Seasonal variations in children’s calls to a help-line: implications for preventive services

Journal of Affective Disorders 70 (2002) 175–180 www.elsevier.com / locate / jad Research paper Seasonal variations in children’s calls to a help-line: implications for preventive services Anne Mari Sund a , *, Gunnar Morken b , Olav M. Linaker c a Department of Child and Adolescent Psychiatry, The Medical Faculty, The Norwegian University of Science and Technology, Trondheim, Norway b Østmarka Hospital, Department of Psychiatry and Behavioural Medicine, The Medical Faculty, The Norwegian University of Science and Technology, Trondheim, Norway c Department of Psychiatry and Behavioural Medicine, The Medical Faculty, The Norwegian University of Science and Technology, Trondheim, Norway Received 26 October 2000; accepted 15 February 2001 Abstract Background: To investigate seasonal variations in telephone calls to a help-line for children, and their correlation to changes in length of day, latitude and age. Method: 691,787 calls to the Red Cross Help-Line in Norway for children in the three-year period 1996–1998 were included. Results: Monthly frequencies of calls deviated significantly from an expected even distribution ( x 2 5 9446.34, df 511, P,0.0001). The frequency curve for calls peaked in April and October and had its lowest level in July and December. Variation was pronounced: the mean number of daily calls varied between 436 in July and 886 in April. There was a strong and positive correlation between the number of calls and the change in length of day across the year (r s 50.76, N512, P,0.01). Increasing latitude correlated positively with the range of the monthly observed / expected ratios of calls (r s 50.79, N57, P,0.05). The frequency of calls was largest among children 12 to 14 years of age. Age correlated negatively with the range of monthly observed / expected ratios of calls (r5 20.94, N512, P,0.001). Limitations: Social and cultural factors could not be explored in the design used in the present study. Conclusions: The frequency of calls from children correlates positively with change in length of day (i.e., maximal in spring and fall), and the magnitude of the seasonal variation correlates positively with latitude and negatively with age. Knowledge of seasonal variation in requests for help may have value in planning services for children.  2002 Elsevier Science B.V. All rights reserved. Keywords: Season; Children; Adolescents; Help-line; Latitude 1. Introduction *Corresponding author. Tel.: 147-73-55-1509; fax: 147-7355-1539. E-mail address: Anne.M.Sund@medisin.ntnu.no (A.M. Sund). Seasonal variations in behavior, mood and physiological factors in children and adults have been examined in some research. At least two different 0165-0327 / 02 / $ – see front matter  2002 Elsevier Science B.V. All rights reserved. PII: S0165-0327( 01 )00339-1 176 A.M. Sund et al. / Journal of Affective Disorders 70 (2002) 175 – 180 patterns of seasonal variations have been described; A summer / winter difference in depressive symptoms as in Seasonal Affective Disorders (SAD) have been described both among children (Magnusson, 1998; Rosenthal et al., 1986) and among adults (Rosenthal et al., 1984) in clinical samples and in epidemiological surveys. Secondly increased frequencies of suicides (Eastwood and Peacocke, 1976; Hakko et ˆ et al., 1987) and of admissions to al., 1998; Souetre hospital for affective disorders (Eastwood and Peacocke, 1976) have been described among adults in spring and to a lesser extent in fall. This second kind of seasonal variation has rarely been reported among children (Neinstein et al., 1995). Symptoms of SAD are reported to increase in frequency with increasing latitude both among children (Sourander et al., 1999; Carscadon and Acebo, 1993) and adults (Rosen et al., 1990). An influence of latitude on seasonal variation has also been reported for suicides (Hakko et al., 1998). Both social (Lester, 1971) and physical environmental factors (Haggag et al., 1990; Kasper et al., 1989) have been proposed as causes for seasonal variation in behavior and mood symptoms. At least two hypotheses concerning change in length of day have been proposed as explanations for seasonal ˆ et variations in behavior and / or symptoms (Souetre al., 1987; Tiihonen et al., 1997); (1) That length of day with maximum light in the summer influences seasonal variation. This hypothesis is compatible with one peak of behavior and / or symptoms during the year. (2) That change in length of day with maximum impact at the equinoxes produces seasonal variation. This would result in two peaks of behavior and / or symptoms during the year (Morken and Linaker, 2000). Length of day varies with latitude, so both hypotheses may extend to differences in frequency patterns of behavior and / or symptoms at different latitudes. Norway is situated in the far north with extreme seasonal variations of light, and appears to be suitable for a study of the influence of light and seasons on human behavior. Help-line services for children are established in several countries and seems to be a valuable supplement to regular healthcare services (Boehm et al., 1998). Studies of seasonal variation in frequencies of use of such services could reveal information about the causes for seasonal variations and produce information relevant for planning the capacity of services for children. In the present study possible seasonal patterns in the monthly frequencies of children’s calls to the Red Cross Help-Line for children in Norway were examined. Based on the notion that light is a contributing factor influencing changes in children’s behavior, we also wanted to examine a possible association between a seasonal pattern in calls to the Red Cross Help-Line and the mean monthly length of day as well as the monthly changes in length of day. A possible association between aspects of the seasonal pattern and increasing latitude was also tested. Finally changes in the seasonal variation related to different age groups were investigated. 2. Method 2.1. Population and setting Norway has a fairly stable population of 4 450 000 inhabitants. The country is situated between the latitudes of 588N and 728N. The total number of children aged 6 to 17 years is 678 000 with a mean of 56 500 at each year of age. The climate is milder than in North America and Asia at comparable latitudes due to the influence of the Gulf Stream. The part of Norway situated above the Arctic Circle (66839N) has periods of Midnight sun during summer and Polar night during winter, and has 450 000 inhabitants. Throughout the country the school year starts around 20th of August and lasts until 20th of June. 2.2. Calls included The Norwegian Red Cross has established a helpline for children and adolescents in all parts of the country. This is the only nation-wide help-line aimed at those age groups. Except for the two northern counties served by one center together, there is one center in each of the 17 other counties. The help-line is mainly targeted at children in the age range 6 to 18, and is accessible from 2 p.m. to 8 p.m. on all weekdays throughout whole year. Calls are free of charge and the counselors are trained adults, usually without formal health or social education. The aim is A.M. Sund et al. / Journal of Affective Disorders 70 (2002) 175 – 180 to provide an opportunity for children to talk to an adult, to share their problems and attempt to find a solution while preserving anonymity. Referrals to other agencies are only effected in emergency situations. The counselors registered all calls including phone calls where it was not possible to register any information. Conversations were defined as calls when the counselor was able to register the callers sex, age or type of problem. More than one problem could be recorded for each conversation. Children from 7 through 17 years of age were recorded with their stated age while the younger and older children were inconsistently recorded and hence left out of the analysis of variations with age. In the summer, some calls could be redirected to another center due to capacity problems. These calls were not recorded separately, but based on spot tests they appear to be few. Centres report the number of calls to the National Red Cross every month. All calls in the years 1996 to 1998, a total of 691 787, were included in the study. Of these calls 220 602 were conversations. For the years 1997 and 1998 the monthly numbers of calls were also obtained separately for each of seven centres at different latitudes to enable study of possible north–south variations. The seven centres were the capital, Oslo, the four largest centres outside the capital area south of the Arctic Circle and the two centres north of the Arctic Circle. The latitudes, maximum length of day, number of inhabitants in the catchment areas of the centers and number of calls received at each center are presented in Table 1. 177 2.3. Assessments The observed number of calls and of conversations for a month was the sums of calls and of conversations for that month for the included years. Based on the expectation that the number of calls and of conversations would be the same every day through the year, the expected number of calls and of conversations for each month was calculated taking into account the different number of days for each month and leap years. The ratios between the observed and expected (O / E) numbers of calls for each month were calculated for the whole country and for each of the seven centers. The ratios between the observed and expected (O / E) numbers of conversations for each month were calculated for each age group. The same procedure for calculating expected numbers of calls and of conversations was used for the chi-square tests. The mean monthly length of day was calculated as the mean time from sunrise to sunset in that month. The numbers of hours from sunrise to sunset were obtained from the Institute of Theoretical Astrophysics, University of Oslo. To describe the speed of change in length of day in a specified month, the monthly change in length of day was defined as the mean monthly length of day in 1 month subtracted from the mean monthly length of day in the preceding month. To describe a possible delayed reaction, the changes in length of day were correlated with the figures of all calls for each of the following 3 months. To include both positive and negative changes in length of day as Table 1 Locations for Red Cross help-line centers for children and adolescents, with inhabitants in their districts, city latitude, maximum length of day, number of calls 1997–1998 for each center a Center Inhab. Latitude Max length of day Number of calls Max O / E ratio Min O / E ratio Range Stavanger Oslo Bergen Ålesund Trondheim Bodø Tromsø 369 059 502 867 431 882 242 538 260 855 238 547 224 261 588589 598559 608229 628279 638259 678179 698409 18 h 30 min 18 h 51 min 19 h 02 min 19 h 54 mm 20 h 36 min 24 h 24 h 37 128 64 678 62 833 23 048 51 435 27 513 18 567 1.30 1.37 1.30 1.32 1.67 1.40 1.62 0.72 0.77 0.70 0.51 0.60 0.67 0.60 0.57 0.60 0.60 0.82 1.07 0.74 1.03 a The maximum and minimum monthly observed / expected ratio for 1 month and the range between maximum O / E and minimum O / E are also shown. A.M. Sund et al. / Journal of Affective Disorders 70 (2002) 175 – 180 178 equivalent possible stressors, we used the absolute values of monthly changes in length of day in the study. A ranking of the mean monthly length of day and of the monthly change of length of day will be the same throughout the whole Northern Hemisphere. The range of the O / E ratios for the 12 months, the maximum monthly O / E ratio and the minimum monthly O / E ratio were calculated for each of the seven centers and for each age group. and the range of the monthly O / E ratios of calls, the maximum monthly O / E ratio of calls and the minimum monthly O / E ratio of calls. Pearson’s bivariate method was used for correlating the range of the monthly O / E ratios of conversations, the maximum monthly O / E ratios of conversations and the minimum monthly O / E ratios of conversations with age. Test results were evaluated with an alfa level of 0.05 for two sided hypotheses. 2.4. Statistics 3. Results The chi-square test for multinominals was used to test for overall deviations between months. The null hypothesis was that calls occur with a frequency proportional to the length of the time interval. The 99% confidence intervals were calculated with the method described by Wonnacott and Wonnacott (1990). The 99% confidence intervals for the observed / expected ratio for a month should not contain 1 to conclude that the observed frequency for that month differs from the expected frequency. Spearman’s rank correlation coefficients (r s ) were calculated between the observed number of calls in each month and the corresponding mean monthly length of day as well as the monthly change in length of day. Based on the assumption that the reaction of a biological system could induce a delay, these calculations were also performed with a delay of 1 and 2 months between light observations and calls. Spearman’s rank correlation coefficients (r s ) were also calculated between the latitudes of the centers More girls, 157 863, than boys, 60 797, had conversations with the Red Cross Help Line for children in Norway in the years 1996 through 1998 ( x 2 543088.85, df 51, P,0.0001). The most frequent issues children raised were requests for factual information (47 654), information about sexuality (54 041), health problems (31 646) and merely seeking contacts with an adult (34 222). Conversations concerning friends (12 052), family (11 750), school (10 343), bullying (5 236) and use of drugs (6 079) were also frequent. The monthly frequencies of calls deviated significantly from the expected ( x 2 59446.34, df 511, P,0.0001). The mean number of calls for each month varied between a daily frequency of 436 in July and a daily frequency of 886 in April. The seasonal profile of variations of calls, given as observed / expected frequency ratios of calls for each month is shown in Fig. 1. Each of the twelve months had 99% confidence intervals that did not contain 1 Fig. 1. Monthly Observed / Expected ratios of 691 787 calls to the Norwegian Red Cross Help-line for children and adolescents. A.M. Sund et al. / Journal of Affective Disorders 70 (2002) 175 – 180 and thus differed from the expected. The frequency curve for the calls showed peaks in April and October and troughs in July and December. The mean monthly length of day did not correlate significantly with the numbers of calls (r s 50.33, N512, P.0.02), but there was a positive correlation between the monthly numbers of calls and the monthly changes in length of day (r s 50.76, N512, P,0.01). Introduction of delays did not improve correlation values. In the seven centres chosen for analyses, increasing latitude correlated positively with the range of the monthly O / E ratios of calls (r s 50.79, N57, P,0.05), with the maximum monthly O / E ratio (r s 50.79, N57, P,0.05), but not with the minimum monthly O / E ratio (r s 5 20.71, N57, P,0.1). In Table 1 the centres, latitude, range, min and max O / E ratios are presented. The frequency of conversations was largest among children 12 to 14 years old. Age correlated negatively with the range of the monthly O / E ratios of conversations (r5 20.94, N511, P,0.001), with the maximum monthly O / E ratio of conversations (r5 20.94, N511, P,0.001) and with the minimum monthly O / E ratio of conversations (r50.69, N511, P,0.05). The maximum monthly O / E ratios of conversations, the range of monthly O / E ratios of conversations and the minimum monthly O / E ratios of conversations for each age are shown in Table 2. All age groups had maximum frequencies in April or May. Table 2 Age groups with number of conversations for each a Age group (y) Number of conversations Max O / E ratio Min O / E ratio Range 7 8 9 10 11 12 13 14 15 16 17 2 567 4 857 7 449 16 847 20 121 32 931 30 739 24 098 15 796 9 740 3 832 1.637 1.630 1.587 1.541 1.463 1.385 1.311 1.252 1.351 1.336 1.220 0.637 0.674 0.674 0.596 0.574 0.606 0.693 0.767 0.774 0.769 0.746 1.001 0.956 0.913 0.945 0.889 0.779 0.618 0.485 0.577 0.566 0.474 a The maximum and minimum monthly observed / expected ratio for 1 month and the range is shown. 179 4. Discussion The results of this study show a monthly variation in frequencies of calls to a help-line among Norwegian children with one maximum in April and another maximum in October. The seasonal variation of calls described in the present paper resembles descriptions of bimodal seasonal variation of behavior among adults such as admissions for mood disorders (Eastwood and Peacocke, 1976), suicides (Hakko et al., 1998) and violence (Morken and Linaker, 2000). Neinstein et al. (1995) reported one peak of suicides among children and adolescents in spring and another peak in fall. The peaks and troughs in the present paper differ from seasonal patterns concerning SAD and related behavioral symptoms in both children and adults. In the present study a positive correlation between the monthly frequencies of calls and the change in length of day was found, but no correlation with the mean monthly length of day was found. This finding is compatible with a hypothesis that the change in length of day influences the frequency of calls, but does not support a hypothesis that the total length of day is an explanatory factor. The increase in seasonal variation with increasing latitude seems to correspond with some reports of increasing frequency of symptoms among adolescents during winter with increasing latitude (Carscadon and Acebo, 1993; Sourander et al., 1999). There is a negative correlation between the magnitude of the seasonal variation in having a conversation with the help-line and the children’s age with a maximum among 7-year-old children and a nearly linear reduction until 15 years of age. The reduction in seasonal variation with increasing age seems mainly to be linked to a reduction in the maximum O / E ratio represented by the peak in spring, and could represent an age related difference in spring activity. This is in contrast to studies of frequencies of increased symptoms among children during winter, which show an enhanced frequency of seasonal variation with increasing age (Sourander et al., 1999; Swedo et al., 1995). The frequency peak of calls to the help-line is in April while the time of the year when children are reported to suffer most from psychiatric symptoms is the winter. Seasonal variation in frequency of con- 180 A.M. Sund et al. / Journal of Affective Disorders 70 (2002) 175 – 180 versations decreases with age while seasonal variation of depressive symptoms seems to increase with age. Affective disorders are not studied in the present paper and implications to seasonal variations of affective disorders represent suggestions rather than facts, that can actually be tested. One might speculate that the seasonal variations in calls are correlated with activated rather than depressed mood. One might also suggest that the variation in frequency of calls could be related to the seasonal variation among adults in admissions for mood disorders and in suicides. It is a paradox that among adults the peak frequency of admissions to hospital for mood disorders and of suicides is in spring and to a lesser extent in fall, times of the year when the frequency of depressive symptoms is low in epidemiological studies. Social and cultural factors could not be explored in the design used in the present study. Norway has a fairly homogenous population and the school year has the same length in the whole country. A possible influence of school holidays and of public holidays is not explored. There are few calls in July and December; both these are vacation months. However, April, which includes easter vacation, has a high frequency of calls. Seasonal patterns do not seem to coincide with known variation in psychosocial activities in any apparent way. Another limitation of our material is that the monthly figures are not correlated with other factors of the physical environment such as pollution, temperature, air pressure, cloud cover or humidity. Studies of seasonal variations in behavior and of physiological phenomena may yield important information about mechanisms influencing such variation. Knowledge of these mechanisms could later give important information for treatment of physical and psychiatric disorders. The seasonal variation of telephone calls is so large that it should be considered at least in planning telephone services and preventive services for children and adolescents. Acknowledgements Financial support from The Norwegian University of Science and Technology, Trondheim, Norway. No conflict of interest. January 25 th 2001. References Boehm, K.E., Schondel, C.K., Ivoska, W.J., Marlowe, A.L., Manke-Mitchell, L., 1998. Calls to teen line: representative concerns of adolescents. Adolescence 33, 797–803. Carscadon, M.A., Acebo, C., 1993. Parental reports of seasonal mood and behaviour changes in children. J. Am. Acad. Child. Adolesc. Psychiatry 32 (2), 264–269. Eastwood, M.R., Peacocke, J., 1976. 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