INTRODUCTION Normal mental health is a state where mental health condition is productive and good relationship with others, and sufcient effort to overcome difculty (Knopf D, 2008). In children, this denition include variety emotional and behaviour problem in which doesn't correlate with mental health disorder or psychiatry (Warner LA, 2010) From the survey of national health policy showed us that the mental health and emotional ratio in children, ages were 4-15 years old, was 104 / 1000 children in 2001-2005. In a prevalence study in Jakarta in 2003, the prevalence of emotional and behaviour problem in primary school students were 27% by using Child behavior checklist instrument. Boys prevalence was greater than girls (30.5% vs 22.6%) (Widya W, 2008) The prevalence of mental health disorder patients in Indonesia was 11,6% according to Riskesdas 2007. These patients reached 1.7 million people in 2013 in Indonesia (Riskesdas, 2007; Riskesdas 2013) A study in Jakarta stated that the mental health disorder prevalence in Junior High School in Central Jakarta by using Mini for Kids instrument was 26.5%. The mental health disorder was mostly found in girls rather than boys (Widya W, 2008) Nail biting in children and teenager is commonly referred to mental health clinic. Nail biting often happens in children and undertreated. The incidence is higher in 4 to 6 years old children compared to younger children. The incidence increases in teenager and decreases in adult. Nail biting is not inuenced by sex in children less than 10 years old. But the male teenagers often have this habit (Ghanizadeh A, 2011) Nail biting can cause complications such as front dental malocclusion, dental root resorption, intestinal parasite infection, bacterial infection, and alveolar destruction. A study in Iran by Ahmad Ghanizadeh, et al, in 2011, showed that prosocial, emotional, and conduct score in Strength and Difculty Questionarre (SDQ) are statistically different between the nail bitng children compared to non nail biing children. Prosocial score inchildren with nail biting is lower than the others. Emotional score and conduct score are higher in nail biting children. From that result, it is suggested that mental health disorder is more common in nail biting children. But a study in Poland in 2014 didn't show any correlation between nail biting and obsessive-compulsive disorder or anxiety disorder (Przemyslaw P, 2014) MATERIAL AND METHODS This was an observasional cross-sectional study in Singkuang, Muara Batang Gadis district, North Sumatera, Indonesia. It was conducted in March 2016. The target population was students of primary, junior high school, and senior high school who had nail biting habit. Psychiatric patients, children with previours nail biting, skin infection before were excluded from this study. The subjects were required to ll in SDQ and nail biting questionarre. This study had been approved by Universitas Sumatera Utara ethic committee. All subjects were required their parents' consent. Subjects' age 11-17 years old could ll in the SDQ and nail biting questionarre by themselves. As the others by their parents. Then the scores of SDQ were evaluated by the researcher. The score consisted of emotional, conduit, hyperactivity, peers, and prosocial problems. All of the data were evaluated, analyzed by chi-square, multivariate analysis by logistic regression where P < 0.05 was statistically signicant in 95% condence interval. The data was analyzed by SPSS software (version 22). Nail biting was dened as an act of inserting nger into the mouth or a contact between nails and mouth. Strength and difculties questionnaire was a questionnare that should be RELATIONSHIP BETWEEN MENTAL HEALTH DISORDER AND NAIL BITING IN CHILDREN Original Research Paper Willy Winata Department of Child Health, Faculty of Medicine, Universitas Sumatera Utara, Indonesia X 119GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS Clinical Research BACKGROUND: It is imperative to acknowledge mental health disorder in order to improve human resources, especially children and teenages because they are nation's next human resources. Nail biting is suspected as a sign and symptom that someone has mental health disorder or suffers certain psychiatric condition. OBJECTIVE: The aim of this study is to evaluate the relationship between mental health disorder and nail biting in children. Methods: A cross-sectional study was conducted in March 2016 in Singkuang village, Muara Batang Gadis district, North Sumatera, Indonesia. The samples were elementary, junior high school, senior high school students. All samples were required to ll in two questionarres, those are nail biting and strength and difculty questionarre. Univariate, bivariate (chi-square), and multivariate analysis by logistic linear regression was performed with condence interval 95%. P<0.05 was statistically signicant. RESULT: There were 583 samples and 140 (23.6%) among themselves had nail biting habit. There were relationship between emotional problem (P = 0.004; PR = 1.803) and peers problem (P = 0.021; PR 1.639) to nail biting habit. The nail biting risk factors in this study were nail biting family history (PR = 4.575; 95% CI 2.451-8.539) and emotional mental disorder (PR = 1.741; 95% CI 1.062-2.855). CONCLUSIONS: There were relationship between emotional disorder and peers problem to nail biting habit. We found nail biting family history and emotional disorder as the risk factors of nail biting in this study. ABSTRACT KEYWORDS : Mental health disorder, nail biting, children, risk factors Munar Lubis* Department of Child Health, Faculty of Medicine, Universitas Sumatera Utara, Indonesia*Corresponding Author Elmeida Effendy Department of Child Health, Faculty of Medicine, Universitas Sumatera Utara, Indonesia VOLUME-8, ISSUE-9, SEPTEMBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra 120 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS lled in 5 minutes by parents or by respondents. It consisted of 25 questions. It included 5 sub-scale such as emotional, conduct, hyperactivity, peer, and prosocial problem. The scores were interpreted as normal, borderline, and abnormal. In this study, the borderline scores were interpreted as abnormal. RESULTS There were 606 students in this population and 593 samples met the inclusion criteria. There were 140 students had nail biting habit. There were 48,6% male students who had nail biting habit while 51,4% female students who had nail biting habit. Table 1. Samples characteristics The SDQ evaluation showed the majority was normal results. The amount of abnormal scores was 28.8% in emotional problem, 24.1% in peer problems, 23.4% in conduct problems, and 8.8% in hyperactivity problems. Table 3. Characteristics of SDQ evaluation Bivariate analysis by using chi square showed that there were a statistically signicant relation between emotional problem and nail biting (P = 0.004), between peer problem and nail biting (P = 0.021). VOLUME-8, ISSUE-9, SEPTEMBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra Characteristics n=593 Age average, years (SD) 12,28 (3,142) Sex, n (%) Male Female 253 (42,7) 340 (57,3) School grade, n (%) Primary school Junior high school Senior high school Nail biting habit, n (%) Yes No 305 (51,4) 184 (31) 104 (17,5) 140 (23,6) 453 (76,4) Nutritional status, n (%) Well nourish Mild malnutrition Severe malnutrition Overweight Obesity 297 (50,1) 155 (26,1) 24 (4) 73 (12,3) 44 (7,4) Family income, n (%) < 500,000 IDR 500,000 to 1,000,000 IDR >1,000,000 IDR Parents education, n (%) Primary school Junior high school Senior high school College None 57 (9,6) 305 (51,4) 231 (39) 401 (67,6) 106 (17,9) 64 (10,8) 11 (1,9) 11 (1,9) Frequency of nail biting n=140 Frequency of nail biting / day, n (%) Frequent (5-6 times / day) Rarely (1-4 times / day) Frequency of nail biting / week, n (%) 30 (21,4) 110 (78,6) Frequent (4 days in 1 week) Rarely (1-3 days in 1 week) 34 (24,3) 106 (75,7) SDQ charcteristics n=593 Emotional problem, n (%) Normal Abnormal Conduct problem, n (%) Normal Abnormal 422 (71,2) 171 (28,8) 454 (76,6) 139 (23,4) Hyperactivity problem, n (%) Normal Abnormal Peer problem, n (%) Normal Abnormal Prosocial problem, n (%) Normal Abnormal 541 (91,2) 52 (8,8) 450 (75,9) 143 (24,1) 511 (86,2) 82 (13,8) Total scores, n (%) Normal Abnormal 394 (66,4) 199 (33,6) Table 2. The frequency of nail-biting habit. Table 4. Relationship between mental health problem parameter and nail biting. Nail biting P* Prevalence Ratio 95% Condence interval Yes No Emotional problem Abnormal (%) 38.6 25.8 0.004 1.803 1.209 – 2.69 Normal (%) 61.4 74.2 Conduct problem Abnormal (%) 29.3 21.6 0.062 1.5 0.979 – 2.3 Normal (%) 70.7 78.4 Hyperactivity problem Abnormal (%) 12.1 7.7 0.106 1.651 0.894 – 3.048 Normal (%) 87.9 92.3 Peer problem Abnormal (%) 31.4 21.9 0.021 1.639 1.076 – 2.496 Normal% 68.6 78.1 Prososial Abnormal (%) 17.9 12.6 0.114 1.51 0.903 – 2.525 Normal (%) 82.1 87.4 Total score Abnormal (%) 39.3 31.8 0.101 1.388 0.938 – 2.056 Normal (%) 60.7 68.2 *Chi square Bivariate analysis between other factors and nail biting showed there was relation between nail biting history in family and nail biting habit (P < 0.001). Tabel 5. Other risk factors and nail biting Nail biting P* Prevalence Ratio 95% Condence interval Yes No Sex Male (%) 48.6 40.8 0.106 1.368 0.935-2.002 X 121GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS VOLUME-8, ISSUE-9, SEPTEMBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra Female (%) 51.4 59.2 School grade Primary school (%) 50 51.9 0.819 Junior high school (%) 30.7 31.1 Senior high school (%) 19.3 17 Nail biting in family Yes (%) 20 5.3 <0.001 4.469 2.493-8.010 No (%) 80 94.7 Live among family Yes (%) 97.9 95.6 0.224 2.109 0.617-7.206 No (%) 2.1 4.4 Nutritional status Severe malnutrition (%) 7 5.1 0.118 Mild malnutrition (%) 27.1 25.8 Well nourish (%) 55.7 48.3 Overweight (%) 10.7 12.8 Obesity (%) 5.7 7.9 Family's income < 500,000 IDR (%) 7.1 10.4 0.482 500,000 to 1,000,000 IDR (%) 54.3 50.6 >1,000,000 IDR (%) 38.6 39.1 Parents' education Primary school (%) 70 66.9 0.661 Junior high school (%) 15.7 18.5 Senior high school (%) 12.1 10.4 College (%) 7 2.2 The logistic regression analysis showed that emotional problem and nail biting in family were the risk factors of nail biting in this study. The prevalence ratio were 4.225 (95% CI 2.282-7.821) and 2.261 (95% CI 1.228-4.164). Tabel 6. Risk factors of nail biting P PR 95% CI Sex 0.110 0.701 0.453-1.083 Nail biting in family 0.0001 4.225 2.282-7.821 Live among parents 0.134 2.836 0.727-11.067 Mild malnutrition 0.459 0.724 0.308-1.703 Severe malnutrition 0.474 0.714 0.284-1.795 Overweight 0.128 5.509 0.610-49.726 Obesity 0.800 0.880 0.328-2.363 Emotional problem 0.009 2.261 1.228-4.164 Conduct problem 0.270 1.375 0.781-2.422 Hyperactivity problem 0.754 1.122 0.546-2.308 Peer problem 0.160 1.446 0.864-2.421 Prosocial 0.459 1.238 0.704-2.178 DISCUSSION According to WHO in 2007, mental health was dened as a welfare state where every individu aware his potential, can resolve stressor in daily living, can work productively, and can contribute to his community. (Kessler RC, 2009; Kelsay K, 2009). A study in India showed that the prevalence of mental emotional disorder child ages under 16 years old was 12.5% (Warner LA, 2010). Our study didn't perform a research to a specic mental disorder. We perform a research of mental health parameter such as emotional, conduct, hyperactivity, peer, and prosocial problem. The prevalence of emotional disorder in our study was 28.8%. The other problems were conduct, hyperactivity, peer, prosocial problems. The prevalence of each of them was 23.4%, 8.8%, 24.1%, 13.8%. SDQ is a screening tool for children ages 4-16 years old. There are several versions to meet researcher, clinician aspect. It is widely used as a screening tool. The benet of SDQ are that it includes a variety of ages, it is available in multilingual. Its sensitivity is 85% and specity is 80% (Strength and difculty questionarre, 2016; Nothern California Training Academy, 2008) According to International Classication of Diseases and Health Related Problems – 10 (ICD-10), nail biting is classied as emotional and health disorder that starts since kids and teenage. This habit is also accompannied with other habits such as excessive masturbation, nose picking, and thumb sucking (Przemyslaw P, 2009) Nail biting is dened as an act of inserting any nger into the mouth or an act of inserting at least one nger and or bite it. (James SB, 2007) This habit usually starts when a child is 3-4 years old. The prevalence increases as the age increases. The prevalence of nail biting in children age 7-10 years old and in teenagers is approximately 20%-33% and 45% (Ghanizadeh A, 2011). The prevalence in our study was 23.6% Nail biting can cause several complications such as relationship problem because of shame, often receive abuse from friends, higher oral infections that can be caused by Enterobacteriaceae, dental root resorption (Ghanizadeh A, 2011) It was stated in a study in Iran in 2011 that boys with nail biting had lower prosocial score than the one without this habit. It also showed that age and prosocial score was associated with nail biting (Ghanizadeh A, 2011). While a study in Kuba stated that the risk factors of nail biting were low birthweight, a child who didn't exclusively breastfed, and disharmony family (Romagosa DER, 2014). Our risk factors ndings were different with other studies. Those were nail biting in family and abnormal emotional problem score. Nail biting can be associated with other psychiatric conditions such as anxiety, obsessive compulsive disorder. The relationship between nail biting with anxiety is still controversial because several studies fail to show the increment of anxiety disorder prevalence. This result is consistent in obsessive compulsive disorder (Halteh P, 2017). But a study in USA showed that there was an increment in prevalence of psychiatric disorder in nail biting groups compared to the other group (18% vs 6%), Unfortunately, there wasn't any specic psychiatric disorder stated in that study (Winebrake JP, 2018). This study still had several limitations. We didn't analyze complete risk factors of mental health disorder, that was, psychiatric disorder in the family. Identication of mental health risk factors in this population had never been performed before. We still hadn't analyzed other risk factors of nail biting in this study. We used questionarre to evaluate parameters of nail biting and mental health disorder. It is encouraged to perform a better study design to analyze the relationship between mental health disorder and nail biting. CONCLUSION Mental health disorder is a state when someone cannot realize the potential of himself, overcome stressor in daily living, work productively, and contribute to his community. 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