The Relationship between Family Harmony with Stress, Anxiety, and Depression in Adolescents

Introduction: Adolescents are a group vulnerable to mental health problems, including stress, anxiety, and depression. This study aimed to examine the interlink of a harmonious family with stress, anxiety, and depression in adolescents. Methods: This study employed descriptive correlational design with cross-sectional approach and examined 851 high school adolescents aged between 16-18 years who were recruited using a total sampling method from five high school in Malang City. Stress, anxiety and depression in adolescents was assessed employing the Depression Anxiety Stress Scale (DASS - 21), while, to assess family harmony, a questionnaire developed by the researcher was used. Data were analyzed through descriptive statistics and bivariate tests using Spearman Rank Correlation. Results: It was revealed that 428 adolescents (50.3%) were male, 321 adolescents (37.7%) came from parents who worked privately, and 482 adolescents (56.6%) had their parents' social status above the minimum wage standard. Eight hundred and two adolescents (94.2%) had harmonious families, while the remaining 49 adolescents (5.8%) had non-harmonious families. Our study concluded that family harmony had a significant relationship with adolescent stress levels (p-value 0.013). On the other hand, the analysis showed that family harmony was not related to adolescents' anxiety (p-value 0.071) and depression level (p-value 0.13). A harmonious family makes children mentally healthy, able to adapt to the environment while a family that is not harmonious can trigger stress because conditions are not as expected, coupled with the burden of schoolwork, stressors from teachers and peers. Conclusion: The results of the research showed that harmony in the family had a significant effect on stress in adolescents. Therefore, it is necessary to provide education and counseling to the family to prevent fights in the family so that it can reduce the emergence of stress in adolescents.


INTRODUCTION
Mental health is a complex problem in society that requires synergistic and sustainable management (Wuryaningsih, Windarwati, Dewi, Deviantony, & Hadi, 2018).Mental health problems are also encountered in adolescents, in the forms of bullying, game or internet addiction, eating disorders (anorexia, bulimia), psychosis, drugs, suicide-self harm, and emotional disorders (e.g., anger, frustration, anxiety, depression) (WHO, 2019).Teenagers also often experience stress due to bullying from peers at schools (Rana et al., 2018).Stress, anxiety, and depression in adolescents are caused by internal factors from within, cognitive, academic achievement, and external factors such as family or peer function (Chi et al., 2020).Gender is a major factor in causing depression in adolescents (Liu et al., 2019).Women have higher levels of depression than men because they have different hormones and quickly respond to stressors from family (Sun et al., 2017).Adolescents tend to experience anxiety due to the formation of self-identity, sensitivity to aspects of self-assessment, and self-compassion (Gill et al., 2018).Late teens are depressed because they are about to face graduation exams and go to college (Liu et al., 2019).
Research has portrayed that the prevalence of mental health disorders among children and adolescents around the world has reached 13.4%, anxiety 6.5%, depression 2,6%, attention deficit hyperactivity disorder 3.4%, and other disorders 5.7% of 87.742 individuals in 27 countries (Polanczyk et al., 2015).Meanwhile, in Turkey, as much as 13.9% of adolescents experienced anxiety (Ercan et al., 2016).Most of the psychiatric morbidity among adolescents in Nigeria is caused by depression (Oderinde et al., 2018).The results of a study conducted on school students with a mean age of 16 years found that the prevalence of depression, anxiety and stress was 65.53%, 80.85% and 47.02% respectively (Sandal et al., 2017).Based on data from the National Institute of Mental Health (2017) in the United States, 13.3% of 3.2 million adolescents aged 12-17 have major depression (Mental Health Information Statistics, 2017).In Indonesia, depression is more common in adolescents than adults as much as 50% and mostly occurs in women as much as 32% (Brooks et al., 2019).
Socioeconomic factors of family, environment, peers, and family dysfunction are external factors related to stress, anxiety, and depression, where socioeconomic status is related to overall health conditions, including life satisfaction and happiness (Guo et al., 2018;Kezer & Cemalcilar, 2020;Leavey et al., 2020).Also, gadget addiction and bullying are external factors of stress, anxiety, and depression because bullying causes psychological distress, aggressive behavior, hostility, and psychosomatic symptoms (Hill et al., 2017;Liu et al., 2020;Zhao et al., 2020).Bullying occurs due to experiences of bullying and a lack of parental affection during childhood, and it is more common among teenagers with stepfamilies (Erika et al., 2017;Fujikawa et al., 2018).Every teenager faces stressors from family, school environment, peers, teachers, and lessons, but not all of them have good coping with adapting (Zheng et al., 2016).Parents who are not harmonious, family dysfunction, and conflict in the relationship between children and parents are significant stressors in the psychological development of adolescents (Guo et al., 2018).Family is a comfortable place to grow and develop for teenagers apart from school and peer groups (Thariq, 2018).Unhappy psychological experiences in the family during childhood lead to depression, low self-concept, and maladaptive coping in adolescents (Hayward et al., 2020;Wong et al., 2019).Good coping and family support can increase self-esteem, a more optimistic view, and reduce stress, anxiety, and depression in adolescents (Han et al., 2018;Nursalam et al., 2017).
Based on the above factors, the family or parents have an attachment to the psychological resilience of children (Liu et al., 2020).Parents have the responsibility to monitor children's behavior and activities, especially in their teens, so as not to commit social deviations and be able to deal with stressors (Ibnu et al., 2020).Poor family parenting causes adolescents to experience internal conflicts, irritability, obsessiveness, frustration, and behavioral deviations (Okaviani., 2018).Adolescents who grow up in disharmonious families are more at risk of mental, anti-social, and emotional disorders (Sas, Nurdin, & Bakar, 2018).Several previous studies have discussed family harmony related to mental health problems in adolescents, such as depression, selfesteem and emotional maturity (Artasari, 2017;Budianti, 2015;Rahmawati et al., 2015;Witantri, 2018).However, the current research not only discusses the relationship between family harmony with depression but also stress and anxiety, especially in high school adolescents in Indonesia.While theoretical research has found a possible relationship between family and adolescents' mental health problems, little attention has been geared to examining the interlink of a harmonious family with stress, anxiety, and depression in adolescents.Therefore, the present study aimed to examine the association between family harmony with stress, anxiety, and depression in adolescents.

MATERIALS AND METHODS
This study employed descriptive correlational design with cross-sectional approach.The population was 851 adolescents aged between 16-18 years in five high schools in Malang City.The total sampling was used to recruit the participants.Data were gathered using a pre-tested semi-structured questionnaire to determine the demographic details and family harmony of the participants during the period August 2019 to January 2020.
Harmony in the family was measured using a questionnaire developed by the researcher and filled out by adolescents.The self-reported questionnaire consisted of questions that ask whether adolescents feel that their families are harmonious, with a choice of harmonious and disharmonious answers.The harmony in the family questionnaire has passed the validity and reliability test (Cronbach's alpha > 0.7).
Furthermore, the Stress Anxiety Stress Scale (DASS-21), which was validated and translated into participants' national language (Indonesian language), was used to determine the level of depression, anxiety, and stress in adolescents aged between 16-18 years.DASS-21 was used to screen patients suffering from depression, anxiety, and stress in the community.The original 42-item DASS of Lovibond was changed to a shorter 21-item version.DASS-21 is a well-established instrument for measuring depression, anxiety, and stress symptoms in clinical and non-clinical samples (Antony et al., 1998;Lovibond & Lovibond, 1995).The DASS-21 questionnaire has passed the validity and reliability test (Cronbach's alpha > 0.7).
Data were analyzed through descriptive statistics and bivariate tests using Spearman Rank Correlation analysis.In this study, p-value <0.05 was considered statistically significant.This study has been approved by the Research Ethics Committee of Politeknik Kesehatan Malang (Reg.No.335/KEPK-POLKESMA/2019), and written consent was obtained from all participants.

RESULTS
It was revealed that almost 50% of the adolescents who took part in the study were female (49.7%).The majority of their parents' backgrounds work as private employees (37.7%) with the social and economic status mostly above the minimum wage standard (56.6%).Most of the participants come from harmonious families (94.2%), with stress levels of

Association between harmony in the family with stress, anxiety, and depression
Table 2 shows a significant relationship between harmony in the family and stress levels in adolescents, as indicated by a p-value of 0.013 (pvalue <α).The correlation coefficient of 0.086 indicated a positive direction with a feeble relationship strength between variables.This showed that the more harmonious the relationship in the family was, the lower the stress level in adolescents.
The results of further analysis related to stress levels and harmony in the family showed that most adolescents who had stress levels in the normal category had harmonious families (53.8%).Meanwhile, only 1.3% of adolescents had unharmonious families and had high to very highstress levels.
There was no significant relationship between harmony in the family and the level of anxiety in adolescents, as indicated by a p-value of 0.071 (pvalue > α).The correlation coefficient of 0.062 indicated a positive direction with a very weak relationship strength between variables.This showed that the more harmonious the relationship in the family was, the lower the level of anxiety in adolescents even though the decrease was not significant.The results of cross-tabulation between anxiety and harmony in the family indicated that the level of anxiety in adolescents with harmonious families and families who were not harmonious was 33.7% and 2.4%, respectively, and mostly in the anxiety category very high when compared to other classes.
There was no significant relationship between harmony in the family and the level of depression in adolescents, as indicated by a p-value of 0.13 (p-value > α).The correlation coefficient of 0.052 indicates a positive direction with a very weak relationship strength between variables.This showed that the more harmonious the relationship in the family was, the lower the level of depression in adolescents, even though the decrease was not significant.The level of adolescent depression in the cross-tabulation showed that most of the adolescents having normal level of depression had a harmonious family (27.7%), while the adolescents with a non-harmonious family had a most moderate depression level (1.9%).

DISCUSSION
This study documented that most of the adolescents who participated in the study were female.This may be the reason for the high levels of anxiety and depression in this study.Female adolescents respond faster to psychological changes and are more sensitive to self-assessment.Theoretically, women experience hormonal changes, exposure to stressors, coping abilities, and cognitive abilities that are different from men (Liu et al., 2019).Men are better able to manage stressors, although they may not obtain much social support in dealing with the problem (Sun et al., 2017;Tyas, 2014).In addition, female adolescents also show a stronger interpersonal orientation and are more responsive to relationships than male adolescents (Shi et al., 2017).
Our study also portrayed parents' occupation as a large private employee with a socioeconomic status of above the minimum wage standard.In this study, the stress level of adolescents was mostly normal; this can be related to the socioeconomic status of the family.Families with good socioeconomic conditions reduce symptoms of depression and stress in adolescents (Bae, 2020).This is influenced by the mother's caring behavior (Xu et al., 2019).Lowincome parents do not care and behave rudely so that their children experience internal problems (Bøe et al., 2017). in addition, physical health problems, selfconfidence, and motivation to go to school are lacking (Zhou et al., 2018).
Family harmony affects adolescent mental health development, self-esteem formation, social behavior, and facing stigma from society.Previous research carried out by Wang et al. ( 2020) declared that family is an essential factor for mental development and higher academic expectations.Family harmony is described by the creation of religious life, understanding, openness, compassion, and mutual trust between children and parents (Sas, Nurdin, & Bakar, 2018).An uncomfortable, unpleasant family atmosphere and unfavorable family relationships can have a psychological impact on children in adolescence (Mulyadi, 2017).Psychological problems of adolescents with single parents (e.g., broken home) tend to occur due to lack of attention and affection.Other factors, such as busy parents, low socioeconomic status, abusive behavior, and negative stigma from the environment, may contribute to adolescents' psychological problems (Ghani et al., 2014).Thus, it takes positive support from parents to reduce the psychological pressure of adolescents (Joyce & Liamputtong, 2017).The psychological wellbeing of adolescents is created when there are harmonious relationships and excellent communication within the family (Tillman & Miller, 2017).Harmony in the family may be related to the high socioeconomic status of adolescents in this study as well as to the stress level of adolescents.
Stress is an emotional problem that often occurs in adolescents due to interpersonal stressors from relationships with family, social environment, and problems at school.According to Widayati et al. (2019), stress is a form of vulnerable emotional disorder, which tends to occur in high school students.Female teenagers experience stress since they worry too much when facing problems, while males tend to be aggressive (Masdar et al., 2016).This behavior is related to adolescent coping abilities.Problem focus coping is one of the strategies that teenagers can do to reduce stressors (Nurlaila, 2019).
Anxiety is a psychopathology that occurs in adolescents with physical and psychological responses to internal and external pressure (Inchley et al., 2011;Wang et al., 2020).Internal pressure that often occurs in adolescents is low self-esteem, negative self-assessment, followed by seeking negative feedback from the environment, which triggers anxiety (Sowislo & Orth, 2013).In this study, most adolescents had normal stress levels related to economic status and harmony in the family.However, the unique thing is that teenagers have a very high category of anxiety.This may be due to other factors not examined in this study.
Depression is related to gender and anxiety.Previous research has reported that women are more at risk of experiencing depression because they tend to be sensitive to stressors, vulnerable to selfcompassion, and self-criticism (Bluth & Blanton, 2015;Sun et al., 2017).Teenagers face multiple demands for final exams and their future, which can lead to depression (Liu et al., 2019).Meanwhile, excellent self-evaluation skills and accepting social criticism can minimize anxiety and reduce depression (Gill et al., 2018).However, when the adolescents' self-concept is not good because the psychological experiences of childhood are less enjoyable, it can lead to depression (Wong et al., 2019).Stressors that cause depression also arise from the school environment and associations in the form of learning loads, social demands, hostility, rejection between friends, disappointment, and intimidating actions (Anyan et al., 2018;Zhao et al., 2020).
Stress in adolescents occurs due to puberty; there is a peak of growth and development, both physically and mentally (Miller & Prinstein, 2019).Stress triggers aggressive actions and social behavior deviations, so it is essential to provide support to adolescents.Lack of support from family and friends when dealing with stressors can trigger stress.Every teenager has different coping strategies in responding to the stressors that arise.Stress management using proper coping can help reduce the level of stress experienced (Ramadhani & Hendarti, 2017).Stress management skills are also influenced by the psychological wellbeing of children in the family (Dewi & Soekandar, 2019).The results in this study indicated that most adolescents having stress in the normal category had harmonious families.A harmonious family makes children mentally healthy, able to adapt to the environment, and show filial piety to parents (filial piety) (Bourassa et al., 2015;Chen, 2014;Meggiolaro & Ongaro, 2014).A family that is not harmonious can trigger stress because conditions are not as expected, coupled with the burden of school work, stressors from teachers and peers (Duarte et al., 2019).This suppresses the mind of adolescents and is often not expressed so that the stressor they feel is not reduced (Kim, Bassett, So, & Voisin, 2019).
It was found that harmony in the family is not related to the level of anxiety and depression in adolescents.Although adolescents are found to freely choose their career pathways and future trajectories, parental support still holds a firm factor for such options.Feeling worried about the future, hopes, and ambiguous desires can cause anxiety.Anxiety per se is experienced by many individuals, especially women, which affects their survival, weakness, and helplessness (Craske et al., 2017).Adolescents with families who are not harmonious, but who are not anxious can be caused by good social support and coping skills.A recent study by Wang et al. (2020) revealed that parents who are not harmonious can still reduce feelings of loneliness, provide affection by accompanying children's activities, pay attention, and fulfill their needs so that children do not feel anxious.Adolescents who experience anxiety or depression tend to face academic difficulties, dropping out of school, maladaptive social relationships, drug abuse, and suicide (Ingul & Nordahl, 2013).Therefore, if the conditions of the family are not harmonious, single parents still have to try to meet the physical and psychological needs of their children, and the environment must reduce the negative stigma of children with broken homes (Ghani et al., 2014).
Adolescence is a transitional period that experiences many new challenges (Guo et al., 2018).Higher education levels and academic stress can play an important role in determining adolescent mental health (Chellamuthu & Kadhiravan, 2017).Depression is a mental health problem in adolescents that is a response to the loss of parents, siblings, friends, or the end of a relationship with a lover (Townsend, 2017).In this regard, adolescents with an unharmonious family are less able to communicate their emotions and thoughts effectively, and they also lack family support, which leads to anxiety and depression (Kleiboer et al., 2015).A family that is not harmonious causes adolescents to lack communication skills, often feel blamed, and tend to experience loneliness (Shi et al., 2017;Wang et al., 2020).However, when adolescents can communicate and have good relationships, and their parents are willing to facilitate it, depression will not occur.This is because an adolescent has a basic need to give and receive a positive response to relationships with others (Beata et al., 2018).
The results of the correlation between anxiety and depression with family harmony in this study showed insignificant value.The insignificant results in this study may be related to the large differences in the distribution of adolescents with harmonious and disharmonious families.The advantage of this research is that it was carried out on a population of adolescents with almost the same age, in addition to which this research was also carried out in a large number of samples.However, this study has limitations; the family harmony questionnaire used in this study is a self-reported questionnaire that reveals youth perspectives on family harmony so that it may not reflect the condition of the family as a whole.However, the results showed that stress in adolescents was significantly related to family harmony.Stress in everyday life is often ignored, even though stress can develop into anxiety and depression and can be very detrimental to mental health (Khan & Khan, 2017).Therefore, to prevent stressful conditions in adolescents, it is necessary to promote mental health by involving teenagers' families.

CONCLUSION
Our study has attempted to uncover the relationship between family and mental health problems in adolescents, such as stress, anxiety, and depression.The results of the analysis showed that harmony in the family had a significant effect on stress.Meanwhile, anxiety and depression in adolescents did not have a significant relationship with family harmony.Although it is not significant, it does not mean that family harmony is not a neglected thing in the handling of anxiety and depression problems in adolescents.Stress in adolescents should be addressed through early detection and promotion of mental health.Mental health promotion activities need to be carried out to prevent increasing stress, anxiety, and depression in adolescents.Therefore, it is necessary to provide education and counseling to the family to prevent fights in the family so that it can reduce the emergence of stress in adolescents.Families also need to improve the relationship between parents and adolescents so that they know better the mental health conditions of adolescents.It is also recommended to explore more deeply about family harmony from the point of view of all family members and broaden the identification of factors contributing to mental health problems through more extensive studies to explore various aspects of mental health in adolescents.

Table 2 .
The Relationship between Stress, Anxiety, and Depression Levels with Family Harmony