Devotional Overload Syndrome: A New Pediatric Psychobehavioral Concern

Rationale

India’s plural society blends devotion with identity formation. Children caught between parental expectations and their own curiosity often internalize stress silently. Recognizing DOS can aid clinicians and educators in identifying early warning signs.

Objectives

1. Identify psychological and behavioral symptoms associated with excessive religious practices in children

2. Determine the prevalence and severity of DOS among school-going children

3. Propose preventive and coping strategies suitable for families, schools, and clinicians.

Study design and setting

A prospective mixed-method cross-sectional design was adopted, combining quantitative survey data and qualitative interviews. The study took place in three urban districts of Madhya Pradesh (Indore, Bhopal, and Dewas) from January to July 2024. This design allowed concurrent measurement of prevalence and exploration of lived experiences.

Study population and sampling

The population comprised school-going children aged 10– 16 years enrolled in both government and private institutions. USING stratified random sampling stratified by age group (10–12, 13–14, 15–16 years) and gender (target 50:50 ratio), 30 schools (10/district) were selected. Within each school, 16–17 children were randomly chosen from class registers using computer-generated numbers (total screened: 600; final n = 500 after exclusions). Sampling ensured proportional representation: ~53% boys, balanced ages.

Sample size determination

Assuming a 25% expected prevalence of DOS symptoms, 95% confidence level, and 5% margin of error, the minimum sample size required was 288. To increase statistical power and ensure subgroup representation, 500 children (265 boys, 235 girls) were finally included.

Inclusion criteria

• Age 10–16 years

• Regular school attendance ≥80 %

• Parent/guardian consent and child assent obtained.

Exclusion criteria

• Known psychiatric illness or neurodevelopmental disorder

• Current psychotropic medication use

• Declined consent or incomplete questionnaires

Control selection

For comparative analysis, 100 age-matched children with minimal religious exposure (<1 h/week) were designated as the control group. They were drawn from similar socioeconomic backgrounds to minimize confounding.

Confounding variables assessed

Socioeconomic status (Kuppuswamy scale), religion, family type (nuclear/joint), and number of siblings were recorded as potential confounders.

Data collection tools

1. DOS screening questionnaire (DOSSQ) development: The 20-item DOSSQ was developed by the researcher based on pilot interviews (n=50) and literature on spiritual stress. Content validity was established by 5 child psychologists (Content Validity Index = 0.89).

   • Structure: Items cover 4 domains (5 items each): Anxiety/guilt, academic interference, sleep/physical, behavioral withdrawal. Response scale: 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Often, 4 = Always.

   • Scoring Method: Total score = sum of all items (range 0–80). Cutoffs: 0–10 = No DOS, 11–20 = Mild, 21–30 = Moderate, 31–40 = Severe (pilot-derived). Cronbach’s α = 0.86; test–retest reliability r = 0.82 (2-week interval). The full questionnaire is shown in Annexure 1.

2. Screen for Child Anxiety-related Emotional Disorders (SCARED).

3. Strengths and Difficulties Questionnaire (SDQ) for behavioral assessment.

4. Semi-structured Interview Schedules with parents (n = 250) and teachers (n = 150) exploring family religiosity, disciplinary style, and observation of behavioral changes (thematic analysis via Braun and Clarke framework).

Demographic and sampling characteristics are presented in Table 1 (Sampling breakdown [Table 1a] and confounding variables [Table 1b]). The prevalence of devotional overload syndrome-related symptoms is shown in Table 2 (Prevalence of devotional overload syndrome-related symptoms). The association between parental religious practices and child stress levels is presented in Table 3 (Parental religious practice versus child stress level). The severity distribution of devotional overload syndrome scores is summarized in Table 4 (DOS score distribution). Recommended prevention and coping strategies are presented in Table 5 (Recommended strategies for prevention).

Procedure

After institutional permissions, participants completed the DOSSQ and standardized scales under supervision. Interviews were audio-recorded (with consent) and transcribed verbatim. The mean time per participant was 40 min.

Ethical considerations

Ethical approval was obtained from the Institutional Ethical Review Board of Amaltas University (AU/ERB/2024/PSY/031). Parents provided written consent; children provided verbal assent. Participation was voluntary, and anonymity was maintained through coded identifiers. The study adhered to the Declaration of Helsinki (2013 revision).

Bias control and masking

• Randomization: Students were randomly selected using computer-generated numbers

• Masking: Data analysts were blinded to participant identities and religiosity levels

• Inter-rater reliability: Two independent raters scored qualitative transcripts (κ = 0.81).

Statistical analysis

Data were entered into the Statistical Package for Social Sciences version 26. Descriptive statistics (mean, standard deviation, frequency, percentages) summarized demographic and clinical variables. Inferential tests included Chi-square, t-test, and Pearson’s correlation coefficient (r). Multivariate regression examined predictors of high DOS score, controlling for gender and socio-economic status. A P < 0.05 was considered statistically significant.

Demographic characteristics

A total of 500 children (265 boys, 235 girls) participated, with a mean age of 13.2 ± 1.8 years. No major gender difference was found in DOS scores (Chi-square = 1.24, P = 0.27). As shown in Figure 1 (Distribution of Devotional Overload Syndrome severity among participants, n = 500), the severity levels of devotional overload syndrome are illustrated.

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Figure 1:

Distribution of devotional overload syndrome severity among participants (n = 500). DOS: Devotional overload syndrome.

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Prevalence and symptom patterns

Overall, 26% (95% confidence interval [CI]: 22.2–29.8%) of children demonstrated moderate-to-severe DOS (t-test vs. controls: t = 5.67, P < 0.001).

Qualitative findings

Thematic analysis of 400 interviews (250 parents, 150 teachers) yielded 3 themes: (1) Enforced Rituals (“He cries if he misses puja—fears God’s anger” - Parent, Indore); (2) Hidden Distress (“Top student, but zones out during examinations due to guilt” - Teacher, Dewas); (3) Coping Gaps (“We thought devotion builds character, not stress” - Parent, Bhopal). 62% of high-DOS cases linked to >3 h daily parental rituals (κ = 0.81 inter-rater) [Table 1].

Association with parental religiosity

Children whose parents practiced >3 h of daily rituals had the highest mean DOS scores (M = 28.3 ± 5.6).

Pearson’s correlation between parental religiosity index and child DOS score was r = 0.72 (P < 0.01), indicating a strong positive relationship.

Multivariate regression

High DOS predicted by parental religiosity (β = 0.45, P < 0.001), joint family (β = 0.22, P = 0.01), and lower socioeconomic status (β=−0.18, P = 0.03); adjusted R² = 0.52 (controls: gender/age).

Principal findings

This investigation identifies DOS as a quantifiable pediatric condition rather than a purely cultural phenomenon. About 26% (95% CI: 22.2–29.8%) of surveyed children showed moderate-to-severe levels of psychological strain directly linked with over-religious parenting. The symptom constellation – anxiety, guilt, concentration loss, and disturbed sleep – mirrors stress responses described in other cultural anxiety disorders. Importantly, the strong correlation (r = 0.72) confirms that excessive parental religiosity is a significant determinant of child distress (regression β = 0.45).

Interpretation in light of previous work

The results align with Bansal and Mehta (2021)^[2] who found elevated anxiety among highly religious families (Odds ratio = 2.3). Bhattacharya (2020)^[3] emphasized “spiritual stress” as an under-recognized adolescent issue; our data extend these observations to younger school-age children (10–16 years), indicating that indoctrination intensity – not faith itself – produces dysfunction. Where previous studies explored spirituality as protective (Das and Kapoor, 2023),^[4] this study underscores its dual nature: Moderate devotion nurtures discipline, but compulsion erodes autonomy. The new construct DOS captures this imbalance succinctly, bridging gaps in Saini (2020)^[5] and Sethi and Pradhan (2021).^[6] Reports from^[7] (NIMHANS, 2023 -Child Psychiatry Annual Report) highlight increasing child mental health concerns. Previous studies have reported identity conflicts and psychological effects related to religious upbringing.^[8-20]

Psychological mechanisms

Children exposed to complex rituals without cognitive readiness internalize fear of divine retribution. Repetitive guilt (“I forgot the mantra, God will punish me”) becomes an intrusive thought pattern resembling obsessive–compulsive features (SCARED subscale correlation r = 0.68). Chronic anxiety disrupts academic focus (51% endorsement), emotional regulation, and sleep rhythm (38%). Qualitative themes confirm this: Parents report children “crying before puja” due to perfectionism, while teachers note “zombie-like concentration” during examinations.^[8-15]

Sociocultural dimensions

India’s collectivist ethos often equates obedience with piety. Hence, refusal to pray may be interpreted as disobedience, reinforced by extended family pressure (joint families: β = 0.22, P = 0.01). Social reinforcement perpetuates over-involvement in rituals. Teachers may also expect devotional conformity during school assemblies, compounding pressure (62% high-DOS cases). Religion distribution (84% Hindu) reflects Madhya Pradesh demographics, yet DOS transcends faith, Muslim children showed a similar prevalence (28%). Recognizing DOS reframes cultural practices within a mental-health lens.^[16-18]

Methodological strengths

Prospective data collection with stratified random sampling (30 schools, 16–17 children/school) enhanced representativeness. The use of validated tools (DOSSQ α = 0.86, SCARED, SDQ) ensured reliability. Mixed-method approach integrated quantitative prevalence (95% CI specified) with qualitative depth (thematic analysis, κ = 0.81). Control group (n = 100, minimal exposure) and multivariate adjustment (R² = 0.52) minimized confounding. Blinding of analysts and randomization reduced bias.^[19,20] As shown in Figure 2 (Study flow chart illustrating participant selection, screening using DOSSQ, SCARED, and SDQ, and final sample inclusion), the methodology and participant flow are presented.

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Figure 2:

Study flow chart. DOSSQ: Devotional overload syndrome screening questionnaire, SCARED: Screen for child anxiety-related emotional disorders, SDQ: Strengths and difficulties questionnaire.

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Limitations

• Urban sample (Indore/Bhopal/Dewas); rural beliefs may differ significantly

• Self-reported religiosity may involve social desirability bias despite anonymity

• Cross-sectional design limits causal inference–temporal relationships need longitudinal confirmation

• DOSSQ requires multi-center validation beyond pilot testing.

Clinical and educational implications

1. Screening: Pediatricians should include questions about home religious routines during psychosocial assessments (“How many hours daily on rituals?”).

2. Parent counseling: Mental-health awareness sessions in schools can educate caregivers on balanced devotion versus compulsion.

3. Teacher training: Workshops to detect early behavioral changes (withdrawal, academic drop) related to ritual overload.

4. Policy level: Incorporate mental-health education into value-education curricula (NIMHANS 2024 guidelines).

Theoretical significance

By conceptualizing DOS, this study bridges psychology, sociology, and religious studies. It introduces a culturally anchored framework to study stress, opening avenues for cross-cultural psychiatry. The DOSSQ provides a novel measure for future research, complementing SCARED/SDQ in spiritual contexts.