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Year : 2019  |  Volume : 16  |  Issue : 1  |  Page : 45-51

Depressive symptoms and aggressive behavior among orphanage female children

Department of Psychiatric and Mental Health Nursing, Faculty of Nursing, Zagazig University, Zagazig, Egypt

Date of Submission09-Dec-2018
Date of Acceptance04-Feb-2019
Date of Web Publication10-May-2019

Correspondence Address:
Marwa A.E.A El-Slamoni
16 El Tayaran Street, Nasr City, Cairo
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ENJ.ENJ_29_18

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Background An orphan’s life is perilous because of their lack of care and support. There are many kinds of stressful events that occur among orphans, such as deprivation from family, aggression, and physical and psychological stress, which may influence their lives and mood, and they become irritable and hopeless individuals.
Aim This study was aimed to assess depression and aggression among orphanage residents at Tanta City.
Participants and methods Using a descriptive cross-sectional design, the study was conducted at three shelters at Tanta City (Al-Wafaa 1 and 2 and Al-Radwa shelters). It included a sample of 94 children who were selected from the previously mentioned settings. The tools of data collection were an interviewing questionnaire form, a depression scale, and aggression scale.
Results The study finding showed that the reason for the increase in depression among adolescents was no known parents (79.6%). There was a statistically significant positive correlation between the depression scores and physical aggression.
Conclusion and recommendation The study concluded that highest depression scores were present among adolescents staying in orphanage for more than 12 years. The study recommended that further intervention studies are proposed to deal with these behavioral problems using various approaches pertaining to the structure and function of the orphanage.

Keywords: aggression, depression, female children, orphanages

How to cite this article:
El-Slamoni MA, Hussien RM. Depressive symptoms and aggressive behavior among orphanage female children. Egypt Nurs J 2019;16:45-51

How to cite this URL:
El-Slamoni MA, Hussien RM. Depressive symptoms and aggressive behavior among orphanage female children. Egypt Nurs J [serial online] 2019 [cited 2020 Jan 22];16:45-51. Available from: http://www.enj.eg.net/text.asp?2019/16/1/45/257968

  Introduction Top

Children in orphanage resident care face many difficulties such as poverty, poor physical health, attachment disorders, inadequate social skills, and mental health difficulties. Added to this is the loss of one or both parents, which is difficult for the children. It makes them more vulnerable to psychological problems, and the effects may not manifest until many years afterward (Atwine et al., 2012).

Aggression is a learned behavior. It is defined as any intentional behavior that results in physical or mental injury to a person. Aggression and anger in children is a serious problem with different possible roots. It may occur in response to life stressors such as loss of parents or divorce. Moreover, children act out if they are unable to express frustration, and some learn to use physical aggressive behaviors for getting what they want. The symptoms of childhood aggression include fighting with others, disobedience, destructive behaviors, verbal hostility, and bullying and may be at high risk for significant disturbances in adulthood, including criminal behavior, alcoholism, drugs abuse, and mental illness (Debord, 2010).

Depression is a deep sadness with long-term harmful effects on the health and development of the individual. When parents die, children not only miss their physical presence but also many positive things they gave them when they were alive such as love, care, and protection. In many instances, orphans and vulnerable children have no one to share their grief with, and this can compound their sense of helplessness. The lack of support during the grieving process and inadequate help in adjusting to an environment without their parents may lead children to become depressed (Masmas et al., 2012).

Orphan children experience neglection. Orphan children are left alone most of the day without protection, with no one to talk to and nothing to do. They can become depressive, aggressive, and disobedient. They may be acting this way to seek attention. Moreover, children in orphanages are exposed to abuse and are spoken to only harshly or are disciplined with frequent or harsh beatings, and therefore, they can become aggressive and disobedient (Nugent and Masuku, 2007).

Significance of the study

In Egypt, there are 250 orphanages hosting 7749 children between 6 and 18 years old, including 102 orphanages hosting 2068 children between 1 and 6 years old. Governmental Orphanage assumed to accept children from 6 to 18 years. These orphanages or shelters provide social and healthcare as well as educational, religious, and recreational activities for children deprived of family care (Ministry of Society Solidarity, 2011). Therefore, this study assessed the behavior and emotional problems among orphans in this setting with the ultimate goal of providing concrete information about the prevalence and severity of these disorders, which may help in their prevention and management.

Orphans may waiver from their societal development path because of anger, stress, and lack of consciousness, which is threatening to their self-esteem and developmental period. These orphans may involve in drug addiction or antisocial activities, which is not expected in our society. Most of the studies in this area have been done in western culture, but in Bangladesh, there are very few studies. Now, the findings of the present study will be helpful to understand the stress and aggression level of orphans. The study would have some applied values and would give new theoretical knowledge about stress and aggression level of orphans. Therefore, the study will help in providing such information, which is very essential for mental health worker (psychologist, sociologist, counselor, and clinical psychologist) and policy maker to initiate intervention program and make an effective program to facilitate their development (Zhao et al., 2017).


The aim of the study was to assess depressive and aggressive symptoms among orphanage female children.

Research questions

  1. What is the percentage level of depressive and aggressive symptoms among orphanage female children in the selected setting?
  2. Is there a relation between depression scores and aggression domain scores among orphanage female children?
  3. What are the common predictors of depression and aggression among orphanage female children?

  Participants and methods Top

Research design

A descriptive cross-sectional design was used in this study to achieve its aim.

Study setting

The study was conducted in three orphanages at El-Gharbia Governorate (Tanta City). Their capacity is 425 children, but the actual number of residents is 274 children, comprising 166 boys and 108 girls in separate shelters (Ministry of Society Solidarity, 2011).

Study sample

A convenience sample of 94 female children was selected from the previously mentioned settings. The inclusion criteria were age 10–18 years (adolescents) and being free from physical disability or chronic illness. The sample size was calculated to estimate an expected prevalence of depression or aggression symptoms of 30% with 3% SE at 95% level of confidence, using the sample size equation for single proportion with finite population correction, and after correcting for a nonresponse rate of ∼5%.

Tools of data collection

  1. Tools I: the researchers prepared an interview questionnaire form for data collection, to assess data related to the personal characteristics of orphan children. It includes age, sex, level of education, duration of stay in orphanage, causes of entering orphanage, and presence of siblings, their number, and location if present.
  2. Tool II: The depression scale was originally designed by Elbasiony (2006) to assess depression in children. It covers a group of depressive symptoms such as disturbance in mood, self-esteem, behavior with others, and effect of depression on education. The scale has 24 items on a three-point scale, ‘most of the time, sometimes, not occurring’, scored 2, 1, and 0, respectively, so that a higher score indicates more depression. The total score is through summation of items’ scores, and this is categorized into ‘depressed’ if the score is 24 or higher, and ‘not depressed’ if less than 24.
  3. Tool III: The aggression scale was originally constructed by Mounir (1983) to assess the aggressive behavior among adolescents 10–18 years old. It consists of 32 items. The items were divided into three dimensions such as physical aggression (eight items as cannot stop myself from hurting others, if he constantly harasses me, I will hit him on the face), verbal (11 items such do not know what to do, always disagree with others, say the words of a monster to the children I hate), and indirect (six items such as when distressed, I shake the door, always fear the children of beatings but I do not hit them). The responses ‘Yes/No’ were scored 1 and 0, respectively, so that a higher score indicates more aggressive behavior. The remaining seven items were for validation of the child’s response. If the child answers ‘Yes’ in six or more of these seven items, the form is considered invalid. For content validation, the tool was reviewed for relevance, comprehensiveness, sequence, and clarity.

Validity of these tools (tool II–III) were tested for their content by a jury of five experts in the field of psychiatric & mental health nursing, psychiatric medicine & nursing administration to ascertain relevance and completeness of the tool and the needed modifications were done.


Reliability of these tools (tools II–III) was tested by the researchers (test–retest) for the internal consistency by administration of the same tool to the same participants after 2 weeks and comparing the results. They showed accepted reliability with Cronbach α coefficients of 0.74 (tool II) and 0.60 (tool III), respectively.

Pilot study

A pilot study was conducted on 10% of study sample to test the applicability of the data collection tool and the feasibility of the study. The tool was finalized based on the pilot results. Those who shared in the pilot study were not included in the main study sample. Based on their recommendations and suggestions, the tool was modified. The pilot also served to assess the reliability of the depression and aggression scales through measuring their internal consistency.


After securing official permissions, the researchers met with the orphanage directors, explained to them the aim of the study and its procedures, and asked for their permission and cooperation for data collection. Then, they met with the children individually, and interviewed them using the data collection form. The interview with each child took 30–45 min according to her response and level of cooperation. The work was done twice weekly during July and August 2015.

Administrative and ethical considerations

The study protocol was approved by the Research Ethics committee of the Faculty of Nursing, Zagazig University. The necessary official approvals were obtained. Verbal informed consents were obtained from the guardians of the children and assent to participate was obtained from the children. Before the interview, the children were informed about the purpose of the study and were assured about the confidentiality of data. They were informed about their rights to refuse or withdraw at any time. The nature of the study could not entail any harm on participants.

Statistical analysis

Data entry and statistical analysis were done using SPSS 20.0 statistical package of social science. Medical publication division, New York. Cronbach α coefficient was calculated to assess the reliability of the developed tools through their internal consistency. Spearman’s rank correlation was used for assessment of the inter-relationships among quantitative variables and ranked ones. To identify the independent predictors of depression and aggression scores, multiple linear regression analysis was used, and analysis of variance for the full regression models was done. Statistical significance was considered at P value less than 0.05.

  Results Top

[Table 1] showed that most children in the study sample were 12 years of age or older (85.1%). Slightly more than half of them were at the preparatory level of education (51.1%). The duration of their stay in the orphanage ranged between 1 and 18 years, with median of 15 years. The main reason for admission was unknown parents (61.7%). Only eight (8.5%) had siblings, and of these, only one (12.5%) knew about the location of her siblings.
Table 1 Sociodemographic characteristics of children in the study sample (n=94)

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As shown in [Table 2], 89.4% of the children in the study sample had valid responses in the depression/aggression scale. The results demonstrated that slightly more than one-third of these had depression (34.5%) and total aggression (36.9%) symptoms. Among the types of aggression, verbal was the most prevalent (67.9%).
Table 2 Depression symptoms and aggression among children in the study sample (n=94)

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[Table 3] indicated the presence of a statistically significant weak positive correlation between the depression score and the total aggression score (r=0.286). [Table 3] also showed that the depression score is only significantly correlated with the physical type of aggression (r=0.417). Concerning the correlations among the three types of aggression, the only statistically significant one is between the physical and verbal types (r=0.394).
Table 3 Correlation matrix of aggression domains scores and depression scores

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Regarding the correlations between the depression and aggression scores and children’s characteristics, [Table 4] shows that the depression score is significantly and positively correlated with the duration of stay in the orphanage (r=0.357). Moreover, the score of physical aggression is also significantly and positively correlated with this period of stay (r=0.230).
Table 4 Correlation between depression and aggression domain scores and children’s age, education, and duration in orphanage

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In multivariate analysis ([Table 5]), the duration of stay in the orphanage is a positive statistically significant independent predictor of the depression score, whereas being of unknown parents is a negative predictor. These two variables explain 23% of the variation in the depression score as indicated by the r2 value.
Table 5 Best-fitting multiple linear regression model for the depression and aggression scores

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Regarding the scores of aggression, [Table 5] demonstrated that, the depression score is the only statistically significant independent and positive predictor of the physical aggression score, and it explained 21% of its variance. Meanwhile, having unknown parents turned to be the only statistically significant independent and negative predictor of the indirect and verbal types of aggression score, as well as the total aggression score.

  Discussion Top

The experience of being abandoned by biological parents is of major significance (Kalus, 2013). Although the orphanages are considered suitable places for those children who lost their parents, they may still have negative effects on the orphans they are rearing. The aim of this study was to assess the depression and aggression levels among orphanage children at El-Gharbia Governorate. The findings indicated generally high prevalence of depressive symptoms and of aggressive behaviors, especially the verbal type. These were influenced by certain child and family characteristics.

According to this study finding, slightly more than one-third of the studied orphans had depression symptoms. This high prevalence is quite expected given the trauma of separation from one or both parents, with the emotional pain of being rejected or abused, in addition to relocation from one relative home to the orphanage. This is associated with devastating psychosocial effects on these children, with increased vulnerability to risky behaviors as demonstrated by Kpozehouen et al. (2015) in a study in Benin. The effects of early deprivation from parents have even been demonstrated through biochemical approaches. Thus, a study in Georgia showed that orphanage-institutionalized children had higher levels of blood neurotransmitters related to anxiety and behavioral disorders such as serotonin and norepinefrin compared with the children living with their families. The results demonstrated the long-term regulatory problems of the stress-responsive system which may result in altered emotionality and behavior in deprived children (Gogberashvili et al., 2011).

Another important factor that may underlie the high prevalence of depression symptoms is related to the orphanage environment such as the feelings of mistrust, insecurity, risk of neglect, abuse, and exploitation, in addition to the poor nutritional status. Moreover, the duration of stay in the orphanage was positively correlated with the score of depression among orphans. In addition, it was identified as a significant independent predictor of depression. This could be explained by the cumulative effect of the untoward conditions the orphans are faced with during their institutionalization period, and the repeated exposures to various types of neglect and abuse, poor caregiving, lack of stimulation, and absence of a consistent caregiver. A similar finding was reported by Helder et al. (2016) in a longitudinal study in the USA, where the length of stay in orphanage was inversely related to children’ mental health status. In this respect, Fluke et al. (2012) in a review of the history of children living outside family care concluded that the sustainable long-term care for these children is relatively weak. Thus, the quality and duration of care are important regardless of setting. They recommended more focus on developing and implementing systems for these most vulnerable children.

In agreement with the foregoing, a study among orphanage children in Karachi, Pakistan, reported high prevalence of behavioral problems among these children, and they were attributed in part to orphanage factors, particularly malnourishment among them (Lassi et al., 2011). Furthermore, Mutiso (2008), in a study in Kenya on institutionalized children in rural and urban settings demonstrated significantly higher prevalence rates of depression symptoms among orphan children compared with the non-institutionalized ones.

Meanwhile, ElEbiary et al. (2010) in a study in Egypt reported a prevalence of depression symptoms of 20–24% among institutionalized orphan children. Similarly, in a study in Zagazig, Fawzy and Fouad (2010) found that approximately one-fifth of institutionalized orphans had depression. These findings are lower than the prevalence in the current study. The difference might be attributed to the general worsening of the orphanage conditions during this period of time owing to the instability in the country following the 2011 revolution and lack of close supervision on these institutions.

This study has also revealed a high prevalence of aggressive behaviors among orphan children. The prevalence was highest for the verbal type of aggression, present in approximately two-third of the children. It was followed by the indirect aggression, whereas the lowest was the physical type. This is understandable as the physical aggression could lead to more problems for the child with the institution, which would be translated into more severe punishment. The high prevalence of aggression could be attributed to the early social deprivation of these children, which would illicit antisocial behaviors among them. In congruence with this, neurophysiological studies showed that institutionalized children show impaired development of central nervous system, in particular development of limbic system and neocortex, probably caused by early social deprivation (Kulenkova et al., 2015). In addition, neurohormonal studies demonstrated hypocortisolism among children experiencing adverse early care, which would explain their behavioral disorders (Koss et al., 2016).The high prevalence of aggressive behavior among the children in the orphanage children in the present study was in agreement with the findings of similar previous studies in different countries. Thus, in Egypt, Gamal (2012) in a national study of the epidemiology of emotional and behavioral problems in children and adolescents reared in orphanages reported a high prevalence of aggressive behavior, which was higher than depression seen in the current study. Similarly, high levels of aggressive symptoms were reported among orphans in Jordan, and this was attributed to the negative effects of orphanage rearing (MacKenzie et al., 2014). Moreover, a study in Gaza strip (Ayas, 2009) agreed with our results in the prevalence of indirect aggression, which was higher than the physical aggression. On the same line, Simşek (2008) in Turkey and Merz (2008) in Russia reported high prevalence of aggressive behavior in studies among orphanage children.

According to this study results, the institutionalized children with unknown parents seem to be less aggressive compared with those with known parents. This was demonstrated in the multivariate analysis for the verbal, indirect, as well as the total aggression. This might be explained by the fact that having unknown parents means that the child is the outcome of an illegitimate relation, which is considered a stigma in most communities, particularly in oriental cultures, where unwed mothers are forced to surrender their infants because of a number of social, religious, and economic pressures (Imperato, 2015). Thus, these children may feel shameful and try to internalize rather than externalize their hostilities and antisocial feelings. Those children, compared with their peers who have known parents, are more susceptible to rejection from the society and expect substantial future problems with marriage, employment, housing, and establishing social networks (Ibrahim and Howe, 2011).

  Conclusion and recommendation Top

The study results lead to the conclusion that orphanage children experience high prevalence of depressive symptoms and aggressive behaviors. These disorders increase with the length of stay in the orphanage. The children with unknown parents seem to be less aggressive, probably owing to internalization of their anger. Therefore, institutionalized orphan children need better rearing care, with physical and psychological support, particularly those with unknown parents. Regular periodic psychological assessment of these children should be done for early detection and proper management of any mental ailments. Further intervention studies are proposed to deal with these behavioral problems using various approaches pertaining to the structure and function of the orphanage.[29]

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Atwine B, Cantor-Graae E, Bajunirwe F (2012). Psychological distress among AIDS orphan in rural Uganda. Soc Sci Med 3:555–564.  Back to cited text no. 1
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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