Preplanned Studies: Exploring Multiple Perspectives on Psychological Health of Adolescents in Relation to Gender and School Grade — Jiangsu Province, China, 2022

The escalating mental health issues among children and adolescents stem from academic pressures, family dynamics, and societal transformations, considerably impacting their life quality, academic success, and future prospects (1-2). Effective promotion of mental health in these groups necessitates cooperative efforts from families and educational institutions. Yet, both caregivers and educators often lack the necessary understanding and strategies to address these issues (3). This study distinctively integrates perspectives from children, caregivers, and teachers, offering a comprehensive assessment of the mental health environment, an aspect frequently overlooked in prior studies. The prevalence of mental health problems and risky behaviors among students can differ according to grade level and cognitive development. Additionally, gender differences are evident as girls are more likely to report symptoms of anxiety and depression (4), whereas boys tend to display increased aggression and disruptive behavior (5). Consequently, it is imperative to factor in both gender and educational level to forge a thorough comprehension of mental health challenges in this demographic. While variations in mental health conditions by sex and grade are recognized, this research furnishes detailed, empirical insights into these discrepancies, elucidating specific mental health difficulties and risky actions across different educational phases and between genders.

This study is part of the extensive, mixed longitudinal cohort study conducted in China, known as the “School-based Evaluation Advancing Response for Child Health (SEARCH).” In this setup, schools act as operational hubs, families play a critical supportive and informational role, and students are the primary focus. The current research employed a digital platform to examine the mental health of students in Jiangsu Province, tracking mental health statuses and developmental changes in a scalable and innovative manner. The study, a cross-sectional analysis conducted from September 2022 through February 2023, targeted students at various educational levels — primary, junior, and senior high school — along with their caregivers and teachers. Ethical approval was obtained from the ethics committee of the affiliated brain hospital of Nanjing Medical University (2022-KY095-02). Data collection occurred across three cities in Jiangsu, selecting three primary schools, four junior high schools, and three senior high schools per city. A stratified whole-group sampling method was utilized to monitor participants. The study aimed for a minimum of 450 children and adolescents aged 10–18, including their caregivers and teachers from each grade. Sample size calculation parameters included μ_α=1.96, μ_β=2.58, P₀=0.20, d=0.05, a design effect of 1.2, a predicted missing visit rate of 10%, and a required sample size of 6,930 participants. The study successfully achieved significant response rates, with 11,427 students, 8,839 caregivers, and 1,656 teachers participating. This broad inclusion of participants allows for comprehensive exploration of mental health development in children and adolescents, highlighting the impact of gender and educational level on mental health-related symptoms and risky behaviors.

The questionnaire was divided into two sections: the first section collected socio-demographic data such as gender, age, school grade, study status, and basic family details. The second section evaluated participants’ mental health using the Depression, Anxiety and Stress Scale (DASS-21), Insomnia Severity Index (ISI), and Ottawa Self-Injury Inventory (OSI). Additionally, the Strengths and Difficulties Questionnaire (SDQ) was administered to identify emotional and behavioral issues among students, with assessments gathered through self-reports from students and reports from caregivers and teachers. The study also investigated various health risk behaviors in children and adolescents, focusing on indicators like smoking and alcohol consumption. Data analyses were conducted using SPSS software (version 27, IBM SPSS Inc., Chicago, USA), comprising descriptive analyses of participant demographics. Chi-square tests were used to compare demographic characteristics across genders and to analyze the distribution of mental health symptoms and health risk behaviors across academic periods, with a focus on gender differences. Internal consistency was evaluated using Cronbach’s alpha to examine inter-rater agreement for SDQ scores, comparing results from self-reports, caregiver reports, and teacher reports across different genders and academic periods. Statistical significance was set at P values <0.05 (two-tailed).

The study involved 11,427 students, comprising 6,083 boys and 5,344 girls (Table 1). Analysis revealed that 23.02% of students displayed depressive symptoms, 33.70% experienced anxiety, and 16.79% exhibited signs of stress. Female students in both junior and senior high school demonstrated significantly higher incidences of depression, anxiety, stress, insomnia, suicidal behavior, self-harm, and suicidal ideation compared to their male counterparts (Table 2). Furthermore, the prevalence of depression, anxiety, stress, and insomnia increased progressively from primary school to junior high and then to senior high. Emotional-behavioral issues and prosocial behaviors showed higher consistency between self-reports and caregiver reports among girls than boys (Table 3). High congruence between self-reports and teacher reports for emotional symptoms, conduct problems, hyperactivity, peer issues, and prosocial behaviors was more prevalent in primary school students compared to those in junior and senior high schools.