|Year : 2017 | Volume
| Issue : 1 | Page : 56-63
Cross-sectional study of anxiety symptoms in students in preexamination period
Prateek Yadav1, Vinay Singh Chauhan1, PS Bhat2, Nidhi Agarwal3, Charu Yadav4, Sameer Bhatia5
1 Department of Psychiatry, Base Hospital Delhi Cantt, New Delhi, India
2 Department of Psychiatry, AFMC, Pune, India
3 Department of Obstetrics and Gynaecology, Guru Gobind Singh Hospital, New Delhi, India
4 Medical Officer, Military Hospital, Jalandhar, India
5 Department of Paediatrics, Military Hospital, Dehradun, India
|Date of Web Publication||16-Jan-2018|
Dr. Prateek Yadav
Department of Psychiatry, Base Hospital Delhi Cantt, New Delhi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Preexamination period is an exceptionally stressful time for schoolgoing children and adolescents, and the propensity of having anxiety symptoms increases.
Aim: This study aimed to assess the presence of anxiety symptoms in students in preexamination period.
Materials and Methods: The study was carried on 619 children from Class VIII to XI. All of them were given a structured questionnaire for sociodemographic profile and Screen for Child Anxiety Related Emotional Disorders questionnaire. Association of various variables with presence of anxiety symptoms was assessed. Statistics was analyzed with SPSS version 17.0 software.
Results: Totally 170 children (27.5%) had anxiety symptoms, similarly the various subgroups had increased frequency compared to the known prevalence in this age group. Age, years spent in the current school, living with parents, presence of domestic stressors, and grade deterioration, all were significantly associated with increased frequency of these symptoms. Similarly, association with various subgroups is described.
Conclusion: This study attempts to give evidence of increased anxiety symptoms, during preexamination phase, compared to the reported prevalence in this age group, and thus to address this becomes imperative which will improve their performance and also the mental health preventing distress along with psychological and behavioral problems.
Keywords: Academic, adolescent, anxiety, schoolgoing, stress, tests
|How to cite this article:|
Yadav P, Chauhan VS, Bhat P S, Agarwal N, Yadav C, Bhatia S. Cross-sectional study of anxiety symptoms in students in preexamination period. Ind Psychiatry J 2017;26:56-63
Anxiety is the subjective sensation that accompanies the body's response to real or perceived threat. Anxiety disorders influence child's school and home functioning and have implication on development. With lifetime prevalence rates of 15%–20% and with >10% of children have impairing anxiety, anxiety disorder (AD) represents the most common childhood psychopathology. Childhood anxiety increases the risk for anxiety onset later in life  and is associated with long-term consequences related to school achievement and development. A study from India reported 36.7% of the children studying in secondary school (class V–X) having anxiety disorder. The mean age of onset for an AD is 11 years as reported by Kessler et al. in 2005.
Preexamination period is an exceptionally stressful time for schoolgoing children and adolescents, and the propensity of these symptoms increases. For some, the perceived academic stress leads to a sense of distress, which manifests itself in a variety of psychological and behavioral problems. The experience of academic stress and adolescent distress has been identified and explored by researchers in Korea and Japan. However, Indian research in this context is lacking. It is relevant to mention that, in India, in the year 2014 alone, 2403 children, or more than six children per day, committed suicide because of failure in examinations.
This study aims to assess the presence of anxiety symptoms in students (class VIII–XI) in preexamination period, i.e., about 3 weeks prior to the annual examination. This period is quite crucial for students and the related stress may unearth the latent symptoms and those with increased propensity to manifest AD may be identified. Further objective was also to screen for various subtypes of AD as mentioned below and to identify variables which are associated with these symptoms during this period. This becomes relevant as there is not much research in this area despite the fact that identification of symptoms and associated factors can be quite helpful in improving the mental status of students, improving their academics, and preventing hazardous or life-threatening consequences.
| Materials and Methods|| |
This was a cross-sectional study; at the end of the assessment, the students were given benefit of a session on examination-related stress and the various means to combat it.
A total of 700 children from class VIII to class XI were taken up for this study from a reputed public school after informed consent was taken from the parents by the school. Confidentiality of the information was ascertained. Children with known chronic medical condition and any known psychiatric disorder were excluded from assessment.
Finally after exclusion, the study was conducted on 619 children.
All of them were given a structured questionnaire for sociodemographic profile and Screen for Child Anxiety Related Emotional Disorders (SCARED) questionnaire. The questionnaire and the instructions to fill it were explained. These were given in small groups and care was taken that they sit separately so that the tendency to “copy and give” is negated.
The SCARED questionnaire consists of 41 items rated on a 3-point scale. A total score of ≥25 may indicate the presence of an AD and scores >30 are more specific. Depending on the score of different items on the questionnaire, specific anxiety disorders such as generalized AD (GD), social AD (SC), panic disorder or significant somatic symptom (PN), separation anxiety (SP), and school avoidance (SH) are indicated. Target population is 8–18 years old and is administered in 10 min. The sensitivity, specificity, positive predictive value, and negative predictive value of the SCARED screening test of the child are 82.35, 48.05, 41.18, and 86.05, respectively.
Various sociodemographic features were assessed [Table 1] including gender, change of schools (in last 5 years), physical presence of single or both parents, friend circle and presence of close friends, stressors in the family like someone suffering from chronic illness (including mental illness), alcohol problems and further stressors like history of physical abuse (including sexual abuse) and experience of neglect at home. Since the period was nearing examinations, time that was used up in the Internet (apart from studies) and physical activity/sports was also assessed. Their association with the presence of anxiety symptoms was then assessed.
The continuous variables were grouped according to the distribution so as to have almost equal size as far as possible within the constraints. What each question in the demographic profile intended was explained to the students so as to have similar results (e.g., alcohol problem in family was explained as – is anyone in the immediate family staying together is consuming alcohol which is causing repeated fights or arguments within family or abnormality in his/her behavior which is troublesome).
Descriptive statistics was analyzed with SPSS version 17.0 software. The Pearson's Chi-square test or the Chi-square test of association was used to determine if there is a relationship between two categorical variables. P < 0.05 was considered statistically significant.
| Results|| |
The sociodemographic profile and various variables assessed are shown in [Table 1], there were 619 students from class VIII to class XI and comprised of children aged 13–18 years. There were about 39% girls and 61% boys in the sample.
The score of ≥25 in SCARED questionnaire indicates the presence of AD and scores >30 is more specific, and in this study, almost 50% of the students had score ≥25 [Table 2]. Taking 30 as the cutoff, which increases the specificity (that followed in this study), shows that 170 children (27.5%) had anxiety symptoms [Table 3]. Frequency of various subtypes of anxiety is shown in [Table 4].
The total anxiety score (with cut-off ≥25) and scores in the three subgroups- GD, PN and SP were higher in females and were all statistically significant [Table 5], [Table 6], [Table 7].
|Table 5: Panic disorder (or significant somatic symptom) score distribution|
Click here to view
Analyzing the age group with total anxiety score, with cutoff >30, [Table 7] shows that 22.5% of children of <15 years had a score more than 30, while in ≥15 years' age group, almost 31% had increased score which was statistically significant. Students, who had spent >5 years in the school, had significantly lower scores than students of 3–5 years' age group. Students with <2 years in the current school had the least frequency. Staying in the house with both parents reduced the frequency of AD. Those staying with single parent or none had progressively increasing frequency of AD in the group and it was statistically significant. Students with the presence of stressors in the family in the form of chronic illness, alcohol problems, or mental illness all showed a statistically significant increase in the score of AD. Presence of more than one sibling or presence of smoking and alcohol use in the sample also shows a significant increase in the frequency of higher scores. Finally, students who had grade deterioration in the last few tests showed a highly significant increase in the frequency of AD. Other variables did not show significant relation with the AD score distribution.
Results of the PN domain [Table 5] association show that while only 30% of students with >5 years in the present school had a higher score, students who had <5 years in this school showed an inflated score in the range of 37%–44% which was statistically significant. Similarly, scores were significantly higher in students who had changed more than one school in the last 5 years. Scores were also significantly higher in students who perceived lack of friends or had grade deterioration in the last few tests. Apart from above, higher scores were associated with the presence of a chronic illness or mental illness or alcohol-related issues in family member and also higher in students who had used alcohol or had smoked, although these were not statistically significant.
Scores for GD [Table 6] also show that presence of friends and close friends appears protective against development of these symptoms and was statistically significant. Similarly, those perceiving that their grades were deteriorating had statistically significant higher scores. Frequency of high scores in SC domain was significantly more in students who had grade deterioration.
Scores of SH [Table 8] are higher in students of age group ≥15 years, further the frequency of having a higher score in this domain increases progressively in students who were living with both single and none parents. It was also more in those with separated parents. It was also higher in students who perceived a lack of friends; all these scores were statistically significant.
Scorings in other variables and the association with total score or subset score were not statistically significant.
| Discussion|| |
The study was conceptualized with the thought to screen for the prevalence of anxiety symptoms during the preexamination period and to further assess if there is any association with the mentioned demographic factors. In this sample, 27.5% students screened positive for anxiety symptoms with a cutoff of 30 (being more specific), while screening with a cutoff of ≥25 showed 49.5% qualifying for the disorder. These figures are more than the reported prevalence of anxiety in this age group as prevalence has been reported to be 8%–20% in various studies,, which, in this study, could be because of the time period in which this assessment was done, and also that here the symptoms were being screened and not the disorder per se. However, this still indicates that the intervention targeted to allay these symptoms must be taken up by school or parents as the increase in anxiety is known to affect the academic performance, interfere with interpersonal relationships, and increase the risk of suicide and other psychopathology.,
The various subtypes of anxiety screened show substantial increased frequency of students crossing the cutoff, like for GD subscale 35% of children screened positive. Similarly, PN has been found more than the cutoff in 38%. Similarly, other subtypes have showed relatively increased percentage of children crossing the cutoff. An Indian study using the same scale for screening shows lesser frequency of symptoms. GD has a prevalence of 1.6% current to 5.1% lifetime. Panic disorder has been found in around 10% of children in both western and Indian studies.,
These figures thus do indicate that, during the preexamination period, anxiety symptoms, if not disorders (as the scale only screens symptoms and the prevalence is probably an overestimate due to the use of only a screening test), are prevalent more than usual, which can be extrapolated to be affecting the performance in these examinations and an unhealthy state of mind which affects the student in a myriad fashion. Interestingly in India, the main documented cause of anxiety among schoolchildren and adolescents is parents' high educational expectations and pressure for academic achievement.
Moving ahead to find certain associated factors influencing these anxiety symptoms, the study shows that, as known, female gender is one predisposing factor in a number of above conditions (GD, PN, and SC), and this has been replicated in numerous studies. The total anxiety score and that of SC were found significantly more frequently in ≥15 years group, while in others, although the frequency was higher but was not statistically significant. This in a world that is critical of an individual's intellectual abilities and appreciates on the basis of academic performance, it is perhaps not surprising that students become more anxious over their academic success and failures as they age and understand the implications, also students in this age group are in class X and XI where the impression is that their future would depend on the grading achieved during these years.
Frequency of AD and the subset PN was more in students having spent >5 years in school, compared to the students with more time in the current school, additionally the latter was also more frequently associated with frequent changes in the school. Although this variable has not been studied in association with AD, it is quite obvious that students will be more confident and comfortable in the school they have spent more time in, which would provide a better social support and familiar environment and thus allaying anxiety of the examinations.
Speaking of social support, AD and SC scores are associated significantly with physical presence of parents in the house, as these scores increase if the students are living with single or none of the parents. In the other four subsets too, there is a progressive increase in the scores in children staying with both, single or none parents, but was not statistically significant. Further, social support in this age group is with peers and colleagues, perhaps consequently the higher scores in PN, GD, and SC were significantly associated with perceived lack of friends or absence of close friends. Social support is considered as one of the most important ways of coping with academic stress. Social support may play an important role at two different points in the causal chain linking stress to symptoms that first it reduces the effects of stress in precipitating them and second it helps in early and easy recovery.
Presence of stress in the family in the form of chronic medical or mental illness or alcohol-related problems also has increased frequency of symptoms across AD and, all subsets (except SC), however only scores of AD and PN were statistically significant. This is also not unusual as these stressors are known to be independent risk factors for anxiety symptoms. Similar pattern was seen in children who had a history of smoking or consuming alcohol (however these habits were not quantified).
Grade deterioration in the last few tests, just before the final examinations, is a big stress for the children and the causes can be variable but definitely take a toll on the confidence level of the students; here association with the anxiety scores show that students who had grade deterioration were more likely to have a higher score in all the subsets of anxiety, and this was statistically significant in AD, SC and GD. Now, whether it was the result of long-standing anxiety symptoms or a cause of it cannot be clearly stated.
Other variables did not show any association with the anxiety scores.
The results in this study provide evidence that the anxiety symptoms increase substantially during preexamination period relative to what is the reported prevalence in this age group which although contemplated but was not substantially proved. Further, the chances are quite high that these go unattended as they may be taken only as normal reaction to stress, which might be true in some but not all cases. Untreated anxiety disorders tend to have deleterious consequences  including lower academic achievement, problems with relationships, negative self-perception, poor self-esteem, and an increased incidence of psychiatric disorders later in life., It is well known that psychiatric disorders being unmasked in times of stress must be addressed, even if present for short duration. Further with rising cases of deliberate self-harm in this age group, particularly related to examination failure, the anxiety symptom, which itself can be a cause of low scores in examination, should be addressed. With anxiety, the executive attention is affected causing impairment in performances  and may also be one of the causal factors of depression.
The study had a good sample size, spreading across four classes, with various precautions during assessment to get valid answers and a variety of anxiety disorders were screened. Being a cross-sectional observation, this study thus has its limitation, and a longitudinal observation with an analysis much earlier in the academic year and a postexamination analysis could increase the level of evidence. Furthermore, many other variables could be assessed for association such as concurrent depression. Further, a diagnostic tool could be used in future studies following screening to increase the specificity, and a parental scale for child anxiety would give further information.
| Conclusion|| |
The preexamination phase is an inescapable period of each student's life, the study gives evidence of increased anxiety symptoms during this phase and the issue is imperative to improve performance and mental health of schoolchildren. A number of variables, such as age, years spent in the school, and recent grade deterioration were found significantly associated with the increased scores in various subsets of anxiety and thus these should be addressed as either contributing or resulting factors. Further studies as stated above would definitely add on the results obtained.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rapee RM, Schniering CA, Hudson JL. Anxiety disorders during childhood and adolescence: Origins and treatment. Annu Rev Clin Psychol 2009;5:311-41.
Beesdo K, Knappe S, Pine DS. Anxiety and anxiety disorders in children and adolescents: Developmental issues and implications for DSM-V. Psychiatr Clin North Am 2009;32:483-524.
Beesdo-Baum K, Knappe S. Developmental epidemiology of anxiety disorders. Child Adolesc Psychiatr Clin N
Joshi A, Kukreja S, De Sousa A, Shah N, Sonavane S, Karia S, et al
. Frequency and types of anxiety-related emotional disorders in secondary school children in an urban population from India. German J Psychiatry 2013;16:112-8.
Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62:617-27.
Lee M, Larson RW. The Korean examination hell: Long hours of studying, distress, and depression. J Youth Adolesc 2000;29:249-72.
National Crime Records Bureau (NCRB): Ministry of Home Affairs, Government of India. Available from: http://www.ncrb.nic.in
. [Last accessed on 2017 Apr 01]
Birmaher B, Brent DA, Chiappetta L, Bridge J, Monga S, Baugher M, et al
Psychometric properties of the screen for child anxiety related emotional disorders (SCARED): A replication study. J Am Acad Child Adolesc Psychiatry 1999;38:1230-6.
Costello EJ, Farmer EM, Angold A, Burns BJ, Erkanli A. Psychiatric disorders among American Indian and white youth in Appalachia: The great smoky mountains study. Am J Public Health 1997;87:827-32.
Costello EJ, Mustillo S, Erkanli A, Keeler G, Angold A. Prevalence and development of psychiatric disorders in childhood and adolescence. Arch Gen Psychiatry 2003;60:837-44.
Gould MS, King R, Greenwald S, Fisher P, Schwab-Stone M, Kramer R, et al
Psychopathology associated with suicidal ideation and attempts among children and adolescents. J Am Acad Child Adolesc Psychiatry 1998;37:915-23.
Wittchen HU, Nelson CB, Lachner G. Prevalence of mental disorders and psychosocial impairments in adolescents and young adults. Psychol Med 1998;28:109-26.
Masi G, Favilla L, Mucci M, Millepiedi S. Panic disorder in clinically referred children and adolescents. Child Psychiatry Hum Dev 2000;31:139-51.
Deb S. A Study on the Negative Effects of Academic Stress. Paper Presented at the International Seminar on Learning and Motivation, Kedah Darul Aman, Malaysia; October, 2001.
Baqutayan S. Stress and social support. Indian J Psychol Med 2011;33:29-34.
] [Full text]
Essau CA, Conradt J, Petermann F. Frequency, comorbidity, and psychosocial impairment of anxiety disorders in German adolescents. J Anxiety Disord 2000;14:263-79.
Ialongo N, Edelsohn G, Werthamer-Larsson L, Crockett L, Kellam S. The significance of self-reported anxious symptoms in first grade children: Prediction to anxious symptoms and adaptive functioning in fifth grade. J Child Psychol Psychiatry 1995;36:427-37.
Ezpeleta L, Keeler G, Erkanli A, Costello EJ, Angold A. Epidemiology of psychiatric disability in childhood and adolescence. J Child Psychol Psychiatry 2001;42:901-14.
Copeland WE, Shanahan L, Costello EJ, Angold A. Childhood and adolescent psychiatric disorders as predictors of young adult disorders. Arch Gen Psychiatry 2009;66:764-72.
Roza SJ, Hofstra MB, van der Ende J, Verhulst FC. Stable prediction of mood and anxiety disorders based on behavioral and emotional problems in childhood: A 14-year follow-up during childhood, adolescence, and young adulthood. Am J Psychiatry 2003;160:2116-21.
Mogg K, Salum GA, Bradley BP, Gadelha A, Pan P, Alvarenga P, et al.
Attention network functioning in children with anxiety disorders, attention-deficit/hyperactivity disorder and non-clinical anxiety. Psychol Med 2015;45:2633-46.
Bittner A, Goodwin RD, Wittchen HU, Beesdo K, Höfler M, Lieb R, et al.
What characteristics of primary anxiety disorders predict subsequent major depressive disorder? J Clin Psychiatry 2004;65:618-26.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]