RESEARCH
Psychiatric illnesses in homeless (runaway or throwaway) girl inmates: a preliminary study
Rajiv Gupta, Dharmender Kumar Nehra1, Vinay Kumar2, Poonam Sharma3, Pradeep Kumar4
Professor and Head, Department of Psychiatry, 1Clinical Psychologist, State Institute of Mental Health, 2Psychologist, Department of Psychiatry, Post Graduate Institute of Medical Sciences, 3Psychologist, Nari Kiketan, Karnal, 4Psychiatric Social Worker, State Institute of Mental Health, Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
Abstract
Introduction: Mental illnesses are continuing to spread worldwide. There is no society and strata that are immune to mental illness; homeless population is also not an exception. The present study estimates the prevalence of psychiatric illnesses in homeless girls who are presently living as inmates. Thirty six girls (aged 14-17 years) who are homeless (either runaway or throwaway) were interviewed along with their primary caregiver. Data were gathered through both a structured interview with the girls and their present caregiver at institute.
Tools: The Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) was used for assessing psychiatric illnesses. Before administering the MINI-KID, their intelligence quotient (IQ) was also measured to assess their intellectual functioning.
Results and conclusion: Findings indicate that the prevalence of depression and posttraumatic stress disorder (PTSD) were higher followed by conversion disorder, mental retardation and panic disorder in present sample. The results also show that more than 60% of inmates met the criteria for at least one psychiatric disorder. Overall, estimates of psychiatric morbidity in the inmate girl are higher than those reported in Western World. The most striking finding of the present study is that more than 80% were classified as runaway and the majority of mentally ill inmates required specialised mental health housing. These findings suggest future challenges not only for mental health professional but also for policy makers.
Gupta R, Nehra DK, Kumar V, Sharma P, Kumar P. Psychiatric illnesses in homeless (runaway or throwaway) girl inmates: a preliminary study. Dysphrenia. 2013;4(1):31-5.
Keywords: Adolescent women. Depression. PTSD. Conversion disorder. ‘Honour’ killing. Anxiety disorder. Social support. Mental retardation.
Correspondence: dknehra@yahoo.com
Received on 16 May 2012. Accepted on 1 July 2012.
Introduction
Homelessness is a prevalent social problem throughout the world; unfortunately the number of homeless people worldwide has grown steadily in recent years.[1] The legal definition of “homeless” varies from country to country. According to the census of India, the homeless people are those who do not live in census houses (a census house is referred to a structure with a roof). By and large, homeless children and youth fall into one of two groups:[2] (i) runaways(who have left the parental home, sometimes due to abuse experienced in the home); (ii)throwaways (who have been kicked out of the home by their parents, often due to parental dysfunction and/or youth behaviour problems). In India, Juvenile Justice (Care and Protection of Children) Act, 2000, is meant for any person who has not completed 18th year of age and does not have parent and no one is willing to take care of, or whose parents have abandoned him, or who is missing and run away. Runaway and homeless are vulnerable to serious health and social consequences.[3] They, by circumstance and necessity, participate in a number of health-compromising behaviours (drug use, prostitution etc.) at a much greater frequency than their non-runaway peers.[4] The precise number of runaway/throwaway is unknown but world literature suggests that between 1.6 and 2.8 million youth have a runaway/throwaway episode each year.[5,6] Several studies have also revealed a high prevalence of mental health problems in homeless population.[7,8] The lifetime prevalence of major mental illness in recent studies is reporting three times greater than for the general population.[9,10] Traditionally homelessness has been viewed from male-centered perspectives, the relationship between women and homelessness is gaining attention as recognition grows that single women and women with children make up two of the most quickly growing subgroups of this population.[11] The growing number of runaway and throwaway adolescents has also urged gender specific concerns. As homeless men experience a variety of social and environmental risks,[12] but women seems to constitute one of the groups worst affected by homelessness. Serial of studies on homeless women and men show that they differ in many respects, including reasons for becoming homeless,[13] the occurrence of alcohol, drug and mental health problems,[14,15] health status and sexual health practices,[16] family and social relationships,[17] history of domestic violence,[11] abuse and victimisation.[15] In a recent study from Asian region, largest number of participant mentioned the immediate reason of their runaway to be punishment at home by parents or guardians.[18] In some cultures, running away of young unmarried girl with a man makes the girl subject to sever punishment.[19] In north India also, a girl generally supposed to marry outside her own village and outside the circle of a carefully chosen list of relatives;[20] otherwise she gets punishment because of bringing dishonour to the family. Khap panchayats (caste-councils) over the centuries have not approved inter caste or class marriages and considers such marriages as immoral, deserving rigorous reprimand, and developed a culture of intolerance.[21] In this culture, elder members of the family are expected to control their children and runaway with someone or runaway marriages are considered as a breakage of cultural norms and customary practices and a significant cause that brings dishonour to the family. Parents who publicly fail to do so may lose status in the community as a result[22] and fear of being ostracised force the parents ‘jacobean’ murder, of these girls, that is considered as a heavenly duty and the executioners feel proud in displaying their cruelty.[21] In our country, at least a thousand women are believed to be killed every year for honour related reasons that is particularly prevalent in parts of Uttar Pradesh, Punjab, and Haryana.[22]
In many important ways homeless girls share common experiences but as general consensus girls who run away with man are even more vulnerable to severe kinds of abuse and violence. In most countries there is a need to address problems relating to adequate health care in the general population and to improve access to health care services by this homeless population. There is dearth of the literature that examines the health care aspects of runaway[4] that is particularly true in Indian context. Keeping this view in mind and going by the adage “absence of evidence is not the evidence of absence” our study attempts to estimate the prevalence of psychiatric morbidities in runaways/throwaways, so that treatment program can be developed, tailored and implemented for this specific and needy population.
Methodology
Sample: This study consisted of 36 inmate participants in the ages of 14 to 17 who were either runaway or thrown away.
Place of study: Nari Niketan, Karnal, Haryana, India.
Tools: The Mini-International Neuropsychiatric Interview (MINI) screening instrument with high validity and reliability scores for the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)[23] based diagnostic categories were used to assess psychiatric morbidity in subjects who were found to be have average intellectual functioning. MINI for Children and Adolescents (MINI-KID)[24] was used to assess psychiatric illnesses. The MINI-KID was used for evaluation of symptoms and diagnosis. The MINI-KID is an abbreviated psychiatric interview for children ages six to 17 years.[25] The MINI-KID is a reliable and valid tool for psychiatric diagnoses in children and adolescents.[26]
Procedure: Data were collected between the periods of November 2011 to February 2012. Written informed consent was obtained (from institutes’ authority) and assent (from inmates). The interviews were carried out by mental health professionals. Before administering the MINI-KID on the sample their intelligence quotient (IQ) were also measured by using appropriate intelligence tests.
Data analysis: Descriptive analysis was done by calculating the frequency and percentage.
Results
The analysis of the data and the results are tabulated below:
Discussion
More than one third of India’s population is below the age of 18 years and approximately 40% of the Indian population is children, making India the country with the highest number of child population in the world i.e. around 440 million.[27] Children and adolescents become homeless for many reasons; many leave intolerable home situations characterised by sexual and physical abuse, strained relationships, and parental neglect.[28] Tiwari et al.[29] found that the most common reason for running away was beating by parents/relatives, followed by a desire for economic independence, maltreatment by step parent(s), being both parents dead, argument with parent etc. But in present study 80% of the sample girls ran away with someone in love and 20% were thrown away by their family members. Runaway and homeless youth are reported to be vulnerable to serious health and social consequences.[30,31] Furthermore, adolescent women are considered among the most vulnerable and medically underserved subgroups within the homeless population.[32] The National Coalition for the Homeless[33] reports that approximately 20-25% of homeless suffer from mental illnesses compared with only four per-cent of the general population;[34] but present study reveal that more than 66% of homeless in our sample suffer from mental illnesses or conditions.
The findings of our study also revealed a high prevalence of depression (22.22%) in the study groups, which is in line with previous limited available data that suggest that rates of depression among homeless adolescents and adults higher than the general population.[35,36]
A strikingly revealing finding of our study is the high prevalence of posttraumatic stress disorder (PTSD) and conversion disorder in our study group (13.88% and 11.11%). These highly significant findings can be explained on account of the established sociocultural patterns of Haryanvi community, where, as general agreement, the woman of the family is considered fundamental to maintaining the honour of the family and if a girl marry without their family’s acceptance or marry outside their caste or religion could be subject of honour killing. The term ‘honour’ killing commonly refers to the murder (or sometimes the attempted murder) of a woman by members of her family who do not approve of her sexual behaviour.[37] Furthermore, honour killing has deep traditional roots and it remains a socially and religiously acceptable method of preserving familial honour as a result honour killings is reported in northern regions of India, including Haryana.[38] Hence, traumas of any nature do not only have physical manifestations[39] but can also effect the mental connotation of the sufferer. In addition, the presence of anxiety disorders (panic disorder 5.55% and generalized anxiety disorder 2.77%) is in agreement with other research findings revealing that the psychological impact of any catastrophe whether in the shape of a natural calamity or human caused disaster gives rise to a number of stress related reactions and psychiatric problems in the affected population.[40]
In addition to above mentioned explanations, these findings can be attributed to decreased social support in present sample (earlier 100% of our sample has family to live with). It is well known fact that, social integration is fundamental for good emotional health. The average person spends about 80% of waking hours in the company of others, and the time with others is preferred to the time spent alone.[41] Social support is viewed as a buffering mechanism, which has been shown on numerous occasions to be a protective influence against adverse event.[42] The absence of social support may result in an inability to form effective coping and adaptive behaviours necessary to re-establish norms and that could lead to emotional problems.
With regard to prevalence of mental retardation, our finding revealed a very high prevalence of mental retardation in the study groups (11.11%). Whereas, prevalence of mental retardation in India is reported to be around two per cent for mild mental retardation and 0.5% for severe mental retardation (defined as IQ less than 50).[43] The difference in the prevalence of mental retardation between the present study group and the previous findings are indicative of the fact that mentally retarded children and adolescents are thrown away because of their disability as all the four girls are thrown away.
These disorders do not necessarily require inpatient treatment; unrecognised mental illness may place inmates at greater risk. This study reinforces the need for appropriate screening and referral for treatment for this vulnerable population. The limitation of the study is its small sample size. Also, the study does not provide an insight into the cause and/or effect association of the studied disorders and homelessness. However, there is considerable evidence suggesting that homeless have more psychiatric illnesses as compared to their counterparts.
Conclusion
The issue of mental disorder among homeless people is not only important but also serious and challenging. The recognition of high number of psychiatric disorders in homeless adolescent population in present study seems to make the situation more dreadful. The reliable estimates of the prevalence of mental disorders in the runaways and throwaways would help policy makers as well as mental health professionals in the development of psychiatric services. Present findings advocate the human rights mainly of the homeless people with mental disorders and it’s a great urgency to eradicate mental illness in this comparatively more vulnerable population.
Further reading
Agarwalla S, Hazarika M. Childhood depression. Dysphrenia. 2012;3:93-7.
Hmar B. Child sexual abuse. Dysphrenia. 2011;2:4-8.
Pillai RR, Sekar K. Impact of tsunami disaster among children. Dysphrenia. 2013;4:21-4.
Raj H, Kumar K, Sinha VK, Dogra R. A comparative study on behavioural problems in children of alcohol dependent parents. Dysphrenia. 2012;3:137-43.
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