Strengths and limitations

The strengths of this study lies in the representativeness of this school sample and the multiple domains of SPEs which facilitated investigation into bullying and how it relates to specific SPEs. The cross-section of secondary students in this school population comprised of mixed social and economic status. Therefore, the generalizability of the study to other

Trinidadian adolescents is likely to be high.

Although this study generated data covering both the last 30 days and the last year, longitudinal associations could not be analysed. Therefore, the cross-sectional nature of the study could not infer causality between bullying and SPEs. No validated measure was used for data collection on bullying; however, the items used were similar to those in previous studies. The use of self-reported measurement tools may impact on reporting of bullying and SPEs because people are trying to answer in a socially desirable way. However, asking about bullying defined on a questionnaire and self-report has been found to yield reliable data (Solber & Olweus, 2003). A continuation of this study should be done with the different types of bullying behaviours. Different types of bullying behaviours were not included in the questionnaire and such information could have shed light on the severity of bullying. This

123 information may have identified mediated/moderated factors for bullying in subjects with specific SPEs.

8.3.2 Conclusions

This study found that being bullied in adolescence appears to be associated with persecutory ideation and magical thinking, while bullying others is associated with perceptual abnormalities and delusional ideas. In light of the findings, adolescents who are being bully victims seem to be vulnerable to paranoia experiences and perpetrators of bullying seem to be a trigger for more pathological expression of psychosis. We also demonstrated no gender differences in bullying behaviours and that the younger individuals were more likely to be involved in bullying.

124 CHAPTER 9

Mental health across culture and how it impacts on peer functioning and school grades:

Evidence from British and Trinidadian adolescents.

9.0 Introduction

Both developing and developed countries have not placed sufficient emphasis on resources geared towards addressing adolescent mental health needs (WHO, 2003). In recent times, however, there have been a number of global collaborative efforts from institutions and individuals to increase awareness, treatment and prevention for mental health problems (Horton, 2007). There is evidence that 75% of mental health problems begin by age 15 for anxiety and 25 for depression (Kessler et al., 2005). Mental health in adolescence has its underpinnings in the physical, psychological and social changes that occur during this critical developmental period. As such, poor mental health impacts adversely on the development of young people including in the social sphere (Kieling et al., 2011). No nation, whether

developed or developing, is spared of the reality of adolescent mental health issues (Bloom et al., 2011). The World Health Organisation (2010) has embarked on a number of initiatives to highlight youth susceptibility to mental illness and discriminatory treatment towards this group of young people. In addition, assistance has been given to less developed countries for the implementation of programs aimed at changing behaviours that negatively influence mental health (Chan, 2010).

The growing global concern has seen the upsurge of a number of cross-national research projects focusing on the prevalence and comparisons of mental disorders in adolescent populations. The most common of mental disorders found in the adolescence

125 period are depression and anxiety, with prevalence rates identified both in national and

international jurisdictions. For example, Giel et al (1981) found a range of 12% to 29% in the prevalence of mental disorders in children 5 to 15 years olds in low income countries.

Another study found that prevalence ranged from 28% to 38% in low income countries (Latin America and the Caribbean) and 31% to 40% in high-income countries (European) (Steel et al., 2014). A study done on Trinidad secondary school students found 25% prevalence rate of depression, with a ratio of 1:4 for those with and those without depression respectively (Maharajh et al., 2006; Maharaj et al., 2008). Similarly, the United Nation General Assembly Report (2010) demonstrated a global prevalence of 20% of young people experience mental health disorders each year (Chan et al., 2010). However, there was as much as 15%

discrepancy in the rates of depression between countries, indicating the need to further understand cross-cultural differences. Such disparities in prevalence across nations are

unlikely confined only to cultural (Caldwell-Harris & Aycicegi, 2006), social (Crone & Dahl, 2012) and methodological (Polanczyk et al., 2007) differences, but also the severity of the symptoms. Not discounting the relevance of diagnostic assessment in these aforementioned studies, the severity of self-reporting depression and anxiety symptoms below diagnostic threshold are of equal relevance to the well-being of adolescents. Since increasing severity of symptoms will occur before meeting a diagnostic threshold, it is important to examine

anxiety and depressive symptoms, even before a diagnostic level is reached. These symptoms provide early warnings and can be applied in anticipation of the need for care.

A relatively large number of studies have shown that social challenges of the

adolescent period, including interpersonal relationships (Patterson & Capaldi, 1990; Kochel et al., 2012) and academic attainment (Andrew & Wilding, 2004; Quiroga et al., 2012) can contribute to mental illness. When faced with negative or poor peer relationships, the severity of mental health symptoms increases to the extent to which problems weigh heavy on the

126 individual psyche (Panak & Garber, 1992). This indicates that poor peer relationships are a risk factor for distress and feelings of loneliness which, in turn, are shown to lead to

depression and anxiety in adolescents (Zimmer-Gembeck & Pronk, 2012). With peer

relations taking priority, parental support gradually declines during the period of adolescence (Rubin, Bukowski & Parker, 2006; Furman & Buhrmester, 1992). The myriad of emerging relationships in adolescence enhances the identity phase, therefore, the need for peer acceptance is important for good quality functioning (Rubin et al., 2006). There is also evidence that adolescents experiencing emotional dysfunction lack the ability to maintain healthy relationships (La Greca & Lopez, 1996) and, therefore, a vicious cycle of mental illness can emerge (La Greca et al., 1998).

These challenges associated with maintaining friendship can be as a result of the worsening of the depression and anxiety symptoms (Rapaport et al., 2005), especially when these two psychopathologies co-occur (Becker et al., 2012). In spite of the negative

consequences of both depression and anxiety, depression seems to have greater negative effect on functioning than anxiety (Rose et al., 2012). There is evidence supporting the seemingly “softening role” of anxiety in its co-occurrence with depression (Cunningham &

Ollendick, 2010) and its protective mechanism in possibly curbing socio-emotional and impulsive/cognitive control systems during peer rejection (Jarreth & Ollendick, 2008). As such, it is important to examine the effects of depression and anxiety on peer functioning both when they co-occur and occur independently. Such investigation is important in

understanding the quality of relationships that will exist and the impact of symptoms above and below the clinical cut-off.

Similarly, associations between academic attainment and depression and anxiety indicate that poor grades and the retention of poor grades are influenced by severe depression

127 and anxiety (Quiroga et al., 2012). In two schools in the UK, Owen et al. (2012) found that lower academic achievement was associated with higher levels of symptoms in depression and anxiety. Research on developmental psychology suggested that failure in academic performance can result from the inability to self-regulate in the school environment, which in turn leads to perceived incompetence, followed by depression and anxiety. In other words, this situation can begin in childhood at the elementary level and subsequently become rooted at secondary school when adolescent’s grades are affected. However, few studies have investigated the extent to which depression and anxiety are associated with lower educational attainment (Kessler et al., 1995; Quiroga et al., 2012). One longitudinal study done on high school students in Australia found prior mental health did not predict school relatedness (Shochet et al., 2006). Instead, most studies have examined the effects of

socio-environmental factors on the severity of depression and anxiety (Kaltiala et al., 1999;

Marano, 2002; Hawker & Boulton, 2000; La Greca & Moore Harrison, 2005; Sowislo &

Orth, 2013). However, over recent times research have examined the reverse role of

depression in the association with peer functioning (Nolan et al., 2003). For example, Chin &

Li (2000) found that depression was negatively associated with social relations and school achievement over time.

The impact of depression and anxiety on educational attainment, from elementary to tertiary level, has implications for failure in academic achievement among adolescents (Freudenberg & Ruglis, 2007). Research has shown that depression in the younger adolescents can predict school drop-out in later years (Rosa et al., 2003; Copeland et al., 2009). The symptoms of depression can precipitate negative affect to the individual self-perception of academic competence and the negative moods attached can hinder positive cognitive ability (Kovacs & Goldstone, 1991). Preconceived notions of academic

incompetence can propel someone to believe that there is less likelihood of finishing school

128 at the required levels and therefore school engagement becomes problematic (Quiroga et al., 2013). Therefore, investigating grades in relation to anxiety and depression is important so as to identify young people at high risk of not completing their schooling.

The exacerbation of the fears of incapable academic achievement can continue to be problematic, and as such worsen fears associated with emotional states such as anxiety (Van Ameringen et al., 2003; Albano et al., 1998). Stein et al. (1996) reported an increase in anxiety, from 50% to 90%, as persons grow older. This increase suggests fear symptoms rise to higher level of severity as the individual develops from childhood to adolescence during school life and can disrupt academic performance. It seems likely that adolescents who experience severe anxiety symptomatology refuses to attend school (Berg, 1992; Berstein &

Garfinkel, 1986). Similarly, Reinherz et al. (1991) found that self-reported high levels of depression symptoms were associated with impaired academic performance. It is plausible that the severity of symptoms can play a crucial role in impairing the ability to function academically (Frojd et al., 2008; Riley et al., 1998). However, in a later study, Reinherz et al.

(1993) found no association between major depression and academic competence. Therefore, the inconsistencies in these associations seem to warrant further investigations.

To investigate the association between different levels of depression on school

performance, Frojd et al. (2008) conducted a study on adolescents aged 13-17 years attending secondary school. They found that the severity levels of depression were more prevalent in participants whose grade point average (GPA) declined. Furthermore, girls reported 13%

moderate and 5% severe depressive symptoms while boys reported 8% moderate and 3%

severe depressive symptoms.

The effect of mental illness on functioning and school grades could be the result of biological changes or psychosocial ones. When depressed and/or anxious, the adolescent

129 brain experiences disruption in the information processing system (Eysenck et al., 2007).

High levels of anxiety disrupts working memory (Calhoun & Mayers, 2006), coupled with the slow maturing cognitive control system (Steinberg, 2008). However, not all adolescents experiencing emotional problems show a decline in academic performance (Dumont &

Provost, 1999). With regards to peer functioning, the adolescent experiences emotional dysregulation which has been found to be a characteristic of depression. Furthermore good interpersonal relationship plays a protective role in maintaining emotional regulation in adolescents with depressive symptoms (Kring & Sloan, 2010; see review Bylsma et al., 2008). The socio-emotional system of the adolescent becomes instantly activated when overburdened with dysfunctional social interactions (Steinberg, 2007). Considering the importance of peer relations and how they comprises of reward seeking and acceptance, adolescents with symptoms of depression and anxiety can experience decline in a number of self-evaluations, such as self-esteem and self-worth, leading to social withdrawal (Ferro &

Boyle, 2015). However, not all adolescents experiencing emotional problems show a decline in academic performance (Dumont & Provost, 1999).

Concomitantly, there is evidence to suggest that depression and anxiety symptoms have the proclivity to induce negative effects on social relationships (Rudolph, 2009) and educational achievement (Freudenberg & Ruglis, 2007; Kovacs & Goldstone, 1991). There is also evidence that there is no support for the assumption that depression and anxiety

predicted peer relations (Siegel et al., 2008) and grades (Shochet et al., 2006). These results indicate conflicting views on depression and anxiety predicting peer function and grades. Yet there is scarce research investigating the consequence of grades when negatively impacted by depression and anxiety in adolescence. Therefore, considering the wide ranging negative impact of depression and anxiety on life course, it is vital to understand these disorders among adolescents. Also, it is important to examine the extent to which the severity of

130 depression and anxiety symptoms affect grades and peer functioning. To my knowledge, few studies have examined the impact of depression and anxiety on students’ academic

performance and interpersonal relationships focusing on the severity of symptoms (Dyrbye et al., 2006; Kessler et al., 2012b; Quiroga et al., 2013). Furthermore, no study was done

comparing developed and developing countries, especially for those countries such as Trinidad which inherited its education system from Britain (Lisle et al., 2010).

The past Crown Colony ruled for Trinidad and the present British system may reflect entrenched similarities between these countries. While a number of changes have been made in five decades since Trinidad independence, there may still be sectors of the Trinidad education system that mirrors that of the British, as well as, some different aspects. For example, the Common Entrance Examination (CEE) adapted by Trinidad from the United Kingdom in 1960 still holds with Trinidad and Tobago. Therefore, it is interesting to compare data on how mental health is associated the educational achievement and peer functioning in both Trinidad and British school students. Findings from this study will be important in a number of ways. First, will narrow the gap in the cross-national inconsistencies in mental health prevalence rate, as well as add knowledge to the literature on how mental health predicts peer functioning in the two school systems. Second, the data will improve on the scarcity of national statistics on mental health symptoms among adolescent and children in Trinidad, particularly symptoms relating to common disorders like depression and anxiety.

Most importantly, findings in this study has implications in facilitating policy makers and other stakeholders in drafting intervention programs and policies for the prevention and intervention of young persons experiencing these symptoms.

The aims of the study are to:-

131 (i) Determine the prevalence of depression and anxiety symptoms in British and

Trinidad adolescent population;

(ii) Investigate the association between the severity of depression and anxiety symptoms and peer functioning and grades in a British and Trinidad adolescent population;

(iii) Determine whether anxiety, in the absence of depression, impacts similarly on peer functioning and grades as when depression and anxiety co-occur.