Child and Adolescent Psychiatry and Mental Health. Open Access RESEARCH ARTICLE

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1 Child and Adolescent Psychiatry and Mental Health RESEARCH ARTICLE Open Access Mental health status, and suicidal thoughts and behaviors of migrant children in eastern coastal China in comparison to urban children: a cross sectional survey Jingjing Lu 1, Feng Wang 1, Pengfei Chai 2, Dongshuo Wang 3, Lu Li 1* and Xudong Zhou 1* Abstract Purpose: Although adolescents mental health problems and self-injurious thoughts and behaviors (SITBs) have been a serious public health concern worldwide, descriptions of risk factors for SITBs often fail to take migration into account. There are roughly 35.8 million migrant children in China who, with their parents, moved from original rural residence to urban areas. Little is known about migrant children s mental health status and levels of SITBs. This study aims to explore the mental health status and SITBs of migrant children living in eastern coastal China in comparison to their urban counterparts. Methods: This study was a cross-sectional survey conducted in 13 schools. Mental health status and SITBs were measured via self-administered questionnaires. Associations between strengths and difficulties questionnaire outcomes and SITBs were investigated. Results: Data from 4217 students (1858 migrant children and 2359 urban children) were collected. After controlling for gender, age, family economic status, parent s education level and parents marital status, migrant children scored higher for total difficulties (p < 0.001) and externalizing problems (p < 0.001) than did urban children and reported higher rates of suicidal ideation (p < 0.05) and self-injurious behaviors (p < 0.05). Conclusions: Migrant children, compared with urban children, have a higher risk of externalizing problems and SITBs. It is urgent to address these problems by providing both mental health services at migrant-exclusive schools and equitable education and social welfare to migrant children. Keywords: Migrant children, SDQ, Suicide ideation, Self-injurious behavior Background Since the mid-1980s when China started to implement the reform and opening-up policy, a growing number of people have migrated from rural to urban areas in search of better jobs and living conditions. In recent years, an increasing number of migrant workers have made the *Correspondence: lilu@zju.edu.cn; zhouxudong@zju.edu.cn Jingjing Lu and Feng Wang are co-first authors 1 The Institute of Social and Family Medicine, School of Public Health, Zhejiang University, 866 Yuhangtang Rd., Hangzhou , Zhejiang, People s Republic of China Full list of author information is available at the end of the article choice to raise their children in cities, creating a new generation of migrant children. In China, migrant children are defined as children under 18 who have left their original residence and migrated to a big city for at least 6 months [1]. According to the most recent statistics, the number of migrant children in China aged between 0 and 17 years is about million [2], and this number continues to grow [3]. Because of the Hukou, China s system of household registration, most migrant children are unable to enroll in public schools or utilize the same social welfare provided to urban children. Unregistered schools specifically set up for migrant children, usually called migrant-exclusive The Author(s) This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

2 Page 2 of 7 schools, are typically small and often lack qualified teachers, standard teaching materials and adequate sanitation facilities [4]. A minority of migrant children can attend public schools due to regional policies, for example, if their parents migrated to a city because of a regional labor-importing policy. However, these migrant children may be socially excluded in their classrooms, treated unjustly by their teachers and discriminated against by the parents of their urban classmates [5]. As such, migrant children experience inequitable health conditions, both physically and mentally, in the process of adapting to a new environment, making them extremely vulnerable. Because of these precarious circumstances, there is great concern regarding the health condition of migrant children, but only limited data at the population-level have been collected regarding the mental health status of migrant children using standardized tools in China. Although the strengths and difficulties questionnaire (SDQ) is a standardized measure of mental health in children and adolescents, with established reliability and validity [6, 7], studies of the mental health status of migrant children using SDQ in China are rarely conducted. Existing studies on the subject reported mixed results. One study conducted in Guangdong found that migrant children scored significantly higher in every SDQ outcome compared to normative scores in China [8]. Another study conducted in Hubei found that migrant children only reported significantly higher scores in emotional symptoms, conduct problems, hyperactivity and peer problems [9] when compared to urban children. Meanwhile, when compared to rural left-behind children who were still living in rural areas, migrant children reported significantly lower scores in emotional symptoms and total difficulties [10]. Despite these studies demonstrating the detrimental effect of migrant status on children s mental health, gaps remain in the existing literature; these studies had small sample sizes, and did not include an appropriate comparison group to verify the impact of migrant status on mental health. Another concern regarding migrant children and adolescents health conditions is self-injurious thoughts and behaviors (SITBs), which is a serious public health concern worldwide [11]. In children and adolescents, two particular types of SITBs are notable: suicidal ideation, referring to thoughts of ending one s own life, and non-suicidal self-injury (NSSI), defined as the direct and deliberate destruction of one s body tissue without the intent to die [12]. Previous international studies have already confirmed migrant status as a risk factor for suicidal ideation [13] and self-injurious behaviors [14]. In China, it is estimated that between and 26.03% of children and adolescents report suicidal ideation [15, 16]; however, studies investigating this phenomenon seldom investigate the impact of migrant status on these behaviors in children and adolescents [17]. Only one study [18], conducted in Shanghai, examined the prevalence of suicidal ideation in migrant adolescents, and found the rate to be 36.80%, without a comparison to their urban counterparts. The present study aims to investigate the mental health status of migrant children living in eastern coastal China in comparison to their urban counterparts, and SITBs among this sample. Based on the aforementioned review of the literature, two major hypotheses were developed: firstly, compared to urban children, migrant children would score significantly higher in all SDQ outcomes and secondly, migrant children would report significantly more SITBs. Methods Sample A cross-sectional survey was conducted in a migrant receiving urban city, the Yinzhou district of Ningbo, Zhejiang Province, between May and June The region has an estimated population of 136 million, of whom 46.60% are migrants. There are two kinds of schools available for migrant children: migrant-exclusive schools, utilized by the majority of migrant children; and public schools, utilized by migrant children whose parents are relatively socio-economically advantaged. As roughly 30% of migrant children in this area attend public schools, 5 migrants schools and 8 public schools were randomly selected from the school roster of the District Education Bureau to ensure the comparability of sample size between the two groups. In each school, all selected students were between grades 5 and 9. Across the 13 schools, 4217 students (1858 migrant children and 2359 urban children) out of 4409 eligible enrolled students completed the questionnaire, representing a response rate of 95.65%. Procedure Study information was sent to the head of each school and the District Education Bureau by mail, and approvals from both parties were obtained. Information packs (an information letter and a consent form) were distributed to parents by school staff to gain verifiable parental consent. The study was performed during lunch breaks and course recesses, during which students with parental consent were assessed collectively by two well-trained investigators. Before filling out the questionnaire, students verbal agreement to participate was obtained after a simplified study introduction given by the investigators. The questionnaire was strictly self-administrated by

3 Page 3 of 7 students under investigators uniform instruction, and teachers were off-site to ensure anonymity. The study was approved by the Ethics Committee of Zhejiang University (Ref no. ZGL ). Measures Socio demographics Socio-demographic characteristics included: age, gender, migrant status, family economic status, parents education level and parents marital status. Family economic status was measured by possession of a number of household items, such as an air conditioner, refrigerator, washing machine, computer and private car [19, 20]. This variable was then coded as low- (zero to two item), moderate- (three to four items), and high-income (five items). Parents education level referred to the highest education level of one parent. The strengths and difficulties questionnaire Child psycho-social wellbeing was measured with the self-reported version of the strengths and difficulties questionnaire (SDQ), which has been validated in China [21]. The SDQ consists of five subscales: emotional symptoms, conduct problems, hyperactivity, peer problems and prosocial behavior; each subscale contains five items in the form of statements requiring a response via a three-point Likert response scale: 1 (not true); 2 (somewhat true); or 3 (certainly true) [6]. The Cronbach s alpha for the emotional symptoms in this study was 0.76; 0.72 for the conduct problems; 0.77 for the hyperactivity; 0.67 for the peer problems; and 0.79 for the prosocial behavior. Emotional symptoms and peer problems were combined to form a single internalizing subscale, conduct problems and hyperactivity were combined to form a single externalizing subscale, and the third subscale, prosocial behavior, remained unchanged. The total difficulties score was calculated by adding the scores of the internalizing and externalizing subscales. Higher scores on the total difficulties, internalizing and externalizing subscales represent higher levels of psychological problems; while higher scores on the prosocial behavior subscale represent lower levels of psychological problems. Self injurious thoughts and behaviors (SITBs) SITBs, including non-suicidal self-injury, suicidal thoughts, suicide attempts and death by suicide, are widely used to obtain information regarding adolescent suicidality [22]. In this study, the SITBs we assessed were suicidal ideation and non-suicidal self-injury. These two items were assessed with the following questions: Did you have suicidal thoughts during the past 2 weeks? and Did you hurt yourself deliberately during the past year? The following statements were identified as a yes answer for suicidal ideation: During the last 2 weeks, I had thoughts of killing myself and During the last 2 weeks, I had thoughts of killing myself but I wouldn t carry them out. The following statements were identified as a yes answer for self-injurious behaviors: During the past year, I hurt myself deliberately once and During the past year, I hurt myself deliberately more than once. Data analysis Chi square tests and t-tests were conducted to compare sample characteristics between migrant and urban children. Multiple linear regression and binary logistic regressions models were applied to examine the associations between the psycho-social outcomes and migranturban status. Suicidal ideation and self-injurious behavior and SDQ outcomes were included as dependent variables and migrant-urban status was examined as an independent variable. Analyses were adjusted for age, gender, family economic status, parents education level and parents marital status. All analyses were performed using SPSS 20.0 version and assumed a statistical significance level of p < Results Table 1 presents the differences in socio-demographic characteristics and the psychological outcomes between migrant children and urban children. There were significantly more males among migrant children (55.90%) than urban children (49.04%). The mean age of migrant children was (SD = 1.52) and the mean age of urban children was (SD = 1.30). Migrant children had a generally lower family economic status (χ 2 = ; p < 0.001), with parents who were less educated compared to urban children (χ 2 = ; p < 0.001). Compared to urban children s parents (6.45%), fewer migrant children s parents (4.29%) were divorced (χ 2 = 9.24; p < 0.01). Migrant children had significantly higher mean scores for total difficulties (t = 47.84, p < 0.001), internalizing problems (t = 65.81; p < 0.001) and externalizing problems (t = 81.15; p < 0.001), and lower mean scores on the prosocial behavior scale (t = 53.35; p < 0.001) compared to urban children. Migrant children reported significantly higher rates of self-injurious behaviors (χ 2 = 4.86; p < 0.05). Table 2 shows the linear regression analyses of SDQ outcomes and the binary logistic regression analyses of SITBs outcomes. After controlling for gender, age, family economic status, parent s education level and parents marital status, migrant children scored higher for total difficulties (β = 0.46; 95% CI = 0.06, 0.85; p < 0.05) and externalizing problems (β = 0.50; 95% CI = 0.26, 0.74; p < 0.001) than did urban children. Migrant children

4 Page 4 of 7 Table 1 The social-demographic characteristics, SDQ and SITBs of migrant compared to urban children Migrant children n = 1858 N (%) Urban children n = 2359 N (%) χ 2 or t p value Gender Male 966 (55.90) 1100 (49.04) < Female 762 (44.10) 1143 (50.96) Age, mean (SD) (1.52) (1.30) < Family economic status < Poor 566 (31.03) 53 (2.26) Fair 821 (45.01) 711 (30.35) Wealthy 437 (23.96) 1579 (67.39) Parents education level < Illiteracy or primary school 319 (17.68) 89 (3.90) Middle school 1100 (60.98) 975 (42.71) High school 329 (18.24) 754 (33.03) College or above 56 (3.10) 465 (20.37) Are your parents divorced? Yes 79 (4.29) 151 (6.45) No 1761 (95.71) 2189 (93.55) Total difficulties, mean (SD) (5.19) (5.56) < Emotional symptoms, mean (SD) 3.09 (2.00) 3.03 (2.12) Conduct problems, mean (SD) 2.43 (1.63) 2.18 (1.60) Hyperactivity, mean (SD) 3.92 (2.16) 3.36 (2.20) Peer problems, mean (SD) 2.84 (1.60) 2.55 (1.65) Prosocial behavior, mean (SD) 6.93 (2.02) 7.39 (2.10) < Internalizing problems, mean (SD) 5.93 (2.88) 5.58 (3.06) < Internalizing problems (> 8) 326 (17.55) 418 (17.72) Externalizing problems, mean (SD) 6.35 (3.30) 5.54 (3.30) < Externalizing problems (> 10) 1796 (96.66) 2231 (94.57) Suicidal ideation Yes 492 (26.67) 584 (24.89) No 1353 (73.33) 1762 (75.11) Self-injuries behavior Yes 189 (10.47) 193 (8.45) No 1616 (89.53) 2091 (91.55) reported significantly higher rates of suicidal ideation (OR = 1.23; 95% CI = 1.03, 1.46; p < 0.05) and self-injurious behaviors (OR = 1.32; 95% CI = 1.01, 1.72; p < 0.05). Discussion As China s economy grows, migrant populations will continue to expand. Migration is a carefully weighed family decision [23]. While migrant children may benefit from staying with their parents, their well-being may be harmed from limited access to social welfare and other social services [24]. This study sought to explore the mental health status and SITBs in migrant children living in eastern coastal China in comparison to their urban counterparts. We found that migrant children, compared to urban children, are more likely to experience externalizing problems (conduct problems and hyperactivity) and SITBs (suicidal thoughts and behaviors). Partly in line with our first hypothesis, after controlling for socio-demographic variables, migrant children reported higher mean scores in total difficulties and externalizing problems (conduct problems and hyperactivity) compared to urban children but not in internalizing problems (emotional symptoms and peer problems). Low familial socioeconomic status (SES) is one of the several environmental adversities that has been found to increase the risk of mental health problems in this age group [25, 26]. Coleman [27] has proposed that three types of capital influence youth s well-being: parents who

5 Page 5 of 7 Table 2 Regression coefficients for SDQ outcomes and SITBs on children group with adjustment for socio-demographic characteristics Emotional symptoms Conduct problems Hyperactivity Peer problems Internalizing problems Externalizing problems Prosocial behavior Total difficulties Suicidal ideation OR (95% CI) Self-injurious behavior OR (95% CI) Group Urban children (0.06, 0.85)* 1.23 (1.03, 1.46)* 1.32 (1.01, 1.72)* 0.09 ( 0.24, 0.07) 0.15 (0.03, 0.27)* 0.35 (0.19, 0.51)*** 0.04 ( 0.08, 0.16) 0.05 ( 0.27, 17) 0.50 (0.26, 0.74)*** 0.10 ( 0.25, 0.05) Gender Male (0.97, 1.30) 1.09 (0.87, 1.36) Female 0.36 (0.23, 0.49)*** Age 0.08 (0.03, 0.12)** Family economic status 0.40 ( 0.49, 0.29)*** 0.02 ( 0.02, 0.06) 0.45 ( 0.59, 0.32)*** 0.17 (0.12, 0.22)*** 0.36 ( 0.46, 0.25)*** 0.01 ( 0.03, 0.04) 0.01 ( 0.18, 0.19) 0.85 ( 1.00, 0.64)*** 0.08 (0.01, 0.15)* 0.19 (0.12, 0.27)*** 0.61 (0.48, 0.74)*** 0.01 ( 0.05, 0.04) 0.84 ( 1.17, 0.51)*** 0.27 (0.15, 0.39)*** 1.22 (1.16, 1.29)*** 1.11 (1.02, 1.20)* Poor (0.87, 1.38) 0.83 (0.59, 1.17) Fair 0.19 ( 0.40, 0.02) Migrant children Wealthy 0.24 ( 0.46, 0.02)* Parents education level Illiteracy/primary school Middle school 0.43 ( 0.64, 0.22)*** High school 0.45 ( 0.69, 0.22)*** College or above 0.05 ( 0.11, 0.21) 0.30 ( 0.20, 0.14) 0.04 ( 0.25, 0.18) 0.20 ( 0.43, 0.03) 0.19 ( 0.35, 0.03)* 0.38 ( 0.55, 0.21)*** 0.38 ( 0.68, 0.09)* 0.62 ( 0.93, 0.30)** 0.02 ( 0.31, 0.34) 0.23 ( 0.58, 0.12) 0.17 ( 0.03, 0.38) 0.50 (0.29, 0.72)*** 0.36 ( 0.89, 0.17) 0.85 ( 1.42, 0.28)** 1.29 (1.01, 1.65)* 1.07 (0.74, 1.54) ( 1.06, 0.50)*** 0.26 ( 0.42, 0.09)** 0.24 ( 0.42, 0.06)** 0.40 ( 0.61, 0.18)*** 0.33 ( 0.55, 0.11)** 0.44 ( 0.68, 0.19)*** 0.82 ( 1.11, 0.53)*** 0.27 ( 0.43, 0.10)** 0.34 ( 0.52, 0.15)*** 0.61 ( 0.83, 0.39)*** 0.69 ( 0.99, 0.39)*** 0.79 ( 1.13, 0.45)*** 1.39 ( 1.79, 0.99)*** 0.59 ( 0.91, 0.26)** 0.68 ( 1.05, 0.31)*** 1.22 ( 1.65, 0.77)*** 0.32 (0.11, 0.52)** 0.49 (0.26, 0.72)*** 0.77 (0.50, 1.04)*** 1.28 ( 1.82, 0.74)*** 1.47 ( 2.07, 0.86)*** 2.60 ( 3.32, 1.88)*** 0.68 (0.54, 0.73 (0.53, 1.01) 0.85)** 0.68 (0.53, 0.69 (0.47, 1.02) 0.88)** 0.74 (0.54, 1.02) 0.90 (0.58, 1.40) Parental martial status Married (0.86, 2.04) Divorced 0.26 ( 0.02, 0.54) 0.36 (0.14, 0.57)** 0.58 (0.29, 0.88)*** 0.15 ( 0.07, 0.37) 0.41 (0.01, 0.82)* 0.94 (0.50, 1.38)*** 0.12 ( 0.39, 0.16) 1.35 (0.63, 2.08)*** 1.70 (1.27, 2.28)*** * p < 0.05, ** p < 0.01, *** p < 0.001

6 Page 6 of 7 are educated (human capital) are assumed to have a better economic status (financial capital) and are more likely to be communicative with their children (social capital). Under this framework, our findings suggest that better family economic status and parental education levels can mitigate against the adverse psychological experiences caused by migration with parents, indicating that material and family support can work as important factors supporting children s psychological well-being. Essentially, migrant children from lower-income families with less-educated parents are susceptible to additional risks for psychosocial disadvantages. Previous studies also have suggested that SES is more closely related to the externalizing than to the internalizing domain [28, 29]. As a possible explanation for this, some scholars suggest that, as children age, they become more exposed to influences outside of the family, which may reduce their internalizing problems [30]. Migrant and urban children in our study were close in age and lived in similar neighborhoods, which may explain why migrant children in our study didn t report higher mean scores of internalizing problems (emotional symptoms and peer problems) than did their urban counterparts. Previous studies have suggested that externalizing problems (conduct problems [31, 32] and hyperactivity [33]) in youth are associated with low family cohesion and the low intellectual/cultural orientation of the family. Families with low levels of intellectual/cultural orientation can only offer limited opportunities for socialization and access to community resources to their children, which may increase children s externalizing problems [34]. Likewise, the strong negative influence of parental divorce highlights the importance of family cohesion on children s mental health [35]. Parental divorce will impair the bonds between family members, which may exert negative influences on a child s development of children. After adjusting for relevant variables, migrant children reported significantly higher rates of suicidal ideation and self-injurious behaviors than did urban children in the present study, supporting our second hypothesis. As noted, externalizing problems are associated with SITBs in adolescents [36, 37]. The risk of suicide is times higher in populations with SITBs than in the general population [38]. Thus, migrant children with suicidal ideation or non-suicidal self-injurious behaviors are at high risk for suicide. In recent years, a growing number of scholars have argued that the existing measures being implemented for youth suicide prevention do not have the same efficiency in migrant children as they do in urban children [39], as migrant workers are too busy to take care of their children [40] and migrant-exclusive schools are usually under-provisioned. Therefore, to prevent suicide among migrant children more effectively, greater importance should be attached to their SITBs and appropriate follow up management should be implemented. Several limitations in the present study were identified when interpreting the study findings, in light of its design and methodological characteristics. Firstly, the sample size was large, yet the study was conducted in a single district within one eastern coastal city of China. Therefore, it is inappropriate to extrapolate the results to the whole country. Secondly, to understand the condition of mental health and SITBs of migrant children, more factors should be taken into consideration, including domestic violence and parents history of mental illness. Adolescents who have experienced family violence were at higher risk of developing externalising problems [41]. Since young children may be reluctant to answer some of these questions, we didn t include them in the questionnaire. Thirdly, our exclusive reliance on adolescents self-reporting may result in the under-reporting of mental health problems [6]. Consequently, mental health problems and SITBs may be underestimated in the present study. Conclusion A comparison of the migrant children and urban children reveals that migrant children are highly likely to face externalizing problems (conduct problems and hyperactivity) and SITBs (suicidal thoughts and behaviors). Actions should be taken to identify migrant children s externalizing problems and SITBs, improve the communication between teachers and parents, and provide mental health services at migrant-exclusive schools. The migration policy should be changed to improve access to equitable education and social welfare for migrant children. Abbreviations SDQ: strengths and difficulties questionnaire; SITBs: self-injurious thoughts and behaviors; NSSI: non-suicidal self-injurious; SES: socioeconomic status. Authors contributions JL analyzed and interpreted the data; and drafted the manuscript. FW and DW drafted the manuscript. PC participated in the coordination of the study. LL participated in critical review of the manuscript; and participated in the conception and design of the study. XZ participated in critical review of the manuscript; and participated in the conception, design and coordination of the study. All authors read and approved the final manuscript. Author details 1 The Institute of Social and Family Medicine, School of Public Health, Zhejiang University, 866 Yuhangtang Rd., Hangzhou , Zhejiang, People s Republic of China. 2 Yinzhou District CDC, 1221 Xueshi Rd., Ningbo , Zhejiang, People s Republic of China. 3 Oxford Road, SG16 Samuel Alexander Building, Manchester M13 9PL, UK. Acknowledgements Not applicable. Competing interests The authors declare that they have no competing interests.

7 Page 7 of 7 Availability of data and materials The data-sets analyzed during this study are available from the corresponding author on reasonable request. Consent for publication Not applicable. Ethics approval and consent to participate The study was approved by the Ethics Committee of Zhejiang University (Ref No. ZGL ). Signed parental consent for student participation was obtained. Additionally, student verbal agreement to participate was required at the time of data collection. Funding The survey was conducted with funding from Zhejiang University Zijin Talent Project and infrastructure support from Yinzhou District CDC. Funders had no role in study design; collection, analysis and interpretation of data; and in writing the manuscript. Publisher s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Received: 20 June 2017 Accepted: 23 January 2018 References 1. Liang Z, Guo L, Duan C. 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