The Influence of Group Therapeutic Intervention on the Enhancement of Emotional and Psychosocial Development in Adolescents

Eni Hidayati1*, Yanuan Ben Olina1, Aureo Frutalegio da Costa Freitas2, Adelina Ximenes Martins2

1Faculty of Nursing and Health Science, Universitas Muhammadiyah Semarang, Central Java 50273, Indonesia

2Cristal Superior Institution, CHJG+X6Q, Díli, Timor-Leste

*Corresponding Author’s Email: eni.hidayati@unimus.ac.id

ABSTRACT

Introduction: Adolescence signifies the progression from adolescence to maturity. An adult's personality may be afflicted with social anxiety disorder because of developmental failure. Group therapy for therapeutic purposes is one method of resolving this. The objective of this study is to ascertain the impact of therapeutic group therapy on the enhancement of adolescents' psychosocial and emotional development. Develop a quasi-experimental design employing a control group methodology of pre-test-post-test. Methods: The research sample comprised 326 individuals who satisfied the inclusion criteria: they were adolescents who were enrolled in school and were willing to participate as respondents. Criteria for exclusion: minors who decline to participate as respondents. The paired t-test is utilized for univariate analysis in research data analysis. Results: There was a significant difference in psychosocial development scores before and following therapeutic group therapy (p-value = 0.000), and in emotional development scores before and following therapeutic group therapy (p = 0.000), according to the study's findings. By implementing therapeutic group therapy with adolescents, nurses can enhance the standard of mental health nursing care. Conclusion: Therapeutic group therapy has the potential to enhance adolescents' psychosocial and emotional development.

Keywords: Adolescents; Emotional and Psychosocial Well-Being; Therapeutic Group Therapy

INTRODUCTION

Mental health is the condition of a person who is aware of his abilities and is physically, mentally, spiritually, and socially healthy (Fauziah et al., 2022). The characteristics of mental health are being aware of your abilities, being able to adapt and overcome problems as usual, being able to carry out activities, accepting yourself, and building good relationships with other people (Rachmad et al., 2023). Mental health is no longer just about talking about mental illnesses; healthy groups and hazards, including teenage mental health, also need to be understood so that society can respond appropriately. When teenagers are unable to adjust to changes in the growing process they are going through, mental health issues might arise (Gurning et al., 2022).

The adolescent era spans the ages of 10 to 19 years. According to the Central Statistics Agency's data for 2023, Indonesia's population has reached 269.6 million people, with 44.8 million teens (10–19 years) accounting for almost 22% of the overall population, implying that one in every four Indonesians is a teenager (BPS, 2023). In the teenage phase, there will be very rapid changes in social, biological, and psychological aspects, one of which is mental health (Sampson, Kubzansky, & Koenen, 2023). Teenagers will go through a period of change in their growth, so they must be able to adjust to avoid psychological alterations such as mental health illnesses. Adolescents grow and develop in three stages: early adolescence (aged 11–14 years), middle adolescence (aged 15–17 years), and late adolescence (18–20 years) (Shoshani & Steinmetz, 2023).

According to data from the National Institute of Mental Health 2023 (NIMH), the highest prevalence of adolescent mental health problems occurs at the age of 17 to 18 years. NIMH also found that suicide in the United States for individuals between the ages of 15 and 24 had a prevalence of 220/100,000. WHO reports that 450 million people worldwide have mental health disorders, with a prevalence of 20% occurring in children (Fauziah et al., 2022). Throughout the world, it is estimated that 10–20% of teenagers have experienced mental health problems that are underdiagnosed and undertreated (Health, 2023). Data from the 2017 Global Health Data Exchange study indicates that 27.3 million Indonesians are dealing with mental health issues. This indicates that mental health illnesses affect one in ten people in this nation. Just 6% of adolescents under the age of 15 had emotional mental disorders with symptoms of anxiety and depression in 2018, according to data on adolescent mental health in Indonesia alone. This represents an increase from 2013, when the prevalence of emotional mental disorders with these symptoms was only 6%. In the meantime, 1.2 per thousand people had a major mental illness like schizophrenia in 2013 (Health Metrics and Evaluation, 2020). Adolescents with poor mental health may have a variety of causes, including the stigma that keeps them from getting treatment or a lack of understanding or awareness of mental health among medical professionals. Health anxiety is a multidimensional concept encompassing mild forms to clinically significant health-related fear, combined with disease convection (Khodabakhsh et al., 2021).

The percentage of adolescents (15–24 years old) with depression is 6.2%. A propensity to injure oneself or even kill oneself is a sign of severe depression. Up to 80–90% of suicide cases have anxiety and sadness as their cause. In Indonesia, there are up to 10,000 suicide instances annually, or one suicide case every hour. Sociologists estimate that 4.2% of Indonesian students have considered suicide. Six percent of students intended to kill themselves, and three percent had already tried (Rusuli, 2022). Teenage depression can result from some circumstances, including familial dynamics, peer pressure, pressure in the classroom, and financial difficulties (Lawrence & Adebowale, 2023). Teenagers are distinct individuals who must go through a variety of physical, psychological, and mental developmental processes. Teenagers may experience behavioral shifts during adolescence that defy social norms because it is a transitory and challenging time in their lives (Afrita & Yusri, 2022). Teenage drug use, smoking, teenage pregnancy, dropping out of school or missing classes, and juvenile delinquency are the most common causes of mental health issues among teenagers (Zhou et al., 2020). Adolescents' ability to assist themselves in the field of mental health, their awareness of the risks associated with mental health, the support and active involvement of stakeholders, and the number of adolescents who adopt mental health-promoting behaviors are all expected to increase with increased knowledge about the importance of mental health in adolescents (Asri et al., 2023). Teenagers' understanding of mental health is shaped by the information they are exposed to, whether it comes from their parents, friends, or the media (Thomas et al., 2022). Most outcomes of diabetic foot exercise were related to physical benefits. However, this study also highlights the mental benefits (Sirait, Said, & Mohamad, 2024).

A preliminary study conducted with instructors revealed that students frequently fought in and out of class, smoked, and were absent without a certificate. Teenagers at school are frequently reserved and uncooperative with their peers, speak impolitely, and lack self-assurance, according to observations. Given the aforementioned description, it is imperative to investigate the impact of therapeutic group therapy on the enhancement of adolescents' psychosocial- emotional development.

METHODOLOGY

Research Design

This is a quantitative study employing a quasi-experimental design and a pre-test-post-test control group methodology (Creswell & Plano Clark, 2020).

Participants

The inclusion criteria were satisfied by 326 participants: they were adolescents who were enrolled in school and were willing to participate as respondents. Criteria for exclusion: minors who decline to participate as respondents (Yani Balaka & Abyan, 2022).

Instrument

The cohort for this investigation was partitioned by the researchers into two distinct groups: the control group and the treatment group. In contrast to health education regarding the psychosocial and emotional development of adolescents, the treatment group received therapeutic group therapy.

Data Analysis

To enable analysis, descriptive statistics are presented in tabular format. The analysis of the data was conducted using SPSS version 21. Univariate analysis was utilized in the analysis of research data to distinguish between independent and dependent variables. Then, employ paired t-tests for bivariate analysis to ascertain the difference in means between the treatment and control groups.

Ethical Consideration

The ethical approval for this study was obtained from the faculty of nursing at Sultan Agung University Semarang, Indonesia with reference number ID no. 681/A.1-KEPK/FIK- SA/IX/2023) on 30th June, 2024.

RESULTS

The research results obtained are the following, with the results of the characteristics of the respondents:

Table 1: Distribution of Respondents Based on Gender Characteristics (N=326)

The data presented in Table 1 indicates that the majority of the 326 respondents were female, with 136 (41.72%) being male and 190 (58.28%) being female.

Table 2: Distribution of Respondents in Indonesia According to Age Attributes

Based on the results of Table 2, it can be seen that most of the respondents' ages were 14 years old, 92 respondents (28.22%) and the smallest age was 16 years old, 10 respondents (3.07%).

Table 3: Distribution of Respondents Based on Characteristics of Residence Status

Based on Table 3, it can be seen that based on the characteristics of residence status, the largest number is living with father and mother, namely 324 respondents (99.39%).

Table 4: Distribution of Respondents Based on Characteristics of Family History of Mental Disorders (N=326)

Based on Table 4, based on the characteristics of the history of mental disorders in the family, there were around 4 respondents (1.23%) and those without mental disorders in the family were 322 people (98.77%).

Table 5: Changes in Emotional Development before and after Intervention in the Treatment Group and Control Group (N=326)

Table 5 in the intervention group suggests that there is a significant difference in the emotional development of adolescents before and after receiving therapeutic group therapy. The paired T-test results show a calculated t-value of 7.375 and a significant value of 0.000, and the significance is smaller than 0.05 (0.000<0.05). This shows that higher emotional development can benefit from therapeutic group therapy.

Table 6: Psychosocial Development Changes in the Treatment Group and Control Group (N=326) before and after Intervention

Based on Table 6 in the treatment group, it can be interpreted that the results of the paired T- test (paired-sample t-test) show a calculated t-value of 7.442 and a significance value of 0.000, meaning that there is a significant difference in the psychosocial development of school-age children between before and after being given group therapy. This indicates that therapeutic group therapy can have a positive effect on psychosocial development.

DISCUSSION

There are differences between the stages of emotional development before and following therapeutic group therapy. For this therapeutic group therapy, children are divided into two groups, with one group comprising twelve adolescents and seven sessions lasting between seventy-five and ninety minutes each (Astriani Hardayati, & Anna Keliat, 2022). The conditions permit effective therapeutic group therapy, and adolescents have sufficient time to learn, share experiences regarding stimulating adolescent development, and have their correct emotional and psychosocial development directly stimulated in the group (Abdel-Aziz & Ahmed, 2021).

Initiating therapeutic group therapy activities during the adolescent identity phase to foster adolescent development (Usraleli, Melly, & Forwaty, 2021). The nurse provides the group with an explanation, supported by examples, regarding the attributes that distinguish productive adolescents from unproductive ones (Bronsard et al., 2022). Subsequently, the adolescent completes a list comprising attributes associated with productive and unproductive adolescents, as well as attributes about the progress of each group member, regardless of whether they are affected by their development or not, to ascertain the state of one's development (Arifuddin & Pangaribuan, 2021).

Psychosocial development in adolescents is defined as a period of identity and role confusion that spans from 12 to 20 years of age (Godfrey, Dean, & Hadiprodjo, 2022). Late adolescence is the anticipated culmination of personality development, the primary objective of which is identity formation during adolescence. A greater awareness of identity develops during adolescence; consequently, he attempts to discover and redefine "who" he is now and "what" he intends to become in the future. Additionally, identity formation during adolescence is crucial because it lays the groundwork for adult psychosocial development and interpersonal relationships (Zhou et al., 2020).

The phases of identity development consist of the following: 1) differentiation (12–14 years). During this stage, adolescents realize that they are psychologically distinct from their parents. This consciousness frequently causes them to doubt and deny the values and counsel of their parents, even when such counsel and values are logical. 2) Stage of application (14–15 years) Adolescents at this developmental stage exhibit the characteristics of self-assurance and the conviction that they are complete idiots. He rejects the necessity of counsel or admonishment and confronts his parents whenever he can. His dedication to his companions also grew stronger. 3) Stage of acclimation (15–18 years). The sorrow and anxiety that adolescents experience during this stage motivate them to relinquish a portion of their parent's authority, albeit under certain conditions. Their conduct frequently fluctuates between adaptation and experimentation; they occasionally challenge their parents but also reconcile and collaborate with them at times. 4) Consolidation stage (18–21 years): On the one hand, he takes responsibility around the house; on the other, he becomes irritated when his parents constantly restrict his movements and activities outside the home (Zenghui et al., 2024).

Adolescents develop a consciousness of their identity during this developmental phase. This awareness serves as the foundation for comprehending both themselves and others, as well as for preserving their autonomy, independence, and individuality. During this developmental phase, adolescents acquire a burgeoning awareness of their individuality, recognizing that they are singular beings endowed with inherent qualities including preferences and aversions, aspirations for the future, and the ability and motivation to direct their own lives (Khodabakhsh & Ramasamy, 2021). This is a difficult time for teenagers because of the transition from childhood to adulthood on the one hand and sensitivity to social and historical changes on the other, so that a teenager feels the deepest suffering compared to other times due to role confusion or identity confusion (identity confusion) (Olive et al., 2023). Adolescents with this disorder experience feelings of seclusion, emptiness, anxiety, and indecision. Additionally, adolescents develop irritability and embarrassment. Adolescents exhibit erratic and unpredictable behavior during this developmental stage. At times, they may exhibit introversion out of fear of rejection or disappointment, while at others, they may be irresistibly attracted to romantic relationships or followers without regard for the repercussions of their actions (Duagi et al., 2024).

Adolescents who successfully develop a stable self-identity will acquire a comprehensive understanding of their being, distinguishing characteristics from those of others, recognizing weaknesses and strengths, exuding self-assurance, demonstrating adaptability to diverse circumstances, possessing the capacity to make critical decisions, and forecasting forthcoming obstacles. future and acknowledge their societal role (Waxmonsky et al., 2021).

Early adolescent psychosocial development encompasses the following: 1) body/physical appearance anxiety; 2) hormonal fluctuations; and 3) the expression of independence and the sense of being an individual rather than merely a family member. 4) Resistance and defiance of authority; 5) Friendships gaining significance; 6) Peer acceptance; girls have friendships while boys form gangs and organizations; 7) Girls have a sense of belonging; 7) Girls demand justice but tend to see things in black and white and from their perspective. The effects on children are as follows: 1) Heightened self-awareness (self-consciousness); 2) Anger; formerly kind males may become aggressive; 3) Identity experimentation through changes in appearance, speech, and attire. 4) Aggressive and insistent on acquiring liberty; 5) Aspire to emulate their peers' appearance, including attire, grooming, and musical preferences; 6) Adolescents are profoundly influenced by their peers and do not wish to deviate from the norm;

7) They exhibit intolerance and find compromise challenging; sibling envy develops (Little, 2023).

Early adolescent psychosocial development consists of the following: 1) increasing the capacity for compromise; 2) acquiring the ability to think independently and make independent decisions; 3) persistently experimenting with a satisfactory self-image; 4) having the compulsion to acquire new experiences and put them to the test, regardless of the dangers involved; 5) Ceased to be preoccupied with oneself; 6) Construct values and norms and shape reality; 7) Require additional companionship and a feeling of allegiance; 8) Commence dating individuals of the opposite species; 9) Intellectuals are more developed, have a broad curiosity, and think abstractly. 10) The cultivation of exceptional intellectual abilities; 11) The establishment of a profound fascination with the arts and athletics; 12) An affinity for exploration and a desire to embark on solitary journeys. A dysfunction of the intestinal microbiota has been associated with a variety of chronic diseases, including cancer, obesity, and digestive disorders (Luqman et al., 2024).

One of the effects on infants is that they become more patient, tolerant, and tranquil. 1) Capable of accepting the views of others, even if they differ from their own; 2) Resistant to parental interference; 3) Whose attire, hairstyles, dispositions, and viewpoints frequently evolve; 4) Commence experimenting with cigarettes, alcohol, and drugs; 5) Become more sociable and less introverted; 6) Challenge family-instilled values and conventions; 7) Begin dating and spend more time with friends; 8) Commence to scrutinize a hitherto unremarkable aspect, the desire to participate in debates and discussions; 9) New interests may cause them to disregard schoolwork (Cuijpers et al., 2023). Late adolescence (17–19 years) is characterized by the following: 1) Attainment of an ideal life; 2) Active participation in extra-family life, work, and relationships; 3) Development of financial and emotional independence; and 4) Improved capacity to form stable relationships with the opposite sex; 5) Gain a mature sense of equality with other members of your family; 6) Be nearly ready to transition into an independent adult personal life. The effects on children encompass the following: 1) Increased engagement in religious and socio-political values; 2) Initiation of stress management skills; 3) Detrimental effects on adolescents' self-esteem due to anxiety and uncertainty regarding the future; 4) Adoption of a more committed romantic partnership; and 5) A proclivity to differentiate one's personal experiences from those of one's parents. Prominent factors that impacted the pain management knowledge of nurses were their academic standing, prior pain education, and on- site training. (Ibrahim, 2024).

Regarding emotional, psychological, and social well-being, mental health is at an exceptionally high level. An individual will experience heightened psychological well-being when positive emotions predominate (Jaya et al., 2021). It can be argued that an individual's psychological well-being is diminished when negative influences predominate, whereas exhibiting a positive attitude and perspective towards society and acknowledging both its positive and negative attributes contribute to a state of equilibrium (Trope et al., 2019). Social closeness is indicative of an individual's concern for their social existence (Defar et al., 2023). Teenagers may perceive their social lives as comprehensible, purposeful, and beneficial if they are socially integrated and exhibit comfort in belonging to a community, perceiving themselves as members of society, and receiving support within it (Matthys & Schutter, 2023).

Limitations

As the present study lacks randomization it may introduce selection bias and affect the generalizability of the results. Thus, further studies are needed in such cases of self-reported measures for assessing psychosocial and emotional development to eliminate response bias.

CONCLUSION

The findings of this study demonstrate that therapeutic group therapy significantly enhances both the psychosocial and emotional development of adolescents, as evidenced by the pre-test and post-test results. This indicates that group therapy is an effective intervention for addressing social anxiety and developmental challenges in this age group. By incorporating therapeutic group therapy into mental health nursing practices, nurses can improve the quality of care for adolescent patients, fostering better mental health outcomes. Future research should explore long-term effects and potential adaptations of this therapy to different adolescent populations and settings. Additionally, further studies could investigate the integration of therapeutic group therapy with other mental health interventions to maximize its benefits.

Conflict of Interest

The authors declare that they have no competing interests.

ACKNOWLEDGEMENT

The authors express their gratitude to the Faculty of Nursing and Health Sciences at Muhammadiyah University Semarang, Indonesia for this collaboration.

REFERENCES

Abdel-Aziz, H. R., & Ahmed, H. A. A. (2021). The effect of group reminiscence therapy on self-esteem and emotional well-being of older adults. Central European Journal of Nursing and Midwifery, 12(4), 513–520. https://doi.org/10.15452/CEJNM.2021.12.0027

Afrita, F., & Yusri, F. (2022). Faktor-faktor yang mempengaruhi kenakalan remaja. Educativo: Jurnal Pendidikan, 2(1), 14–26. [ Afrita, F., & Yusri, F. (2022). Factors Influencing Juvenile Delinquency. Educativo: Jurnal Pendidikan, 2(1), 14–26.] https://doi.org/10.56248/educativo.v2i1.101

Arifuddin, A., & Pangaribuan, H. (2021). Pengaruh terapi kelompok terapeutik terhadap peningkatan perkembangan psikososial dan emosi anak remaja. Madago Nursing Journal, 2(1), 15–21. [The Effect of Therapeutic Group Therapy on Increasing the Psychosocial and Emotional Development of Adolescents. Madago Nursing Journal, 2(1), 15–21.] https://doi.org/10.33860/MNJ.V2I1.440

Asri, Y., Amina, T., Fahrul, A., Keperawatan, P., Soepraoen, I., Hystory, A., & Mental, K. (2023). Peer education : kesehatan mental remaja untuk pencegahan gangguan mental remaja di desa ngadas. Journal of Health Innovation and Community Service, 2(2), 65–70. [Peer Education: Adolescent Mental Health to Prevent Adolescent Mental Disorders in Ngadas Village. Journal of Health Innovation and Community Service, 2(2), 65–70]. https://doi.org/10.54832/JHICS.V2I2.155

Astriani Hardayati, Y., & Anna Keliat, B. (2022). The effect of terapi kelompok terapeutik (tkt) on readiness for the aspect and development task of adolescent. The Indonesian Journal of Health Promotion, 5(7). [The effect of terapi kelompok terapeutik (tkt) on readiness for the aspect and development task of adolescent. The Indonesian Journal of Health Promotion, 5(7)]. https://doi.org/10.31934/mppki.v2i3

BPS. (2023). Statistical yearbook of indonesia in infographics 2023. In BPS-Statistics Indonesia. https://www.bps.go.id/en/publication/2023/09/26/0e70a59af34c8964e775f4b7/statistical- yearbook-of-indonesia-in-infographics-2023.html. Accessed on 28th August, 2023

Bronsard, G., Cohen, D., Diallo, I., Pellerin, H., Varnoux, A., Podlipski, M. A., Gerardin, P., Boyer, L., & Campelo, N. (2022). Adolescents engaged in radicalisation and terrorism: a dimensional and categorical assessment. Frontiers in Psychiatry, 12. https://doi.org/10.3389/fpsyt.2021.774063

Creswell, J. W., & Clark, V. L. P. (2017). Designing and conducting mixed methods research. Sage Publications, United States. https://toc.library.ethz.ch/objects/pdf/z01_978-1-4129- 7517-9_01.pdf

Cuijpers, P., Karyotaki, E., Ciharova, M., Miguel, C., Noma, H., Stikkelbroek, Y., Weisz, J. R., & Furukawa, T. A. (2023). The effects of psychological treatments of depression in children and adolescents on response, reliable change, and deterioration: a systematic review and meta- analysis. European Child and Adolescent Psychiatry, 32(1), 177–192. https://doi.org/10.1007/s00787-021-01884-6

Defar, S., Abraham, Y., Reta, Y., Deribe, B., Jisso, M., Yeheyis, T., ... & Ayalew, M. (2023). Health related quality of life among people with mental illness: The role of socio-clinical characteristics and level of functional disability. Frontiers in Public Health, 11, 1134032. https://doi.org/10.3389/fpubh.2023.1134032

Duagi, D., Carter, B., Farrelly, M., Lisk, S., Shearer, J., Byford, S., James, K., & Brown, J. S. L. (2024). Long-term effects of psychosocial interventions for adolescents on depression and anxiety: a systematic review and meta-analysis. Eclinical Medicine, 68, 102382. https://doi.org/10.1016/J.ECLINM.2023.102382

Fauziah, M., Lusida, N., Ernyasih, E., Fajrini, F., & Herdiansyah, D. (2022). Adolescents’ mental health efforts in the implementation of worship. Indonesian Journal of Islam and Public Health, 2(2), 94-112. https://doi.org/10.53947/ijiph.v2i2.334. Accessed on 27th September, 2023.

Godfrey, P., Dean, B. J., & Hadiprodjo, N. A. (2023). Therapeutic play, fidelity, and the adolescent. In Integrating Therapeutic Play into Nursing and Allied Health Practice: A Developmentally Sensitive Approach to Communicating with Children (pp. 123-135). Cham: Springer International Publishing. https://doi.org/10.1007/978-3-031-16938-0_10

Gurning, M., Pademme, D., Mansoben, N., Manoppo, I. A., & Banna, T. (2022). Pendidikan Kesehatan Tentang Kesehatan Jiwa Emosional Pada Remaja. Jurnal Pengabdian Kepada Masyarakat, 6(1), 45–49. [Health Education About Emotional Mental Health in Adolescents, Jurnal Pengabdian Kepada Masyarakat, 6(1), 45–49.] https://doi.org/10.30822/BERBAKTI.V1I2.2644

Hardayati, Y. A., & Keliat, B. A. (2022). Pengaruh Terapi Kelompok Terapeutik (TKT) Terhadap Peningkatan Aspek dan Tugas Perkembangan Remaja. Media Publikasi Promosi Kesehatan Indonesia (MPPKI), 5(7), 824-827. [The Effect of Therapeutic Group Therapy (TKT) on Improving Aspects and Tasks of Adolescent Development, Media Publikasi Promosi Kesehatan Indonesia (MPPKI), 5(7), 824-827] https://doi.org/10.31934/mppki.v2i3

Health Metrics and Evaluation. (2020). Global Health Data Exchange | GHDx. Global Health Data Exchange. https://ghdx.healthdata.org/. Accessed on 28th August, 2023

Ibrahim, R. H. (2024). The influence of nurses' attributes and educational background on pain management: perspectives, beliefs, and clinical application. International Journal of Sustainable Biome and Life Care (IJSBLC), 1(1), 13-20.https://ijsblc.org/index.php/journal/article/view/3

Jaya, I. K. P. A. P., Purwaningsih, P., Ismiriyam, F. V., & Susilowati, E. (2021). the effect guide imagery (five fingers hypnosis) toward decreasing of anxiety to the quarantine isolation patient in covid-19. KLASICS, 1(02), 01–08. https://doi.org/10.46233/klasics.v1i02.493

Khodabakhsh, S., & Ramasamy, S. (2021). Anxiety and coping strategies among women with hyperemesis gravidarum in Malaysia. Central European Journal of Nursing and Midwifery, 12(3), 420–429. https://doi.org/10.15452/CEJNM.2021.12.0017

Khodabakhsh, S., Ramasamy, S., Teng, T. Y., & Leng, C. S. (2021). Impact of internet addiction on health anxiety in Malaysian youth during COVID-19 pandemic. Malaysian Journal of Medical Research (MJMR), 5(2), 12-18. https://doi.org/10.31674/mjmr.2021.v05i02.003

Lawrence, K. C., & Adebowale, T. A. (2023). Adolescence dropout risk predictors: Family structure, mental health, and self-esteem. Journal of Community Psychology, 51(1), 120–136. https://doi.org/10.1002/jcop.22884

Little, M. A. (2023). Childhood Narcissism: Strategies to Raise Unselfish, Unentitled, and Empathetic Children. Rowman & Littlefield.

Luqman, A., Hassan, A., Ullah, M., Naseem, S., Ullah, M., Zhang, L., ... & Wang, G. (2024). Role of the intestinal microbiome and its therapeutic intervention in cardiovascular disorder. Frontiers in Immunology, 15, 1321395. https://doi.org/10.3389/fimmu.2024.1321395

Matthys, W., & Schutter, D. J. L. G., (2023). Moral thinking and empathy in cognitive behavioral therapy for children and adolescents with conduct problems: a narrative review. Clinical Child and Family Psychology Review, 26, 401–415. https://doi.org/10.1007/s10567- 023-00429-4

National Institute of Mental Health (NIMH) (2023). Mental Illness - National Institute of Mental Health (NIMH). https://www.nimh.nih.gov/health/statistics/mental-illness. Accessed on 20th July, 2023.

Olive, L., Dober, M., Mazza, C., Turner, A., Mohebbi, M., Berk, M., & Telford, R. (2023). Surf therapy for improving child and adolescent mental health: A pilot randomised control trial. Psychology of Sport and Exercise, 65, 102349. https://doi.org/10.1016/j.psychsport.2022.102349

Rachmad, Y. E., Agnesiana, B., Agama, I., Ambon, K. N., Sukmawati, E., Ramli, A., ... & Zebua, Y. (2023). The analysis of parenting patterns in instilling morals of early childhood. Journal of Childhood Development, 3(1), 13–21. https://doi.org/10.25217/jcd.v3i1.3247

Rusuli, I. (2022). Psikososial remaja: Sebuah sintesa teori erick erikson dengan konsep islam.Jurnal As-Salam, 6(1), 75-89. https://doi.org/10.37249/assalam.v6i1.384

Sampson, L., Kubzansky, L. D., & Koenen, K. C. (2023). The missing piece: A population health perspective to address the US mental health crisis. Dædalus, 152(4), 24-44. https://doi.org/10.1162/daed_a_02030

Shoshani, A., & Steinmetz, S. (2023). Positive Psychology at School: A School-Based Intervention to Promote Adolescents’ Mental Health and Well-Being. Journal of Happiness Studies, 15, 1289–1311. https://doi.org/10.1007/s10902-013-9476-1

Sirait, H. S., Said, F. M., & Mohamad, N. A. (2024). Successful aspects and impacts of diabetic foot exercise among indonesian type 2 diabetes mellitus patients: a literature review. International Journal of Advancement in Life Sciences Research, 7(2), 9-16. https://doi.org/10.31632/ijalsr.2024.v07i02.002

Thomas, I., Martin, A., Wicker, A., & Benoit, L. (2022). Understanding youths’ concerns about climate change: a binational qualitative study of ecological burden and resilience. Child and Adolescent Psychiatry and Mental Health, 16(1), 110. https://doi.org/10.1186/s13034-022- 00551-1

Trope, A., Anderson, B. T., Hooker, A. R., Glick, G., Stauffer, C., & Woolley, J. D. (2019). Psychedelic-assisted group therapy: a systematic review. Journal of Psychoactive Drugs, 51(2), 174–188. https://doi.org/10.1080/02791072.2019.1593559

Usraleli, U., Melly, M., & Forwaty, E. (2021). Enhancing the application of therapeutic group therapy (TKT) for school-age children in Delima, Pekanbaru. Community Empowerment, 6(9), 1565–1571. https://doi.org/10.31603/ce.4925

Waxmonsky, J. G., Baweja, R., Bansal, P. S., & Waschbusch, D. A. (2021). A review of the evidence base for psychosocial interventions for the treatment of emotion dysregulation in children and adolescents. Child and Adolescent Psychiatric Clinics, 30(3), 573-594. https://doi.org/10.1016/j.chc.2021.04.008

Yani Balaka, M., & Abyan, F. (2022). Metodologi Penelitian Kuantitatif [Quantitative Research Methodology]. www.penerbitwidina.com. Accessed on 19th August, 2023.

Zenghui, S., Jichang, H., Yanan, L., Liangyan, Y., Lei, S., & Jiakun, Y. (2024). Effects of large-scale land consolidation projects on ecological environment quality: A case study of a land creation project in Yan'an, China. Environment International, 183, 108392. https://doi.org/10.1016/j.envint.2023.108392

Zhou, W., Ouyang, F., Nergui, O.-E., Bangura, J. B., Acheampong, K., Massey, I. Y., & Xiao, S. (2020). Child and adolescent mental health policy in low- and middle-income countries: challenges and lessons for policy development and implementation. Frontiers in Psychiatry, 11. 150. https://doi.org/10.3389/fpsyt.2020.00150