Perceived Self Efficacy and Mental Health among Elderly

DELHI PSYCHIATRY JOURNAL Vol. 13 No. 2 OCTOBER 2010 Original Article Perceived Self Efficacy and Mental Health among Elderly Anand P. Singh*, Archana Shukla**, Pratibha A. Singh** *School Social Sciences and Buddhist Studies, Gautam Buddha University, Greater Noida, India **Department of Psychology, Lucknow University, Lucknow, India ***Department of Psychiatry, Institute of Human Behaviour and Allied Sciences, Delhi, India Introduction India, a sub-continent that carries 15 per cent of the world s population, is gradually undergoing a demographic change. In 1951, the sixty plus population was around 21 million. Three decades later in 1981, it was a little over 43 million, a further decade later in 1991, this had increased to 54.7 million and for 2001 it is projected to be nearly 76 million (medium projections). Thus, there has been a sharp increase in elderly population between 1991 and 2001 and it has been projected that by the year 314 Abastract Objectives: Perceived self-efficacy is a belief centers on appraisal vs. misappraisal of capabilities within the individual to produce designated level of performance. It mediates the relationship between functional decline, health condition and the need for formal care services. The present stduy aimed to study the impact of perceived self efficacy on mental health and to explore the predictor of mental health among elderly population. Method: The study consisted of 160 elderly respondents. Half of these were males and the other half females. They were further sub-divided into eight groups on the basis of their gender and age. Each of eight subgroups consisted of 20 respondents and assessed on the measures of Perceived Self Efficacy (PSE) and Mental Health i.e. General Health Questionnaire (GHQ). Results: The mean differences showed that the elderly males scored higher on the measure of PSE and GHQ and showed better meatal health than elderly females. Again the younger elderly groups scored higher on the measures of PSE and GHQ and reported better mental health than the elderly of advanced age groups. Conclusion: The present study revealed that the problem of elderly is emerging not only due to their increasing proportion of age but also due to their own faulty cognitions and perceptionof aging. Perceived self efficacy emerged as an imjportant predictor of mental health among elderly males and females i.e. elderly who perceive themselves self efficacious to have control over their environment reported better mental health and vice versa. Keywords: Perceived Self Efficacy, Mantal Health, Elderly. Delhi Psychiatry Journal 2010; 13:(2) Delhi Psychiatric Society 2050, the number of elderly people would rise to about 324 million. 1 Though, the India has acquired the label of an ageing nation with 7.7% of its population being more than 60 years old 2 and sixty one percent of the elderly population has at least some kind of mental health problems 3 but Geriatric medicine/geropsychology is yet to acquire an important place in India. Since, the major life changes in later years are brought about by retirement, relocation, and loss of friends or spouses. Such changes induce demands on

OCTOBER 2010 DELHI PSYCHIATRY JOURNAL Vol. 13 No. 2 interpersonal skills to cultivate new social relationships that can contribute to positive functioning and personal well-being. Although some older people may use such situations to learn and to grow but for most old age indeed means an abundance of physical, social and psychological problems. 4 Jeffrey Schwartz in his book, The Mind and the Brain, stated that we can sometimes choose to think differently about things, which in turn will change the physical wiring of our brain and, in doing so create a kind of upward spiral for ourselves. 5 Health psychologists who focus on the mind body interaction have demonstrated that individual s thinking and belief can either increase the risk of disease on the one hand or restore health and composure on the other. 6 Perceived self-efficacy is again people s beliefs about their capabilities to produce designated levels of performance that exercise influence over events that affect their lives. It mediates the relationship between functional decline, health promoting behaviors and the need for health care services. 7 Bandura s 8,9 social cognitive theory of self-efficacy has been found useful in explaining the perceived abilities, physical exercise and health behaviors among older adults. 10-14 The self-efficacy issues among elderly focus mainly on reappraisals and misappraisals of their capabilities. 15 Many physical and mental capacities do decrease as people grow older, thus, the reappraisals of self-efficacy i.e. the perception of gains in knowledge, skills, and expertise can compensate some of these losses in physical and mental capacity and helps in enhancing the self esteem, self confidence and health behaviors. 16 Luszcynska, et al. 17 found that general self-efficacy constructs were found closely related to a variety of psychological constructs, such as stress appraisals, social relationships, quality of life, selfesteem and mental health of an individual. The older adults who perceived themselves efficacious and participated in physical activity reported greater levels of life satisfaction and lower levels of depression than their sedentary counterparts. 18 Bandura 8,9 argued that people will choose a course of action based on their expectation about their own ability to perform a given behavior and this perceived ability plays an important role in improving exercise adherence 19 (Davis et al 2006) and mental well being & functioning. 9 As, the Health Belief Model and Attribution Theory have proven over and over that thoughts, attitudes, perceptions and beliefs have a direct impact on physical and mental health and these complex mental states drive people to feel and act in one way or another towards the detriment or the advancement of their health. The major role transition, deterioration in physical health and other significant losses like loss of spouse, loss of offspring and financial loss often contribute the development of negative beliefs and negative thoughts among elderly and further leads the development of rumination of these negative thoughts, negative situations, and negative events. These eventually induce psychological disturbances among people of old ages. Thus, believing in this premise that as one moves forward in age, there are changes in one s thinking, perception of ability and the way one feels about oneself, others and the world around, encouraged to formulate the present study with specific objectives of measuring the impact of perceived self efficacy on mental health and identifying the perceived self efficacy as an important predictor of mental health among elderly population. Material and Methods Sample: The present study was regarded as an exploratory research in nature as it attempted to examine perceived self efficacy in relation to mental health among various groups of elderly. The sample consisted of 160 elderly respondents. Half of these were males and the other half females. They were further sub-divided into four groups on the basis of their age i.e. (60-64 years, 65-69years, 70-74years, and 75+ years). Each of eight subgroups consisted of 20 respondents. Inclusion Criteria: Only those males and females elderly were included in the study who: (1) were educated at least up to 10 th standard; (2) did not have any apparent physical disability or chronic illness; (3) were married irrespective of whether their spouses were or were not alive at the time of the study; and (4) were from urban background. Exclusion Criteria: Any respondent who had been ever diagnosed with a psychiatric illness and /or was being treated for that was not included in the study. Delhi Psychiatry Journal 2010; 13:(2) Delhi Psychiatric Society 315

DELHI PSYCHIATRY JOURNAL Vol. 13 No. 2 OCTOBER 2010 Variables and Measures: The present study utilized two classificatory variables and two psychological variables. Brief descriptions of these variables are as below. (A) Classificatory Variables: The two classificatory variables of age and sex were used to divide respondents into eight groups: elderly males and females falling in the age range of 60-64 years, 65-69 years, 70-74 years and 75+ years. (B) Psychological variables: The other variables of interest in the study are Perceived Self Efficacy and Mental Health. (1) Perceived Self Efficacy; refers to people s belief about their capabilities to exercise control over events that affect their lives. In the present study Perceived Self Efficacy was assessed by the General Perceived Self Efficacy Scale (GPSES) developed by Schwartzer and Jerusalem. 20 The scale consists of 10 items to be rated on a four points rating scale ranging from not at all true scored as 1 to exactly true scored as 4. The theoretical range of scores on this scale ranges from 10-40 with high score indicating high self efficacy and vice-versa. (2) Mental Health; WHO defines health as a state of complete physical, mental and social well being and not merely the absence of disease or infirmity? The present study focused mainly on mental health. It was measured with the help of the 12 items version of General Health Questionnaire (GHQ) developed by Goldberg. 21 It uses a four points rating scale ranging from not at all scored as 0 to much more than usual, scored as 1, the first two categories are combined and given a score 0, while the last two categories are combined and given a score of 1. The total score on this scale could thus range from 0-12. The cut of point which gives optimum discrimination between psychiatric cases and normal is at 3 and 4 i.e. the respondents with 3 or smaller score are considered normal and those with 4 or more are considered psychiatric cases. Procedure: The present study proceeded through the following steps. (1)Questionnaire Construction: Questionnaires were constructed consisting of two parts. The first part contained the informed consent form which was filled up by all the subjects, and personal data sheet to elicit demographic information regarding subjects age, gender, education, marital status and other relevant variables. The second part included items from the General Perceived Self Efficacy Scale (GPSES) and General Health Questionnaire (GHQ). (2)Data Collection: For collecting the data, personal face to face interviews were conducted. The elderly meeting all the inclusion and none of the exclusion criteria were recruited from general population through survey method. Thus a total of 160 subjects of both the genders formed the sample and studied. (3)Statistical Analyses: The data were analyzed using Means, SDs and ANOVAs to see the differences of means among various groups on the measures of PSE and GHQ caused due to respondents age and sex. (ii) The regression analysis was done to explore whether perceived self efficacy can predict mental health among elderly or not. (4) Ethical Consideration: Informed consent was taken from all the participants included in the study. All the participants were ensured about the confidentiality of information and were allowed to have the free will or option of withdrawing their participation from the study at any point of time due to any reason. Results Hypothesizing that the cognitions/beliefs are the key factor of mental health, the present study focused to study the nature of relation between perceived self efficacy and mental health. A total of 160 elderly, from both the genders, who met the inclusion criteria constituted the sample of the present study. The first set of statistical analyses included means, standard deviation and analysis of variances. These analyses helped to identify differences due to sex and age with respect to perceived self efficacy and mental health. (1) Means SDs and ANOVAs The result obtained from basic statistics and ANOVAs are presented in Tables 1.1 and 1.2 regarding the psychological variables of perceived self efficacy and mental health. Each of these tables has two parts: A, and B, containing means & SDs and summary ANOVAs respectively. Table 1.1 deals with perceived self efficacy of respondents. The Part B of this table shows that the main effect of sex is not significant, suggesting that elderly males and females do not differ in their perception about self efficacy. But the main effect of age (F=3.61, P<.05) as well as interaction effect of age and sex (F=3.16, P<.05) is significant indicating that perceived self 316 Delhi Psychiatry Journal 2010; 13:(2) Delhi Psychiatric Society

OCTOBER 2010 DELHI PSYCHIATRY JOURNAL Vol. 13 No. 2 efficacy decreases with advancement of age and this is more so in case of the female respondents (m=32.20, 30.10, 31.20, and 25.25 for the age groups 60-64 years, 65-69years, 70-74years, and 75+ years respectively) than for the male respondents (m=31.50, 28.95, 31.15 and 31.00 for the age groups 60-64 years, 65-69 years, 70-74 years, and 75+ years respectively). Again the Table 1.2 contains the results about mental health of the elderly. This table shows a significant main effect of sex favoring the male elderly. That is elderly females as groups are found to have lower mental health than elderly males. The mean GHQ score shows that elderly females were rated significantly higher on psychiatric symptoms than elderly males (m=3.94 vs. 2.79, F=5.731, P<.01). The other important findings are age related differences. As noted earlier the elderly of advanced age (75+yrs) have poorer mental health than elderly of younger age groups. The means thus show that the mental health decreases with increasing age (means for males are 1.55, 3.80, 2.75 and 3.05; means for females are 2.30, 3.55, 4.30 and 5.60; F=4.502, P<.01). Further the interaction effect of age and sex was not found significant (F=1.531, P>.05). (2) Regression Analysis One of the objectives of this study was to identify the perceived self efficacy as a predictor of mental health among elderly. For this purpose stepwise multiple regression analyses were done. For the first set, separate regression equations were calculated for the male and female elderly. For the second set, four additional regressions were computed corresponding to the four sub samples of the respondents formed on the basis of their age. Major findings from the regression analyses are presented in Table 2.1 and 2.2. The Table 2.1 shows that the perceived self efficacy emerged as an important predictor of mental health among elderly males and females. Beta coefficient for perceived self efficacy is negative suggesting that the perceived self efficacy is positively related to mental health. That is people who perceive themselves efficacious have better mental health and vice versa. As, the highest value of R 2 is.446 and.483 for the males and females respondents respectively therefore it can be said that a average proportion (approximately 45-48%) of variance in criterion variable of mental health is explained however about 52% of the variance in mental health is thus left unexplained. This point towards the possibility that some other variables, not included in the study, could have possible potential for the prediction of mental health than the variable assessed in the present study. Again the Table 2.2 contains the regression equations corresponding to various age groups of elderly. Purpose of this analysis was to identify if predictor of mental health vary with advancing age. The table reflects that the perceived self efficacy emerged important twice for the elderly group aged 65-69 yrs and also for those above 75+ yrs. Table 1.1: Perceived Self Efficacy among Elderly Males and Females A. Means and SDs Age Males N=20 Females N=20 60-64 years, Mean (SD) 31.50 (5.19) 32.20 5.27 65-69 years, Mean (SD) 28.95 (6.78) 30.10 7.30 70-74 years, Mean (SD) 31.45 (4.17) 31.20 5.71 75+ years, Mean (SD) 31.00 (5.13) 25.25 5.32 Total Mean (SD) 30.73 (5.40) 29.69 6.43 B. Summary ANOVAs df MS F Sex 1 43.06 1.33 Age 3 116.66 3.61* Sex x Age 3 102.11 3.16 *Significant at. 05 level Delhi Psychiatry Journal 2010; 13:(2) Delhi Psychiatric Society 317

DELHI PSYCHIATRY JOURNAL Vol. 13 No. 2 OCTOBER 2010 Table 1.2: Mental Health among Elderly Males and Females A. Means and SDs Age Males N=20 Females N=20 60-64 years, Mean (SD) 1.55 (2.54) 2.30 2.39 65-69 years, Mean (SD) 3.80 (3.52) 3.55 3.52 70-74 years Mean (SD) 2.75 (2.95) 4.30 3.40 75+ years Mean (SD) 3.05 (3.10) 5.60 2.64 Total Mean (SD) 2.79 (3.10) 3.94 3.20 Table-2.1. Severity of illness and Verbal learning and Memory among ADHD Children Variables ADHD < 22 ADHD>22 t-value P-Value (n=9) (n=11) df=18 Learning Total Mean 42.333 42.727 -.287.778 SD 2.12 3.635 Recall after interference Mean 7.777 7.454.574.573 SD.803 1.507 Delayed Recall Mean 6.111 5.818.642.529 SD.781 1.167 Recognition Mean 12.333 12.454 -.264.794 SD 1.000 1.035 Table-2.2. Severity of illness and Verbal learning and Memory among Children with Emotional Disorder Variables DPCL< 12 DPCL>22 t-value P-Value (n=10) (n=10) df=18 Learning Total Mean 53.60 52.300.721.480 SD 4.551 3.434 Recall after interference Mean 11.30 10.660 1.400.179 SD.949 1.265 Delayed recall Mean 9.400 9.500 -.142.889 SD 1.074 1.957 Recognition Mean 13.200 13.100.200.844 SD 1.032 1.197 But for the other age groups such as 60-64yrs and 70-74yrs it could not be found important predictor of mental health. However, it should not be taken to suggest that the perceived self efficacy is less important at other ages rather this could be due to small sample size and problem of analysis that it could not be emerged important predictor for these groups. What is important is that out of six regression equations perceived self efficacy got included in four and emerged as an important predictor of mental health in elderly population and attempted to explain about 50% variance in the criterion variable of mental health. 318 Delhi Psychiatry Journal 2010; 13:(2) Delhi Psychiatric Society Discussion Cognitive theorists suggest that thinking in irrational and illogical ways may have several serious health related consequences. Epictetus writes men are disturbed not by the things but by the views which they take of them, and Shakespeare states in hamlet: There is nothing either good or bad but thinking makes it so (Ellis, 1962). The present study was designed with the aim to explore the importance of perceived self efficacy for health among elderly. People avoid situation and activities that can be aversive not because they are

OCTOBER 2010 DELHI PSYCHIATRY JOURNAL Vol. 13 No. 2 beset with anxiety but because they believe they will be unable to manage the risky aspects. Those who believe themselves efficacious in managing threats neither fear nor shun them. In the present study the findings revealed that respondents who perceived themselves self efficacious showed poor mental health and vice versa. The present study revealed that the mean differences on the measures of PSE and GHQ suggest that the elderly males perceive themselves more self efficacious and reported better mental health than elderly females. The study further revealed that younger elderly groups of both the genders perceived themselves more efficacious, showed strong sense of control over their things and reported better mental health than elderly of advanced age groups. The mean scores suggested that the elderly of age groups 60-64yrs & 65-69yrs scored higher on the measure of PSE and reported very less symptoms on GHQ however with advancing age the elderly of both the genders were found reporting more symptoms on GHQ and also scored poorer on the measure of PSE. The findings of the present study are consistent with earlier research findings which have stated that the belief of can do cognition is a sense of control over one s environment 22 and an individual s sense of personal control and mastery plays an important role in improving overall functioning as well as other aspects of illness management 23 however, those with low sense of self efficacy, low sense of control and poor perceived social support have been found to be less likely to engage in healthy behaviors and report poor mental health. 24 Further, the regression analysis also showed that perceived self efficacy emerged as an important predictor of mental health among elderly groups. Perceived self efficacy predicted mental health positively i.e. greater the perceived self efficacy better the mental health and vice versa. The study revealed that the perceived self efficacy emerged important predictor equally for both the genders elderly males and females. However, the age specific variation could be observe, the perceived self efficacy predicted mental health positively for elderly of age groups 65-69 yrs and 75+ yrs but could not emerged important predictor for the age groups 60-64 yrs and 70-74 yrs which is paradoxical in nature as the perceived self efficacy cannot be presumed less important at any age and if discrepancy is there it may be due to sampling errors and problem of analysis. Many earlier studies have also testified the importance of efficacious beliefs. Beckham et al. 25 stated that patients with higher degree of perceived efficacy were found to be less functionally debilitated by their condition and less bothered by pain, anxiety and depression after controlling for age, sex and actual severity of their disease. A strong sense of personal self-efficacy is related to better health and a person who believes in being able to produce a desired effect can lead a more active and self-determined life. 9,26 Some other studies have also reported that the perceived self efficacy affects the reductions in depression achieved through treatment and how well the improvement is maintained over time. 27 The study further supported the learned helplessness model in which individuals become helpless and depressed when they perceive events as uncontrollable and beyond their self efficacy. 28 Thus, the study concludes with this remark that the perceived self efficacy predict mental health positively in elderly and it s not aging rather ageism that make elderly disabled or dementiated. Let s believe in Browning s beauty of aging... Grow old along with me! The best is yet to be, The last of life, for which the first was made (Browning,1864). Conclusion Aging is a natural phenomenon. Every created thing is destined to age. However, what is unfortunate is that aging is often seen as ubiquities decline, all doom and groom. This is far from truth. It could be a journey of endless growth. Yet, what this requires is that each individual prepares himself/herself in rational and efficacious ways for the effects of time. The present study revealed that the problem of elderly is emerging not only due to their increasing proportion of age but due to their own faulty cognitions and perception of aging. The study revealed that the elderly who perceived themselves self efficacious and demonstrated self attribution to control the environment showed better mental health than their counterparts. The study further revealed that the elderly females, and of advanced old age perceived themselves less Delhi Psychiatry Journal 2010; 13:(2) Delhi Psychiatric Society 319

DELHI PSYCHIATRY JOURNAL Vol. 13 No. 2 OCTOBER 2010 efficacious and attributed more to chance, luck and fate for their health condition and consequently showed poor mental health. Limitations In spite of interesting findings the present study does have certain limitations. (1) the locale of the present study; as the respondents of present study are residents of urban area only therefore the respondents from rural, urban and semi urban areas would have contributed its better generalizability. (2) The sample in the present study was small and incidental. A random sample could have been more authentic and reliable to generalize the findings. (3) The present study was a cross-sectional survey research. A longitudinal research starting with respondent s young age- to- much advanced years of life would have revealed interesting effects of aging on cognition and mental health. Acknowledgement I acknowledge my thanks to all the respected elderly who participated in the study and cooperated their best to conduct this study and to reach to its objectives. I further extend my thanks to Resident Welfare Associations of Lucknow city that helped me to collect the data from their colonies and colonies park where I had opportunity to interact with elderly groups. References 1. Age care statistics 2007. Available from: http:// www.helpageindia.com. 2. Rajan IS. Demography of ageing. In: Ageing in India, Situational analysis and planning for the future. Dey AB, editor. New Delhi: Rakmo Press, 2003. 3. Nandi PS. Banerjee G. Mukharjee SP. Nandi OS. Nandi DN. A study of psychiatric morbidity of the elderly population of a rural community in West Bengal. Indian J Psychiatry 1997; 39 : 122-129. 4. Banerjee S. MacDonald A. Mental Disorder in an elderly home care population: Association with health and social services use. Br J Psychiatry 1996; 168 : 750-756. 5. Betsy H. Don t worry: Think Happy to be Happy. Sunday Times, 2007; January, 14. 6. Ronald K. Thinking Can Alter the Way Body Fights Disease, New Research Shows. News- 320 Delhi Psychiatry Journal 2010; 13:(2) Delhi Psychiatric Society Sentinel Fort Wayne, Indiana, 2006; October 23. 7. Schwartzer R. Measurement of perceived selfefficacy: psychometric scales for cross-cultural research. Berlin, Ger: Frei Universitaat Press, 1993. 8. Bandura A. Self Efficacy: Towards a unifying theory of behavior change. Psychol Rev, 1977; 84 : 191-215. 9. Bandura A. Self-efficacy: The Exercise of Control. New York: W.H. Freeman and Company, 1997. 10. McAuley E. Self-efficacy and the maintenance of exercise participation in older adults. J Behav Med 1993; 16 : 103-113. 11. McAuley E. Katula J. Mihalko SL. Blissmer B. Duncan TE. Pena M. et al. Mode of physical activity and self-efficacy in older adults: A latent growth curve analysis. Journal of Gerontology: Psychol Sci 1999; 54B : 283-292. 12. McAuley E. Jerome GJ. Marquez D. Elavsky S. Blissmer B. Exercise self-efficacy in older adults: Social, affective and behavioral influences. Ann Behav Med 2003; 25 : 1-7. 13. Resnick B. Palmer MH. Jenkins LS. Spellbring AM. Path analysis of efficacy expectations and exercise behavior in older adults. J Adv Nurs 2000; 31 : 1309-1315. 14. Resnick B. Orwig D. Magaziner J. Wynne C. The effect of social support on exercise behavior in older adults. Clin Nurs Res 2002; 11 : 52-70. 15. Bandura A. Self-regulation of motivation through anticipatory and self-regulatory mechanisms. In Perspectives on motivation: Nebraska symposium on motivation, Dienstbier RA. (Ed.), Lincoln: University of Nebraska Press, 1991; 38 : 69-164. 16. Schunk DH. Self-efficacy and cognitive skill learning. In Research on motivation in education. Ames C. Ames R. (Eds.), San Diego: Academic Press, 1989; 3 : 13-44. 17. Luszcynska A. Gutiérrez-Doña, B. Schwarzer R. General self-efficacy in various domains of human functioning: Evidence from five countries. Int J Psychol 2005; 40 : 80-89. 18. Barriopedro MI, Eraña I, Mallo LL. Relationship of physical activity with depression and life satisfaction among the

OCTOBER 2010 DELHI PSYCHIATRY JOURNAL Vol. 13 No. 2 elderly. Revista de psicología del deporte 2001; 10 : 239-246. 19. Davis AHT. Carrieri-Kohlman V. Janson SL. et al. Effects of treatment on two types of selfefficacy in people with chronic obstructive pulmonary disease. J Pain Symptom Manage 2006; 32 : 60 70. 20. Schwartzer R. Jerusalem M. General Perceived Self Efficacy Scale. In Measures in Health Psychology. Causal and control beliefs: A user s portfolio. Weinman J. Wright S. Johnston M. Windsor; U.K.: NFER-Nelson, 1993; 33-37. 21. Goldberg DP. The detection of Psychiatric Illness by Questionnaire. London, Oxford University Press, New York, Toronto 1972. 22. Schulz U. Dona BG. Sud S. Schwarzer R. Is general self-efficacy a universal construct? Psychometric findings from 25 countries. Eur J Psych 2002; 18 : 242-251. 23. McCathie HCF. Spence S. Tate RL. Adjustment to chronic obstructive pulmonary disease: the importance of psychological factors. Eur Respir J, 2002; 19 : 47 53. 24. Cardarelli KM. Vernon SW. Baumler ER. et al. Sense of control and diabetes mellitus among US adults: A cross-sectional analysis. Biopsychosoc Med 2007; 1 : 1 19. 25. Beckham JC. Rice JR. Talton SL. Helms MJ. Young LD. Relationship of cognitive constructs to adjustment in rheumatoid arthritis patients. Cogn Ther Res 1994; 18 : 479-496. 26. Schwarzer R. Self-efficacy: Thought control of action. Washington, DC: Hemisphere, 1992. 27. Kavanagh DJ. Wilson PH. Prediction of outcome with a group version of cognitive therapy for depression. Behav Res Ther 1989; 27 : 333-347. 28. Takakura M. Sakihara S. Psychosocial correlates of depressive symptoms among Japanese high school students. J Adoles Health 2001; 28(1) : 82 90. Delhi Psychiatry Journal 2010; 13:(2) Delhi Psychiatric Society 321