Original Article

Mental Health Problems and the Associated Family and School Factors in Adolescents: A Multilevel Analysis


Objective: Mental health is one of the most important issues in adolescents’ life. Adolescents’ health is highly important, because of their role in the future. This study was conducted using multilevel analysis to investigate the risk factors at student and school levels.

Method: This was a cross sectional study for which 1740 students and 53 schools were selected between February and March 2018 in Qazvin, Iran. Multistage stratified cluster sampling was used for data collection. Mental health problems were measured by the Strengths and Difficulties Questionnaire (SDQ). Emotional symptom, conduct problem, hyperactivity, peer relationship problem, and prosocial behavior were the subscales. This study used multilevel analysis to determine the association between each of the questionnaire scales and students and schools variables.
Results: The prevalence of the mental health problems was 16.2%. Conduct problem was more prevalent than others (21.1%). Overall, the score of mental health problems was significantly lower in boys’ schools, in adolescents with physical activity, and in families with high socioeconomic status. Hyperactivity and emotional symptoms were significantly higher in girls’ schools. While prosocial behavior and peer relationship problems were significantly higher in boys’ schools. The association between variables and the scales of mental health problems was different.
Conclusion: Results indicated desirable physical activity and socioeconomic status are effective components in the adolescents’ mental health, and, mostly girls’ schools were more vulnerable than boys’ schools. Therefore, the educational authorities and health policymakers should consider this diversity to design interventional programs and pay more attention to the high-risk adolescents in different schools.

1. Bhatia BD, Craig M. Elements of psychology and mental hygiene for nurses in India. Bombay: Orient Longmans; 1958:40-53.
2. Soltanian AR, Amiri M, Namazi S, Qaedi H, Kohan GR. Mental Health Changes and Its Predictors in Adolescents using the Path Analytic Model: A 7-Year Observational Study. Iran J Psychiatry. 2014;9(1):1-7.
3. Khaleghi A, Mohammadi MR, Zandifar A, Ahmadi N, Alavi SS, Ahmadi A, et al. Epidemiology of psychiatric disorders in children and adolescents; in Tehran, 2017. Asian J Psychiatr. 2018;37:146-53.
4. Srinath S, Kandasamy P, Golhar TS. Epidemiology of child and adolescent mental health disorders in Asia. Curr Opin Psychiatry. 2010;23(4):330-6.
5. Mohammadi MR, Ahmadi N, Salmanian M, Asadian-Koohestani F, Ghanizadeh A, Alavi A, et al. Psychiatric Disorders in Iranian Children and Adolescents. Iran J Psychiatry. 2016;11(2):87-98.
6. Rabbani A, Mahmoudi-Gharaei J, Mohammadi MR, Motlagh ME, Mohammad K, Ardalan G, et al. Mental health problems of Iranian female adolescents and its association with pubertal development: a nationwide study. Acta Med Iran. 2012;50(3):169-76.
7. Sharifi V, Mojtabai R, Shahrivar Z, Alaghband-Rad J, Zarafshan H, Wissow L. Child and Adolescent Mental Health Care in Iran: Current Status and Future Directions. Arch Iran Med. 2016;19(11):797-804.
8. Bakhteyar K, Bastami F, Ebrahimzadeh F, Almasian M, Hosseinabadi R, Farhadi A. Factors associated with mental health of high-school students in the Islamic Republic of Iran. East Mediterr Health J. 2018;24(4):368-76.
9. Ahmadpanah M, Nazaribadie M, Mohammadi MR, Hooshyari Z, Alavi SS, Ghaleiha A, et al. The Prevalence of Psychiatric Disorders in Children and Adolescents in Hamadan Province, West of Iran. J Res Health Sci. 2018;18(4):e00432.
10. Mohammadi MR, Ahmadi N, Khaleghi A, Mostafavi SA, Kamali K, Rahgozar M, et al. Prevalence and Correlates of Psychiatric Disorders in a National Survey of Iranian Children and Adolescents. Iran J Psychiatry. 2019;14(1):1-15.
11. Mehrdadi A, Sadeghian S, Direkvand-Moghadam A, Hashemian A. The prevalence and risk factors of mental disorders among students in Ilam: A cross-sectional study. International Journal of Epidemiologic Research. 2017;4(1):31-6.
12. Hassanzadeh J, Rezaei F, Khazaei Z, Noroozi M, Jahangiry L. The Prevalence of Mental Health Problems and the Associated Familial Factors in Adolescents in the South of Iran. International Journal of Pediatrics. 2019;7(4):9317-25.
13. Amiri S, Mohammadi MR, Ahmadi N, Khaleghi A, Nourouzi S, Asl Rahimi V, et al. Prevalence of Psychiatric Disorders Among Children and Adolescents in the East Azerbaijan Province, Tabriz, Iran in 2017. Iranian Journal of Psychiatry and Behavioral Sciences. 2019;13(4).
14. Moharreri F, Habrani P, Heidari Yazdi A. Epidemiological survey of psychiatric disorders in children and adolescents of Mashhad in 2009. Journal of Fundamentals of Mental Health. 2015;17(5):247-53.
15. Noorbala AA, Bagheri Yazdi SA, Faghihzadeh S, Kamali K, Faghihzadeh E, Hajebi A, et al. Trends of Mental Health Status in Iranian Population Aged 15 and above between 1999 and 2015. Arch Iran Med. 2017;20(11 Suppl. 1):S2-s6.
16. Kieling C, Baker-Henningham H, Belfer M, Conti G, Ertem I, Omigbodun O, et al. Child and adolescent mental health worldwide: evidence for action. Lancet. 2011;378(9801):1515-25.
17. Caqueo-Urizar A, Flores J, Escobar C, Urzua A, Irarrazaval M. Psychiatric disorders in children and adolescents in a middle-income Latin American country. BMC Psychiatry. 2020;20(1):104.
18. Stengård E, Appelqvist-Schmidlechner K. Mental health promotion in young people–an investment for the future. WHO Regional Office for Europe, Copenhagen, Denmark. 2010: 1-10.
19. Galanti MR, Hultin H, Dalman C, Engstrom K, Ferrer-Wreder L, Forsell Y, et al. School environment and mental health in early adolescence - a longitudinal study in Sweden (KUPOL). BMC Psychiatry. 2016;16:243.
20. Merikangas KR, Nakamura EF, Kessler RC. Epidemiology of mental disorders in children and adolescents. Dialogues Clin Neurosci. 2009;11(1):7-20.
21. Long E, Gardani M, McCann M, Sweeting H, Tranmer M, Moore L. Mental health disorders and adolescent peer relationships. Soc Sci Med. 2020;253:112973.
22. Hosseinkhani Z, Hassanabadi H, Parsaeian M, Karimi M, Nedjat S. Academic Stress and Adolescents Mental Health: A Multilevel Structural Equation Modeling (MSEM) Study in Northwest of Iran. J Res Health Sci. 2020; 20(4): e00496.
23. Goodman R, Meltzer H, Bailey V. The Strengths and Difficulties Questionnaire: a pilot study on the validity of the self-report version. Eur Child Adolesc Psychiatry. 1998;7: 125-30.
24. Ghanizadeh A, Izadpanah A. Scale validation of the strengths and difficulties questionnaire in Iranian children. Iran J Psychiatry. 2007; 2(2):65-71.
25. Gwatkin DR, Rutstein S, Johnson K, Suliman E, Wagstaff A, Amouzou A. Socio-economic differences in health, nutrition, and population within developing countries: an overview. Niger J Clin Pract. 2007;10(4):272-82.
26. Filmer D, Pritchett LH. Estimating wealth effects without expenditure data--or tears: an application to educational enrollments in states of India. Demography. 2001;38(1):115-32.
27. Van de Poel E, Hosseinpoor AR, Speybroeck N, Van Ourti T, Vega J. Socioeconomic inequality in malnutrition in developing countries. Bull World Health Organ. 2008;86(4):282-91.
28. Jewell NP. Statistics for epidemiology. 1st ed. Chapman and Hall/CRC, 2003:121-35.
29. Soleimani MA, Pahlevan Sharif S, Bahrami N, Yaghoobzadeh A, Allen KA, Mohammadi S. The relationship between anxiety, depression and risk behaviors in adolescents. Int J Adolesc Med Health. 2017;31(2).
30. Emami H, Ghazinour M, Rezaeishiraz H, Richter J. Mental health of adolescents in Tehran, Iran. J Adolesc Health. 2007;41(6):571-6.
31. Ganjali M, Saravani S, Jalalinejad R, Davoodi M. Mental health status of Zabol city high school students and the factors influencing it during the academic year 2014-2015. Int J Pharm Technol. 2016;8(3):19086-93.
32. Hajloo N. The Study of Counselling Services Effect on Iranian Adolescence's Mental Health. Procedia Soc Behav Sci. 2011;30:312-5.
33. Soltanian AR, Nabipour I, Akhondzadeh S, Moeini B, Bahreini F, Barati M, et al. Association between physical activity and mental health among high-school adolescents in Boushehr province: A population based study. Iran J Psychiatry. 2011;6(3):112-6.
34. Zahedi H, Kelishadi R, Heshmat R, Motlagh ME, Ranjbar SH, Ardalan G, et al. Association between junk food consumption and mental health in a national sample of Iranian children and adolescents: the CASPIAN-IV study. Nutrition. 2014;30(11-12):1391-7.
35. Blair SN, LaMonte MJ, Nichaman MZ. The evolution of physical activity recommendations: how much is enough? Am J Clin Nutr. 2004;79(5):913S-20S.
36. Alidosti M, Baneshi M, Gharlipour Z. The Determination of Physical Activity among Girl Adolescents based on Trans-theoretical model (TTM). Int J Pediatr. 2017;5(7):5315-26.
37. Dunn AL, Weintraub P. Exercise in the prevention and treatment of adolescent depression: a promising but little researched intervention. Am J Lifestyle Med. 2008;2(6):507-18.
38. Kleppang AL, Hartz I, Thurston M, Hagquist C. The association between physical activity and symptoms of depression in different contexts - a cross-sectional study of Norwegian adolescents. BMC Public Health. 2018;18(1):1368.
39. Mikkelsen K, Stojanovska L, Polenakovic M, Bosevski M, Apostolopoulos V. Exercise and mental health. Maturitas. 2017;106:48-56.
40. Turner D, Carter T, Sach T, Guo B, Callaghan P. Cost-effectiveness of a preferred intensity exercise programme for young people with depression compared with treatment as usual: an economic evaluation alongside a clinical trial in the UK. BMJ Open. 2017;7(11):e016211.
41. Eddolls WTB, McNarry MA, Lester L, Winn CON, Stratton G, Mackintosh KA. The association between physical activity, fitness and body mass index on mental well-being and quality of life in adolescents. Qual Life Res. 2018;27(9):2313-20.
42. Jalali-Farahani S, Amiri P, Chin YS. Are physical activity, sedentary behaviors and sleep duration associated with body mass index-for-age and health-related quality of life among high school boys and girls? Health Qual Life Outcomes. 2016;14(1):30.
43. Angelini V, Howdon DDH, Mierau JO. Childhood Socioeconomic Status and Late-Adulthood Mental Health: Results From the Survey on Health, Ageing and Retirement in Europe. J Gerontol B Psychol Sci Soc Sci. 2019;74(1):95-104.
44. Reiss F. Socioeconomic inequalities and mental health problems in children and adolescents: a systematic review. Soc Sci Med. 2013;90:24-31.
45. Reiss F, Meyrose AK, Otto C, Lampert T, Klasen F, Ravens-Sieberer U. Socioeconomic status, stressful life situations and mental health problems in children and adolescents: Results of the German BELLA cohort-study. PLoS One. 2019;14(3):e021370.
IssueVol 16 No 1 (2021) QRcode
SectionOriginal Article(s)
DOI https://doi.org/10.18502/ijps.v16i1.5373
Adolescents Iran Mental Health Multilevel Analysis Students SDQ

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How to Cite
Hosseinkhani Z, Parsaeian M, Hassanabadi H-R, Khoshkchali A, Alinesaei Z, Nedjat S. Mental Health Problems and the Associated Family and School Factors in Adolescents: A Multilevel Analysis. Iran J Psychiatry. 2021;16(1):13-20.