The Prevalence of Behavioral Problems Among Primary School Children in Outskirts of Mashhad City, Iran


Zeynab Abdolahzadeh 1 , Imanolah Bigdeli 1 , * , Ali Mashhadi ORCID 1

1 Department of Psychology, Ferdowsi University of Mashhad, Mashhad, Iran

How to Cite: Abdolahzadeh Z, Bigdeli I, Mashhadi A. The Prevalence of Behavioral Problems Among Primary School Children in Outskirts of Mashhad City, Iran, Iran J Psychiatry Behav Sci. 2018 ; 12(2):e10050. doi: 10.5812/ijpbs.10050.


Iranian Journal of Psychiatry and Behavioral Sciences: 12 (2); e10050
Published Online: March 24, 2018
Article Type: Original Article
Received: December 15, 2016
Revised: June 20, 2017
Accepted: October 11, 2017


Background: Planning to decrease mental health problems in children requires knowledge of the extent and type of behavioral problems in this age group. Given that children comprise a large proportion of the population in the outskirt areas of cities, evaluation of the prevalence of behavioral problems in children in outskirt areas could be effective in the prevention and treatment of mental disorders.

Objectives: The aim of this study, performed during year 2015, was to detect the prevalence of behavioral problems in children in the outskirt areas of Mashhad city, Iran.

Methods: This was a descriptive study. The study sample that was selected by the accessible sampling method consisted of 450 males, who were in the first to fifth grade. The instrument used to measure behavioral problems was the Achenbach child behavior checklist, which was completed by parents. The findings were analyzed by the SPSS 19 software using descriptive statistics.

Results: The prevalence of behavioral problems on elementary school males was 36.44% on outskirts of Mashhad. The most common behavioral problem was defiant behavioral problems with 23.11% prevalence and social problems with the lowest prevalence of 7.33%. On scholastic grades, the students of the second grade most commonly had behavioral problems with a prevalence of 25.6% and the students of the fifth grade least frequently had behavioral problems with a prevalence of 13.4%.

Conclusions: The prevalence of childhood behavioral problems in outskirts of Mashhad was large. These results suggest that more attention to children of outskirt areas and precise planning for reducing their behavioral problems is necessary.

1. Background

Child Mental health problems are common and cause high costs (1). If these behavioral and emotional problems are detected and treated at an early age, their possibility in turning to chronic disorders in adults will be reduced (2).

Emotional and behavioral problems in children can be defined as signs or symptoms that do not meet the criteria for a mental disorder but that cause a potential for development of disorders later in life (3). For example, aggression, disobedience, sleeping problems, nail biting, and anxiety are some of these emotional and behavioral problems. To provide adequate mental health services to children in the society, the first step is to identify the emotional and behavioral problems that children face (4). Thus, some studies have investigated the prevalence of behavioral problems and disorders in children. In one study, Iranian researchers investigated the prevalence of behavioral disorders among elementary students of Hamadan. In this study, 16% of students were diagnosed with behavioral disorders, which were more commonly found in males rather than females (5). Overall, the prevalence of behavioral disorders in children and adolescents in different studies have been reported from 10% to 42%, being more common among males (5-7).

Several types of factors may increase a child’s vulnerability to mental health problems, including biological factors, genetic factors, psychosocial factors, and environmental factors (8). Marital discord, maternal psychopathology, paternal criminality, and parental death or separation from parents are some of environmental factors associated with increased psychological and behavioral problems in children (8-10). Environmental and psychological stressors in certain areas, such as outskirt areas of cities can be observed more frequently. The outskirt areas, regions that are away from the main areas of the city and their people encounter economic and social problems, such as poverty, addiction, and crime (8). As a result, children living in these areas are exposed to greater behavior problems. Children exposed to violence and maltreated children have been shown to be at an increased risk of depressive and anxiety disorders, alcohol and drug abuse, and personality disorders (10-12). The results of one study indicated that children exposed to substance abusers more commonly had mental health problems when compared with the general population (13).

Poverty is another common risk factor for emotional and behavioral difficulties in children (12, 14). Takeuchi et al. (1991) analyzed longitudinal data from a national survey in the United States and reported that emotional and behavioral problems were greater in children of parents, who reported higher levels of financial stress (15). In another study, food insecurity was associated with greater behavioral problems (16).

It is important to note that children of families, who live in outskirt areas of cities, more than urban families, are exposed to risk factors, such as low income, lack of environmental security, and addicted parents. On average, around 33% of the population in large cities of the world are marginalized (17). Inadequate conditions forliving in outskirts have many consequences, one of which could be increased behavioral problems in children in these areas. Mashhad, as the second largest metropolis in the world of religious cities, is no exception because about 700,000 people of its population of 2 million live in the outskirts of the city (17).

Given that behavioral problems begin in half of cases before 14 years of age (18) and lead to impaired developmental, and interpersonal and education problems (19), an investigation of the mental health status of children in outskirt areas is very necessary. So far, no study has investigated the mental health of children in the outskirt cities of Iran. These findings are useful for effective therapeutic programs and prevention of mental disorders in different societies (20).

2. Objectives

The purpose of this study was to investigate the prevalence of behavioral problems in school-aged children in the outskirts of Mashhad. The focus of this study was on male students because according to the literature research, the prevalence of behavioral problems in males is higher than females (5, 6).

3. Materials and Methods

3.1. Participants

This study was based on the descriptive method. The study population consisted of 4570 males, aged 7 to 11 years old, living in one of Mashhad’s outskirt areas. Through accessible sampling method, 450 children, whose parents referred to 4 health centers in the North Tabarsi area, were selected. The sample size was determined based on a previous research. In the current study, children’s behavior problems were recorded through the completion of Achenbach child behavior checklist (CBCL) by parents. It should be noted that additional information on how to plan, objectives, design, and data confidentiality were provided for the parents. Before participation, parents gave their informed consent. The inclusion criteria in this study were age of 7 to 11 years old and studying in public and normal schools in outskirt areas of Mashhad city. Exclusion criteria included the presence of intellectual disability, blindness, and deafness.

3.2. Instruments

3.2.1. Demographic Inventory

This contains 7 questions about student’s demographic information, such as age, education, father’s occupation, mother’s occupation, father and mother’s education level.

3.2.2. Child Behavior Checklist (CBCL)

The child behavior checklist for ages 6 to 18 was used to assess behavioral problems. The CBCL is a questionnaire developed in the United States, in which parents evaluate their child’s behaviors (21). Two areas are assessed, including competences and behavioral/emotional problems. The competence items of CBCL measure the child’s abilities. The competence items were not used in the present study. The second area consisted of 113 problem items that parents rated as follows, 0 = not true, 1 = somewhat or sometimes true, or 2 = very true or often true, based on the past 6 months. The items included 8 syndromes, 3 scales (internalizing, externalizing, and total problems), and 6 DSM-oriented scales (4). In this study, the second part of the check list that included 113 questions, was related to behavioral emotional problems and physical health of children, which were completed by parents (21). Raw item scores were converted to T-scores, which are classified as normal, borderline or clinical (13). High test-retest reliability and strong internal consistency were reported by Achenbach and Rescorla (21). A Cronbach’s alpha in a range of 0.48 to 0.75 was calculated for 8 subscales in Iran (22). Findings showed that the Persian version of CBCL had good reliability (22).

3.3. Statistical analysis

The statistical analysis was performed with the SPSS software, version 19.0. To describe the data, measures of central tendency, variation, and frequency distribution were used.

4. Results

The average age of participants was 9.02 years with standard deviation of 1.32 years. Median of grades was third class. The proportion of students in each of the second, third, and fourth grade was 22% and in each of the first and fifth grade was 16%.

As the results on Table 1 show, 49% of fathers had high school education, and 43% of mothers had elementary education.

Table 1. Education Level of Parents of Primary School Children In Outskirts of Mashhad City-Iran
Education LevelIlliterate, %Elementary, %High school, %Licensee, %

As the results of Table 2 show, 36.44% of students were in the clinical range with a variety of behavioral problems, 8.44% of students were in the borderline range, and 55.11% of students were in the normal range.

Table 2. Comparison of Students of Primary School Children in Outskirts of Mashhad City Regarding Behavioral Total Problems Scale
Total problems16436.44388.4424855.11

The results of Table 3 show that the second grade had the highest prevalence of behavioral problems among education grades with a prevalence of 25.6%, and the fifth grade had the lowest prevalence with a prevalence of 13.6%.

Table 3. Comparison of Prevalence of Behavioral Problems on Education Grades of Primary School Children in Outskirts of Mashhad City
ScaleFirst GradeSecond GradeThird GradeFourth GradeFifth Grade
Total problems3219.54225.63018.33823.22213.4

The most common behavioral problem in the clinical range was oppositional behavior problems with a prevalence of 23.11% (from DSM-oriented scales). The second most common behavioral problem on DSM-oriented scales was conduct problems with a prevalence of 20.44%. These results are reported on Table 4.

Table 4. The Prevalence of Behavioral Problems Primary School Children in Outskirts of Mashhad City in DSM-Oriented Scales
Behavioral ProblemsClinicalBorderlineNormal

As shown in Table 5, the most common behavioral problems in the clinical domain inexperience-oriented scales was offence behaviors with a prevalence of 22.22%; it had the highest frequency among students after oppositional behavior. Social problems had the lowest frequency in students.

Table 5. The Prevalence of Behavioral Problems of Primary School Children in Outskirts of Mashhad City in Experience-Oriented Scales
Behavioral ProblemsClinicalBorderlineNormal

5. Discussion

The present study included an estimation of behavioral problems prevalence among male children, aged 7 to 11 years from outskirts of Mashhad city. This study estimated a prevalence rate of 36.44% among male children. The rate was similar to the study results in Brazil. Bordin et al. (2009) reported that 36.9% of poor children aged between 6 and 17 years in urban areas had one of anxiety, depression, offence disorders or both (8). In another study, the rate of prevalence of behavior problems among primary school children of Brazil was reported as 32.5% (23). In Iran, only 1 research reported the prevalence of behavior problems in children as 31%, which was consistent with the current study results (7). A large number of studies in other countries have reported the prevalence of behavior problems as less than that estimated in the current study. Many studies in Iran have reported the prevalence of behavior disorders as 10% (24) and 16.1% (5) in primary school children. The rate of prevalence in other countries was less than what was obtained in this study; for example, 7% in Bergen of Norway (20), 8% in Scotland (25), and 15% in Nigeria (26). It should be noted that all of these studies focused on urban areas, so that no study had reviewed the rates of childhood behavioral problems in the outskirts of Iran, while the number of studies from other parts of the world are also very scarce. As stated, only a few results of previous studies are consistent with the results of the current study. Considering the doubled or tripled results of the current study compared to other studies from Iran and other countries, it could be said that the difference in results is associated with special features of outskirts and high traumatic factors, such as family conflict, poverty, parental substance abuse, and low levels of parental education. Overall, the difference in psychological, social, and familial conditions of children’s life could cause various levels of behavioral problems (27). Using different tools to measure behavioral problems in a variety studies could be another influential factor, regarding the difference in rates.

Consistent with previous reports (7, 24, 27), the current study found differences in prevalence of behavioral problems amongst different education grades, so that second-grade students had the greatest amount of difficulty and fifth graders had the least difficulties. Increase of behavioral problems in the early years of primary school children could be due to poor compatibility with the school environment and failure to effectively communicate with teachers and classmates. With child’s growth and greater awareness of how to manage problems, the amount of damage will be reduced. Based on the results, oppositional behavior problems, offensive behavior, and conduct problems were the most common behavioral problems in students of outskirts of Mashhad. The results support the findings of Murray et al. (28) and Heiervang et al., (20). Risk factors, such as physical abuse, physical punishment, and mental health problems in parents, single parent families, and poor socioeconomic conditions increase problems, such as conduct disorder and oppositional behavior in children (28). The evidence supports the finding that children living in low-income families are more vulnerable to the development of anti-social behavior, oppositional behavior, and conduct problems than other children (29) because they encounter stressful events, environmental deprivation, family conflicts, migration, and violence (30, 31). These experiences have detrimental effects on children’s development and lead to greater vulnerability to mental health problems (29).

In summary, the present study indicated that the prevalence of behavior problems, for example offensive behavior, oppositional behavior and conduct problem, in children of outskirts is higher than other children.

Given that conduct problems and oppositional behavior during childhood could lead to antisocial personality disorder and criminal behavior in adults, comprehensive research and planning for the treatment of disorders are necessary. The current study had a number of limitations. First, since the participants consisted of only males of Mashhad’s outskirts, the result may not be generalized to child populations of other outskirts of cities. Considering that the children’s behavioral problems questionnaire was completed by parents, the mental health of parents may have affected the rate of children’s behavior problems. For example, a mother with depression may report her child’s natural behavior as a hyperactive behavior. In this regard, further studies are suggested to investigate the parents’ mental health and psychological assessment of children, simultaneously.

5.1. Conclusion

The prevalence of behavioral problems was 36.44% among males aged 7 to 11 years old in the outskirts of Mashhad. This rate of prevalence was relatively high in this region compared to other developing countries and other parts of Iran.




  • 1.

    Paula CS, Lauridsen-Ribeiro E, Wissow L, Bordin IA, Evans-Lacko S. How to improve the mental health care of children and adolescents in Brazil: actions needed in the public sector. Rev Bras Psiquiatr. 2012;34(3):334-51. doi: 10.1016/j.rbp.2012.04.001. [PubMed: 23429780].

  • 2.

    Paula CS, Vedovato MS, Bordin IA, Barros MG, D'Antino ME, Mercadante MT. [Mental health and violence among sixth grade students from a city in the state of Sao Paulo]. Rev Saude Publica. 2008;42(3):524-8. [PubMed: 18461252].

  • 3.

    National Research Council . Preventing mental, emotional, and behavioral disorders among young people: Progress and possibilities. Washington, D.C: National Academies Press; 2009.

  • 4.

    Rocha MM, Rescorla LA, Emerich DR, Silvares EF, Borsa JC, Araujo LG, et al. Behavioural/emotional problems in Brazilian children: findings from parents' reports on the Child Behavior Checklist. Epidemiol Psychiatr Sci. 2013;22(4):329-38. doi: 10.1017/S2045796012000637. [PubMed: 23181948].

  • 5.

    Jalilian F, Rakhshani F, Ahmadpanah M, Zinatmotlagh F, Moieni B, Moghimbeigi A, et al. [The prevalence of factor associated with behavioral disorder in school children, Hamedan]. Iran Int J. 2012;19(4):62-8. Persian.

  • 6.

    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(8):837-44. doi: 10.1001/archpsyc.60.8.837. [PubMed: 12912767].

  • 7.

    Islamiyah MM. [Prevalence of behavioral disorders among elementary students in Tehran]. Iran Int J. 2008;6(1):98-109. Persian.

  • 8.

    Bordin IA, Duarte CS, Peres CA, Nascimento R, Curto BM, Paula CS. Severe physical punishment: risk of mental health problems for poor urban children in Brazil. Bull World Health Organ. 2009;87(5):336-44. doi: 10.2471/BLT.07.043125. [PubMed: 19551251].

  • 9.

    Bauman LJ, Silver EJ, Stein RE. Cumulative social disadvantage and child health. Pediatrics. 2006;117(4):1321-8. doi: 10.1542/peds.2005-1647. [PubMed: 16585330].

  • 10.

    Maciel MR, Mello AF, Fossaluza V, Nobrega LP, Cividanes GC, Mari JJ, et al. Children working on the streets in Brazil: predictors of mental health problems. Eur Child Adolesc Psychiatry. 2013;22(3):165-75. doi: 10.1007/s00787-012-0335-0. [PubMed: 23073672].

  • 11.

    Assis SG, Avanci JQ, Oliveira Rde V. Socioeconomic inequalities and child mental health. Rev Saude Publica. 2009;43 Suppl 1:92-100. [PubMed: 19669070].

  • 12.

    Goodman A, Fleitlich-Bilyk B, Patel V, Goodman R. Child, family, school and community risk factors for poor mental health in Brazilian schoolchildren. J Am Acad Child Adolesc Psychiatry. 2007;46(4):448-56. doi: 10.1097/chi.0b013e31803065b5. [PubMed: 17420679].

  • 13.

    Vilela TR, Silva RS, Grandi CG, Rocha MM, Figlie NB. Emotional and behavioral problems in children living with addicted family members: Prevention challenges in an underprivileged suburban community. Paidéia. 2016;26(64):225-34. doi: 10.1590/1982-43272664201610.

  • 14.

    Mejia A, Calam R, Sanders MR. A review of parenting programs in developing countries: opportunities and challenges for preventing emotional and behavioral difficulties in children. Clin Child Fam Psychol Rev. 2012;15(2):163-75. doi: 10.1007/s10567-012-0116-9. [PubMed: 22427004].

  • 15.

    Takeuchi DT, Williams DR, Adair RK. Economic stress in the family and children's emotional and behavioral problems. J Marriage Fam. 1991;53(4):1031. doi: 10.2307/353006.

  • 16.

    Slopen N, Fitzmaurice G, Williams DR, Gilman SE. Poverty, food insecurity, and the behavior for childhood internalizing and externalizing disorders. J Am Acad Child Adolesc Psychiatry. 2010;49(5):444-52. [PubMed: 20431464].

  • 17.

    Bakhtiari T, Hashemi T, Seyedi A. [The impact of social marginalization on crime]. Iran Int J. 2013;5(2):137-62. Persian.

  • 18.

    Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593-602. doi: 10.1001/archpsyc.62.6.593. [PubMed: 15939837].

  • 19.

    Baker JA, Grant S, Morlock L. The teacher-student relationship as a developmental context for children with internalizing or externalizing behavior problems. Sch Psychol Q. 2008;23(1):3-15. doi: 10.1037/1045-3830.23.1.3.

  • 20.

    Heiervang E, Stormark KM, Lundervold AJ, Heimann M, Goodman R, Posserud MB, et al. Psychiatric disorders in Norwegian 8- to 10-year-olds: an epidemiological survey of prevalence, risk factors, and service use. J Am Acad Child Adolesc Psychiatry. 2007;46(4):438-47. doi: 10.1097/chi.0b013e31803062bf. [PubMed: 17420678].

  • 21.

    Achenbach TM, Rescorla LA. Manual for the ASEBA school-age forms & profiles: an integrated system of multi-informant assessment. Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families; 2001.

  • 22.

    Ahadi B. [Comparison of behavior problems and school achievement between children with and without motor problems]. Iran Int J. 2009;10(1):32-6. Persian.

  • 23.

    Vitolo YL, Fleitlich-Bilyk B, Goodman R, Bordin IA. [Parental beliefs and child-rearing attitudes and mental health problems among schoolchildren]. Rev Saude Publica. 2005;39(5):716-24. [PubMed: 16254646].

  • 24.

    Khushabi K, Moradi SH, Shojaie S, Hemati GH, Dehshiri GH, Esamorad A. [Prevalence of behavioral disorders among elementary students in Ilam]. Iran Int J. 2009;8(29):28-33. Persian.

  • 25.

    Emerson E. Prevalence of psychiatric disorders in children and adolescents with and without intellectual disability. J Intellect Disabil Res. 2003;47(Pt 1):51-8. doi: 10.1046/j.1365-2788.2003.00464.x. [PubMed: 12558695].

  • 26.

    Abiodun OA. Emotional illness in a paediatric population in Nigeria. East Afr Med J. 1992;69(10):557-9. [PubMed: 1473508].

  • 27.

    Khodam H, Modanloo M, Ziaee T, Keshtkar A. [Behavioral disorders and related factors in school age children of Gorgan]. Iran J Nurs Res. 2009;4(14):29-37. Persian.

  • 28.

    Murray J, Anselmi L, Gallo EA, Fleitlich-Bilyk B, Bordin IA. Epidemiology of childhood conduct problems in Brazil: systematic review and meta-analysis. Soc Psychiatry Psychiatr Epidemiol. 2013;48(10):1527-38. doi: 10.1007/s00127-013-0695-x. [PubMed: 23644723].

  • 29.

    Curto BM, Paula CS, do Nascimento R, Murray J, Bordin IA. Environmental factors associated with adolescent antisocial behavior in a poor urban community in Brazil. Soc Psychiatry Psychiatr Epidemiol. 2011;46(12):1221-31. doi: 10.1007/s00127-010-0291-2. [PubMed: 20931327].

  • 30.

    Bradley RH, Corwyn RF. Socioeconomic status and child development. Annu Rev Psychol. 2002;53:371-99. doi: 10.1146/annurev.psych.53.100901.135233. [PubMed: 11752490].

  • 31.

    Patel V, Flisher AJ, Nikapota A, Malhotra S. Promoting child and adolescent mental health in low and middle income countries. J Child Psychol Psychiatry. 2008;49(3):313-34. doi: 10.1111/j.1469-7610.2007.01824.x. [PubMed: 18093112].

  • Copyright © 2018, Iranian Journal of Psychiatry and Behavioral Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License ( which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited