among school students originated from family related issues; They are most commonly parents’ expectations of children’s academic performance, conflicts between parents and children, inappropriate disciplining methods, parents’ violence towards children, and family discord. “Parents having too high expectations of children’s academic results”, “always pushing children to study too much”, “often compare their children to other children”, and “parents causing pressure on [children’s] studies”. were frequently cited by the students in the interviews. The school children shared feelings of stress due to their parents’ high expectations of their academic performance: “My parents made me study a lot to get into prestigious schools”, “My grade point average needs to be higher”, “In terms of ranking, my parents will only be happy if I rank first”, “…it’s just that I don’t like learning English, but my parents keep pushing me to get higher grade point average” (FGD, female students, grade 8). “Well-performing students are often pressurized by their parents, it’s like they keep wanting their children to do better” (FGD, female students, grade 6). “[My] parents are not pleased with an 8 score, it’s like it’s compulsory to get scores of 10. Everything has to be 10, has to be perfect” (IDI, male student, grade 8).

The secondary school students also reported feelings of worries, stress and fear of being scolded by parents when they get bad marks: “once, I got a bad mark, and then my mother often scolded me… Sometimes when I get a poor mark for my test, I’m so down, thinking about handing that paper to my parents, I don’t know how they will react. At those times, I feel nervous and worried” (IDI, female student grade 7); “Usually during exam periods, parents often tell [their children] to get high marks; if the marks are not up to their parents’ expectations, they often feel sad, and worried, not knowing how their parents would react”; “I see that students from other classes, when they get bad marks, they also say that their parents scold them because of the bad marks” “I see that [name] is one of the best students in the class. Her parents have quite a lot of expectations of her; they insist that she has to do well in school. And there’s another student, her parents said that if she didn’t earn an excellent student’s title, her phone would be confiscated from her, so she was scared” (FGD, female students, grade 6).

In addition to parents’ high expectations on children’s performance in school, families with marital discord or parents’ violence towards children also increase children’s risks of mental health problems. “Her father often beats her, and scolds her. At home, she often goes out and wanders around, wandering everywhere before going home,” “It’s like she wanted to die, in general, her parents were fighting, but at school, she was very happy.” (FGD, female students, grade 8). An in-depth interview with a student revealed feelings of sadness, downheartedness, even thoughts about suicide because he had to witness domestic violence between the parents, and his parents unjustly vented their anger upon him while they were in bad moods/fighting each other: “I was upstairs in my room, playing as usual, and then my parents were fighting downstairs, and then my mother came up and scolded me, saying I was too lazy to study and this and that, and then she started hitting me”; “sometimes when I just touch the computer, my parents will start scolding me, and then compare me to other people’s children all the time. I don’t like that”; “[My parents] scold me, yelling me in the face”; “[I] intended to [commit suicide]. That time, I was intending to do that [commit suicide] but then I thought twice and then decided not to… I thought not yet, I wouldn’t try it yet” (IDI, male student, grade 8).

One student opened up in the in-depth interview about his feelings of depression, anxiousness, and even wanting to take his own life when faced with pressure from his parents in terms of academic performance, housework, and especially the negative feelings when his parents compared him with other people: “I’m under so much pressure from my family, I am suppressed, like they want to force me to do this and that, they want me to do this right and do that right. It’s like I’m repressed, it’s like I have to do all these things in one day, impossible to spread them out… they force me to study”, “…they want me to do better. It’s like they compare [me] to other children in the neighbourhood, like this person is this good, that person is that good, all sorts… They compare me [to others] and force me to study like them, but I can’t focus. And then I will get bad marks, and my parents will again scold me”; “I feel restless, it’s a feeling like I want to die, to leave this world so that my father would be happy, for example” (IDI, male student, grade 8).

In summary, beside academic pressure in school and complicated relationships with peers and teachers, parents’ high expectations of children’s academic performance and other related family problems also contribute to students’ negative emotions and behaviours, such as anxiousness, stress, restless, downheartedness, sadness, fear, and even symptoms of depression and suicidal thoughts.

5. Conclusions

It is possible to conclude that both quantitative and qualitative surveys have found evidence of negative mental health symptoms among the students in the sample. Quantitative data analysis suggests that the most common symptoms are hyperactivity/inattention problems, followed by emotional problems. Most noteworthy is the relatively high percentage of children reporting feelings of anxiousness, sadness, downheartedness and headaches. This study also found negative mental health symptoms among secondary school students related to behavioural problems such as getting angry and losing one’s temper easily, a lack of self-control or not doing as one is told. Negative social behaviours are the least common within the studied sample. In other words, this study observes positive prosocial behaviours among the students, such as trying to treat other people nicely and helping others. The qualitative data also demonstrated negative mental health symptoms among the school children across different problems/domains of mental health, and raises various issues of concern, especially symptoms related to emotional problems, autism, hyperactivity/inattention, and behavioural disorders. Nevertheless, it is necessary to point out that due to the small sample size, there is not enough data to adequately describe the degrees of negative mental health symptoms among secondary school children.

This study provides evidence which, to some extent, helps explain the causes of negative mental health symptoms among secondary school children. Factors related to academic pressure and expectations of academic performance are critical and persisting causes, in addition to those originating from in-school relationships such as relationships with peers, including violence and bullying, and relationships with teachers. Particularly, this study has revealed alarming information about parents’ excessive pressure on children over their studies, and their high expectations of children’s academic achievement, leading to numerous negative mental health risks for the children. Moreover, conflicts between parents and children, inappropriate methods of discipline, the use of violence by parents towards children and family discord are causes of more serious mental health problems, including symptoms of depression, sadness and suicidal thoughts. However, it is necessary to understand that the factors causing school children’s negative mental health symptoms often overlap or are interdependent, and it is a tremendous challenge to clearly identify which cause is the most important.

Lastly, this study has also raised various matters which call for further research. The prevalence of negative mental health symptoms among secondary school children in various mental health dimensions as reflected by this study’s data implies that there might be gaps in existing policies and intervention models related to mental health, in schools. Therefore, studying and exploring the actual situation and the effectiveness of current mental health policies and models for school children are of extreme importance. It is necessary to discover shortcomings and develop appropriate policies to intervene and support children, schools and families in order to protect children’s mental health by, preventing negative symptoms from becoming medical conditions that require complicated treatment and adversely affect the life and development of children.

References

Dang Bich Thuy. (2019), Negative Symptoms of Mental Health among Secondary School Students (A Case Study in Hanoi), Research paper of a study on Negative Symptoms of Mental Health among Secondary School Students (A Case Study in Hanoi) lead by IFGS.

Dang Hoang Minh, Bahr Weiss, Nguyen Cao Minh. (2013). Mental health of children in Viet Nam: Situation and Risk Factors. National University, University of Education.

Ministry of Health, General Statistics Office, World Health Organization and the United Nations Children’s Fund. (2005). Survey Assessment of Vietnamese Youth, Hanoi, Viet Nam.

NCPFP, ADB, UNFPA. (2010). Survey Assessment of Vietnamese Youth Round 2 (SAVY 2), Hanoi, Viet Nam.

Nguyen Thi Minh Thu, Nguyen Ha Bich Van, Nguyen Cao Minh Tuan, Vo Thi Thanh Kieu. (2019). Depression Among High School Students in Ho Chi Minh City (Summary Report). Proceedings from the 5^th International Conference on Child Mental Health in Vietnam: Mental Health Literacy in Schools and the Community. VNU Publishing House, Hanoi. Page 197- 198.

Samuels F., Jones N., Tavessi G., Thuy D.B. and Le D.H. (2017). Mental Health and Psychosocial Well-being of Children and Young People in Viet Nam, A Research Report for UNICEF Viet Nam.

Tran Thi Huyen. (2019). The Mental Health of Secondary Students in Long Xuyen City, An Giang Province: The situation and suggestions, Proceedings from the 5^th International Conference on Child Mental Health in Vietnam: Mental Health Literacy in Schools and the Community. VNU Publishing House, Hanoi. Page 289-296.

WHO. (2019). Child and Adolescent Mental Health. (Tham khảo trên trang web: https://www.who.int/mental_health/maternal-child/child_adolescent/en).

* Ph.D., Institute for Family and Gender Studies, Vietnam Academy of Social Sciences.

[1] The study was carried out in 60 areas across 10 representative provinces of Vietnam. The sample included 1,314 parents of 6-16 year old children, and 591 adolescents aged between 12 and 16. The cited statistics reflected the analysis of the responses of 12-16 year old adolescents based on SDQ scale.

[2] The study was conducted with 447 secondary school children in An Giang, based on CED-D Depression Scale and Zung’s Anxiety Scale.

[3] The study was conducted in 10 districts of Ho Chi Minh City, with a sample of 550 high school students.

[4] See http://www.copmi.net.au/images/pdf/Research/sdq-english-uk-self-scoring.pdf for scoring method.

Sources cited: JOURNAL OF Family and Gender Studies. Vol. 15, No. 1, p. 16-37