Child Psychiatry Hum Dev DOI 10.1007/s10578-014-0443-9
ORIGINAL ARTICLE
Gender Differences in Factors Associated with Perceived Need and Use of Korean Adolescents Mental Health Services Nam Hee Kim • Ki Young Lim • Young Ki Chung Jae Sung Noh • Yun Mi Shin
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Ó Springer Science+Business Media New York 2014
Abstract This study investigated the socio-demographic characteristics and emotional and behavioral factors associated with the perceived need and actual use of adolescent mental health services according to genders in Korea. We assessed 1,857 middle school students aged 14–16 years. We administered a self-reported questionnaire including questions on their socio-demographic data, Korean Youth Self Report, and self perceived need and actual use of mental health services. Overall, 11.6 % of the adolescents demonstrated a self perceived need for mental health services regarding their emotional or behavioral problems, while 2.1 % had sought mental health services. There were discrepancies between the perceived need and actual use. Most adolescents (81.6 %) used mental health services without self-perceived need, and only 3.3 % of adolescents with self-perceived need utilized mental health services. The perceived need of mental health services is positively influenced by the adolescent’s anxious/depressed problems in both genders. The use of them is negatively influenced by the withdrawn problem in adolescent boys, while positively influenced by the aggressive behavior in adolescent girls. To increase the actual use of mental health services more attention needs to be focused on their internalizing problems, such as anxious/depressed and withdrawn problems, in addition to externalizing problems in both genders.
N. H. Kim K. Y. Lim Y. K. Chung J. S. Noh Y. M. Shin (&) Department of Psychiatry and Behavioral Sciences, Ajou University School of Medicine, 5 Woncheon-dong, Yeongtong-gu, Suwon 443-721, Korea e-mail: [email protected]
Keywords Adolescents Mental health service Perceived need Use
Introduction Recent psychiatric studies in Korea have found high rates of mental health problems among adolescents [1, 2]. Statistics Korea recently announced that suicide was the number-one cause of mortality among young people between 15 and 19 years of age in South Korea [3]. A large-scale online survey on youth health behavior with a sample of 73,238 Korean adolescents aged 14–19 years found that 43.8 % experienced high levels of stress, and 37.4 % suffered from depressive symptoms. The rate of depression among this sample was more than double that of the adults [4]. Previous studies have shown that untreated psychopathology in childhood and adolescence persisted or progressed to psychiatric disorders in adulthood [5, 6]. A longitudinal community study which assessed the prevalence and development of psychiatric disorders from age 9 to 16 years showed that children with a history of psychiatric disorders were 3 times more likely than those without previous disorders to have a diagnosis at any subsequent wave [5]. Adolescents diagnosed with panic disorders, psychosis, verbal tics, encopresis and enuresis, and substance use disorders (SUD) showed a high tendency of it developing into a more serious disorder once they reached adulthood, even more so higher in females [5]. A general population study in Dutch province of zuid Holland using the completed child behavior checklist (CBCL) of 2,076 caregivers which investigated the 10-year course of initially aged 11–19 years found that adolescent problems tended to persist into adulthood to a moderate degree and
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high rates of problems during adolescence are risk factors for psychiatric disorders in adulthood [6]. A prospective longitudinal study based on repeated structured diagnostic interviews from age 11 to 26 found that half of the individuals who met the criteria for a major DSM-IV diagnosis at 26 years of age had a diagnosed disorder at 11–15 years of age [7]. Among cases diagnosed at 26 years of age, approximately one quarter sought professional mental health services [7]. A longitudinal study has shown that individuals who sought mental health services at adolescents significantly reduced the chances of their disorder progressing [8]. Early detection and appropriate intervention in adolescence can help reduce instances of recurrent or persistent psychopathology through adulthood. Many international studies have shown that only a small number of adolescents with psychiatric disorders have utilized specialized mental health services [7, 9, 10]. In an American study on youth aged 9–17 years showed that fewer than 25 % of the youths with a diagnosed psychiatric disorder received services from a mental health specialist [11]. In an Australian study on 4–17-year olds, only 25 % of those with mental health problems had attended a professional service [10]. These findings suggest that an alarmingly high number of adolescents who suffer from mental health problems do not receive appropriate services. Many factors contribute to the utilization of child and adolescent mental health services. The age, gender, ethnicity, socioeconomic status (SES) and the parents’ own use of mental health services [12–16]. It has been documented that females are generally more willing than males in seeking mental health services [17, 18]. Studies focused on culture including both minority and majority groups, have shown differences in the way they seek mental health services [19]. Manifestation of the symptoms also played a role in the help seeking behavior of the child and adolescent. A communitybased study in the Netherlands on children and adolescents aged 4–18 years found that their internalizing, externalizing and academic problems, and family stress were the most potent factors associated with the need or utilization of mental health services [12]. Another study suggested that externalizing problems, as opposed to internalizing problems, were more prominent among adolescents and children who visited mental health services [20]. Most studies investigating the use of mental health services among children and adolescents rely on information from caregivers. In addition, there is insufficient consolidated research on the need for mental health services and it’s utilization by adolescents. Attention toward the perceived need of mental health services for adolescents needs to be more focused on, as there is often a discrepancy between their self-reported need and their caregivers’ accounts of such a need; this is commonly due to caregivers’ lack of awareness and education of
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adolescents’ mental health problems [21]. The adolescent’s subjective difficulties may indicate an underlying psychiatric disorder or the risk of developing such a disorder [6]. The Korean medical system differs from that of other countries [22]. In the United Kingdom or the Netherlands, for example, general practitioners are the formal point of entry when referring patients to mental health care [12, 17]. In Korea, caregivers seek mental health services directly without referral by a general practitioner. Therefore, adolescents’ utilization of mental health services is at the sole discretion of the adolescents and their caregivers. The degree and patterns of use may be different from other countries. Research on factors associated with the need and use of mental health services may help find ways to reduce and hopefully prevent adolescent mental health problems. However, as most previous studies on this issue have been conducted in Western countries [12, 17, 18, 20, 23, 24], further research using a wider spectrum is necessary. This study investigated (1) the degree of the perceived need for mental health services and their use among Korean adolescents, and (2) the factors associated with such a need and the use based on gender.
Methods Participants Of a total of 1,923 eligible students, 1,857 (96.5 %) students, participated in the study. Of the nonparticipants, 45 (2.3 %) declined to participate, and we excluded 21 (1.0 %) owing to incomplete data. There were no significant Table 1 Socio-demographic characteristics of the adolescents Variables
N (%)
Gender (n = 1,857) Male
910 (49.0)
Female
947 (51.0)
Family structure (n = 1,854) Living with both parents Other Education of the father (n = 1,805) [12 years B12 years
1,798 (97.0) 56 (3.0) 582 (32.2) 1,223 (67.8)
Education of the mother (n = 1,797) [12 years
322 (17.9)
B12 years
1,475 (82.1)
Economic status (n = 1,840) High Middle Low
296 (16.1) 1,428 (77.6) 116 (6.3)
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differences in gender or school between participants and nonparticipants. The group of adolescents included 910 boys (49 %) and 947 girls (51.0 %). The mean ages were 13.75 years (SD = 1.0). We summarize the characteristics of the adolescents in the Table 1. Procedures This study was based on an examination of 1,857 Korean adolescents between the ages of 14–16 from all 6 middle schools throughout the Osan city in October 2006 (one school for the mentally disabled was excluded). The city has a population of 120,000 with similar socioeconomic profile to the national average and is located 30 miles southeast of the capital city of Seoul [25]. The availability and scale of accessible mental health services (two private outpatient clinics, one mid-sized psychiatric hospital) did not differ with other cities in Korea. After explaining the objectives and benefits of this study and giving assurances of confidentiality to teachers, parents and adolescents, written consent was obtained. Each student completed a 45–60 min, inclassroom survey during school hours, under the direction of research assistants. Ethical approval was given by the Ajou University Hospital Institutional Review Board. Measures Socio-Demographic Factors and Perceived Need and Use of Mental Health Services The adolescents completed a general questionnaire covering age, gender, family structure, parental education and economic status. Family structure included the composition (e.g., adolescent living with both biological parents). Economic status was divided into three categories based on family income. Perceived need and use were determined as follows. The first question asked: ‘‘Have you considered seeking mental health service for your emotional or behavioral problems during the past 12 months?’’ For adolescents responding affirmatively, a second question asked: ‘‘Did you receive treatment for those problems during the past 12 months?’’ The responses were recorded as dichotomous variables (e.g., yes or no). Although these specific questions have not been validated, other studies have used similar items [26, 27]. Based on the completed questionnaire, the adolescent’s subjective difficulties may indicate an underlying psychiatric disorder or the risk of developing a disorder [6].
report competence and problem behaviors for the last 6 months. It was developed for adolescents between the ages of 11 and 18 years. The YSR yields age- and genderbased T-scores for 13 empirically derived subscales, such as anxious/depressed, attention problems, aggressive behaviors, externalizing and internalizing problems, etc. The YSR also includes a competence scale reflecting the adolescent’s social and school functioning. The YSR has been reported to have adequate psychometric properties [28]. As is the case for the YSR, the K-YSR has been normed for gender- and age-specific groups and has been used widely for clinical and research purposes in Korea. The Korean version of YSR has good reliability and discriminant validity [29]. It has an internal consistency from 0.63 to 0.85 and test–retest reliability from 0.11 to 0.72. Based on the Korean normative samples, the K-YSR scores were dichotomized into those in the normal range and those in the borderline or clinical range of the scoring distributions. The cut offs were made at a T-score of 63 for the syndrome scales and the Total, Internalizing, and Externalizing Problem scales [29]. Statistical Analysis Chi square analyses evaluated associations among categorical variables (Fisher’s exact test was used when it showed low expected frequencies). First, with the perceived need for mental health services and the actual use of such services serving as dependent variables, and the sociodemographic data and psychopathology serving as independent variables, a logistic regression analysis evaluated the association between the variables based on gender. Odds ratio (OR) and 95 % confidence intervals (95 % CI) were calculated using univariate and multivariate logistic regression analyses for all variables significant at the P \ .05 level. Due to the hierarchical relationship of the eight YSR syndrome scales, the Externalizing, Internalizing, and Total Problem scales, regression analyses performed according to three different sets of variables were necessary: the first set included the total problem score; the second set, the externalizing and internalizing scores; and the third set, the eight syndrome scores [17]. All explanatory variables were dichotomized. We used the Statistical Package for the Social Sciences (SPSS) to analyze the data.
Results
Korean-Youth Self-Report (K-YSR)
Demographic and the Perceived Need and Actual Use of Adolescent Mental Health Services
Korean-Youth Self-Report (K-YSR) is the companion version of Child Behavior Checklist for adolescents to self-
Of the total sample (N = 1,857), 32.2 % had a father with a post-high school education and 322 (17.9 %) had a
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Child Psychiatry Hum Dev Table 2 Multivariate logistic regression analysis: adolescent and family characteristics influencing perceived need and utilization of mental health services in adolescent boys Self-perceived need for help OR (95 % CI)
Table 3 Multivariate logistic regression analysis: adolescent and family characteristics influencing perceived need and utilization of mental health services in adolescent girls
Mental health service use OR (95 % CI)
Including K-YSR total problem
Self-perceived need for help OR (95 % CI) Including YSR total problem
Mother’s low education level (year B 12)
Mother’s low education level (year B 12)
Father’s low education level (year B 12)
Father’s low education level (year B 12)
Living with both parents
Living with both parents
Income high level (reference = lower level)
Income high level (reference = lower level)
Income middle level (reference = lower level)
Income middle level (reference = lower level)
YSR Total problem
1.04*** (1.03–1.06)
YSR Total problem
Including K-YSR internalizing, Externalizing problem
1.04*** (1.03–1.05)
Including YSR internalizing, externalizing problem
Mother’s low education level
Mother’s low education level
Father’s low education level
Father’s low education level
Living with both parents
Living with both parents
Income high level
Income high level
Income middle level Internalizing
Income middle level 1.10*** (1.07–1.13)
0.91* (0.82–0.99)
Externalizing
Internalizing
1.09*** (1.07–1.12)
Externalizing
1.08* (1.01–1.16)
Including K-YSR syndrome Including YSR syndrome
Mother’s low education level Father’s low education level
Mother’s low education level
Living with both parents
Father’s low education level
Income high level
Living with both parents
Income middle level
Income high level
Withdrawn Somatic complaints Anxious/depressed
Mental health service use OR (95 % CI)
0.66* (0.48–0.89) 1.17*** (1.12–1.23)
Income middle level Withdrawn Somatic complaints Anxious/depressed
Thought problems Attention problems
Thought problems
Delinquent behavior
Attention problems
Aggressive behavior
Delinquent behavior
OR odds ratio, CI confidence interval, K-YSR Korean-Youth Self Report * P \ .05; ** P \ .01; *** P \ .001
0.85** (0.76–0.96) 1.25*** (1.19–1.33)
Aggressive behavior
1.10* (1.01–1.21)
OR odds ratio, CI confidence interval, YSR Youth Self Report * P \ .05; ** P \ .01; *** P \ .001
mother with a post-high school education. Most of the participants (97.0 %) lived in two-parent homes, and most families (77.6 %) were of average socio-economic status (Table 1). About 11.6 % of participants (n = 213) perceived a need for mental health services, while only 2.1 % (n = 38) had actually received mental health services
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12 months prior to the study to treat emotional or behavioral problems. In addition, more girls (14.1 %) perceived a need for mental health services than boys (8.9 %), while both boys (2.2 %) and girls (1.9 %) showed equally low rates of actual use. No significant gender differences
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existed (P = 0.09, v2 = 2.79, df = 1). There was a large discrepancy between the perceived need for mental health services and the actual use. Only 3.3 % of the adolescents who perceived a need to use mental health services actually used the services, but there was no significant difference between boys (5.0 %) and girls (2.3 %) with regard to the actual use of these services. Factors Associated with the Perceived Need and Actual Use of Mental Health Services According to Gender The factors associated with the perceived need for mental health services, as well as the factors associated with the actual use of such services, were investigated. In a multiple logistic regression model (adolescent boy), as shown in Table 2, the major predictors of the perceived need were YSR total problem (OR 1.04, 95 % CI 1.03–1.06), internalizing problems (OR 1.10, 95 % CI 1.07–1.13), anxious/depressed problem (OR 1.17, 95 % CI 1.12–1.23). Internalizing problems (OR 0.91, 95 % CI 0.82–0.99) withdrawn problems (OR 0.66, 95 % CI 0.48–0.89) were associated with actual mental health service use. In a multiple logistic regression model (adolescent girl), as shown in Table 3, the major predictors of the perceived need were YSR total problem (OR 1.04, 95 % CI 1.03–1.05), internalizing problems (OR 1.09, 95 % CI 1.07–1.12), anxious/depressed problem (OR 1.25, 95 % CI 1.19–1.33) withdrawn problems (OR 0.85, 95 % CI 0.76–0.96). Externalizing problems (OR 1.08, 95 % CI 1.01–1.16) aggressive behavior (OR 1.10, 95 % CI 1.01–1.21) were associated with actual mental health service use.
Discussion The perceived need for mental health services in the present study was 11.6 %, similar to the rate in other studies. Zwaanswijk et al. [17] reported self-perceived need for mental health services among Dutch adolescents (aged 11–18 years) as having problems that are more serious than other adolescents’ problems (problem recognition or need) was 10.5 %. The present study found that about 2.1 % of the sample had received some kind of mental health professional help or evaluation. This finding is lower to the 3–8 % reported in previous studies, such as from the Netherlands and the US [30]. These results suggest that the threshold for adolescent utilize mental health services is high. Therefore, measurements need to be taken to examine the factors giving rise to the perception These differences may be ascribed to variances in the definitions of the need for mental health services and its utilization, differences in the age of adolescents; the organization of mental health
services in which country the study was conducted in; and the prevalence rates of adolescent psychopathology based on culture [31]. Especially, this may be ascribed to the fact that Korean schools are not equipped with physicians or counselors; thus, adolescents and parents must seek mental health services directly, which may make it difficult for Korean adolescents to seek mental health services. Cultural taboos may in part explain the discrepancy, as Asian cultures are known to prefer informal methods of dealing with mental health problems in lieu of seeking professional mental health services [32, 33]. According to a culture comparative study on societal preconceptions of mental disorders in Australia and Japan, the Japanese culture was found to regard such matters as private affairs to be resolved within the family without outside assistance [34]. The values of conformity to norms, emotional self-control, collectivism, family recognition through achievement, and filial piety are some of the most common traits found throughout Asian culture. Anything that falls outside of these categories including mental illnesses are generally not accepted. Many people of Asian descent outcast people with mental illnesses and class them as dangerous and aggressive [35]. Asian American college students were subjected to a study that explored the impact of Asian cultural values, public stigma, and attitudes toward seeking professional psychological help by Shea and Yeh [36]. In this study, adolescent girls had higher rates of selfperceived need than adolescent boys, but this did not affect the difference in the actual use mental health services based on their gender. Previous research found the females tend to report feelings of depression, anxiety and suicidal ideation more than their male counterparts and were more willing to seek help [37, 38]. This may in part explain woman’s positive attitudes toward seeking help. Our results show that regardless of gender, adolescents with total problems, internalizing problems, anxious/ depressed problems tend to express a self-perceived need to use mental health services. In addition, there was a positive association between aggressive behavior, externalizing problems and actual mental health service use in girls. Sourander et al. (2001) studied concurrent and predictive associations of several child and family factors and service use when they reached the age of 16. This study concluded that parent-reported externalizing, internalizing, and total behavior problems were associated with the students utilizing mental health services. Verhulst and Van der Ende [12] found that not only was there an association with utilization but also with service needs when parents reported on their child’s externalizing and internalizing problems. Our findings are in line with other results proving that self-perceived internalizing problems had a stronger association with perceived problems than externalizing problems [39]. While adolescents experiencing
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internalizing problems tend to recognize the problematic nature of their state, but do not seek further help, which is also reflected in the significant effects of internalizing problems on self-perceived unmet need. Internalizing problems such as depression and anxiety should be considered a major public health issue among adolescents. Research has found that many psychiatric disorders present in adulthood originated in childhood or adolescence. The present rate of depression among Korean adolescents is more than double that of adults, which could be the reason why suicide is the number-one cause of mortality among young people in South Korea [3] and depression is one of the most well-known and preventable cause of adolescent suicidal attempt [40, 41]. Early detection and treatment of childhood and adolescent disorders may be preventive of adult mental disorders. An effective method increasing the mental health access rate of adolescents with internalizing problems could be to make the awareness of mental health problems more widely known. Social support from family and friends is also important, as adolescents usually turn to them first when seeking help [42]. The family education in identifying depression and anxiety disorders of adolescents and close observation by family members are important factors in increasing the access rate of mental health services. Adolescents and children who utilized mental health services, predominantly expressed externalizing problems as opposed to internalizing problems [17, 20]. There was a negative association between withdrawn problems and actual mental health service use in boys whereas the negative association was with perceived need for mental health services for girls. The social withdrawal scale includes one’s behavior of shyness, introverted feelings and withdrawn behavior, and includes items such as ‘‘Preferring to be alone’’; ‘‘Secretiveness’’ and ‘‘Withdrawn’’. These items are all suggestive of difficulties in social interactions. Due to such withdrawal problems adolescents tend to avoid self-disclosure to others which may reduce actual use of mental health services. Social withdrawal has been linked with such internalizing difficulties as anxiety and depression in childhood and adolescence [43]. A recent study on adolescent help-seeking behavior has drawn an important distinction between individual and structural determinants of such behavior [44]. Individual determinants include factors such as knowledge on mental health, attitudes, and perceived stigma relating mental health problems. Structural determinants include family, school or community support systems, referral pathways and health system structures. These factors have on impaction on when and how adolescents seek and access mental health services [42]. Therefore, mental health professionals/service providers must educate problematic
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adolescents with sufficient knowledge of mental health issues and sources of help [45, 46]. This study has several limitations. The first limitation is that this is a cross-sectional report that requires further research from a longitudinal perspective. Second, discrepancy in the health care system of Korea and other countries must be taken into account before any definitive conclusion can be made. Additional sources of information, such as teachers’ reports omitted here, as well as family factors such as parental sensitivity, knowledge and even support for mental health services may provide greater specificity and shed insight on the complexity of factors shaping self perceived need and decisions to solicit psychiatric services for their symptoms. Finally, because the present study relied solely on the subjective reports of adolescents willing to participate, there remains the possibility that not all the data collected may not be accurate, which is one of the major weakness of this study.
Summary This study investigated the status of adolescents’ self-perceived need for and their actual use of mental health services, associated with relevant socio-demographic and psychopathological factors. Although the perceived need for mental health services is high, only a small proportion of adolescents sought mental health services. There is a discrepancy between the perceived need and actual use, in addition to the factors associated with them. To increase the actual use of mental health services more attention needs to be focused on their internalizing problems, such as anxious/depressed and withdrawn problems, in addition to externalizing problems in both genders.
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ORIGINAL ARTICLE
Gender Differences in Factors Associated with Perceived Need and Use of Korean Adolescents Mental Health Services Nam Hee Kim • Ki Young Lim • Young Ki Chung Jae Sung Noh • Yun Mi Shin
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Ó Springer Science+Business Media New York 2014
Abstract This study investigated the socio-demographic characteristics and emotional and behavioral factors associated with the perceived need and actual use of adolescent mental health services according to genders in Korea. We assessed 1,857 middle school students aged 14–16 years. We administered a self-reported questionnaire including questions on their socio-demographic data, Korean Youth Self Report, and self perceived need and actual use of mental health services. Overall, 11.6 % of the adolescents demonstrated a self perceived need for mental health services regarding their emotional or behavioral problems, while 2.1 % had sought mental health services. There were discrepancies between the perceived need and actual use. Most adolescents (81.6 %) used mental health services without self-perceived need, and only 3.3 % of adolescents with self-perceived need utilized mental health services. The perceived need of mental health services is positively influenced by the adolescent’s anxious/depressed problems in both genders. The use of them is negatively influenced by the withdrawn problem in adolescent boys, while positively influenced by the aggressive behavior in adolescent girls. To increase the actual use of mental health services more attention needs to be focused on their internalizing problems, such as anxious/depressed and withdrawn problems, in addition to externalizing problems in both genders.
N. H. Kim K. Y. Lim Y. K. Chung J. S. Noh Y. M. Shin (&) Department of Psychiatry and Behavioral Sciences, Ajou University School of Medicine, 5 Woncheon-dong, Yeongtong-gu, Suwon 443-721, Korea e-mail: [email protected]
Keywords Adolescents Mental health service Perceived need Use
Introduction Recent psychiatric studies in Korea have found high rates of mental health problems among adolescents [1, 2]. Statistics Korea recently announced that suicide was the number-one cause of mortality among young people between 15 and 19 years of age in South Korea [3]. A large-scale online survey on youth health behavior with a sample of 73,238 Korean adolescents aged 14–19 years found that 43.8 % experienced high levels of stress, and 37.4 % suffered from depressive symptoms. The rate of depression among this sample was more than double that of the adults [4]. Previous studies have shown that untreated psychopathology in childhood and adolescence persisted or progressed to psychiatric disorders in adulthood [5, 6]. A longitudinal community study which assessed the prevalence and development of psychiatric disorders from age 9 to 16 years showed that children with a history of psychiatric disorders were 3 times more likely than those without previous disorders to have a diagnosis at any subsequent wave [5]. Adolescents diagnosed with panic disorders, psychosis, verbal tics, encopresis and enuresis, and substance use disorders (SUD) showed a high tendency of it developing into a more serious disorder once they reached adulthood, even more so higher in females [5]. A general population study in Dutch province of zuid Holland using the completed child behavior checklist (CBCL) of 2,076 caregivers which investigated the 10-year course of initially aged 11–19 years found that adolescent problems tended to persist into adulthood to a moderate degree and
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high rates of problems during adolescence are risk factors for psychiatric disorders in adulthood [6]. A prospective longitudinal study based on repeated structured diagnostic interviews from age 11 to 26 found that half of the individuals who met the criteria for a major DSM-IV diagnosis at 26 years of age had a diagnosed disorder at 11–15 years of age [7]. Among cases diagnosed at 26 years of age, approximately one quarter sought professional mental health services [7]. A longitudinal study has shown that individuals who sought mental health services at adolescents significantly reduced the chances of their disorder progressing [8]. Early detection and appropriate intervention in adolescence can help reduce instances of recurrent or persistent psychopathology through adulthood. Many international studies have shown that only a small number of adolescents with psychiatric disorders have utilized specialized mental health services [7, 9, 10]. In an American study on youth aged 9–17 years showed that fewer than 25 % of the youths with a diagnosed psychiatric disorder received services from a mental health specialist [11]. In an Australian study on 4–17-year olds, only 25 % of those with mental health problems had attended a professional service [10]. These findings suggest that an alarmingly high number of adolescents who suffer from mental health problems do not receive appropriate services. Many factors contribute to the utilization of child and adolescent mental health services. The age, gender, ethnicity, socioeconomic status (SES) and the parents’ own use of mental health services [12–16]. It has been documented that females are generally more willing than males in seeking mental health services [17, 18]. Studies focused on culture including both minority and majority groups, have shown differences in the way they seek mental health services [19]. Manifestation of the symptoms also played a role in the help seeking behavior of the child and adolescent. A communitybased study in the Netherlands on children and adolescents aged 4–18 years found that their internalizing, externalizing and academic problems, and family stress were the most potent factors associated with the need or utilization of mental health services [12]. Another study suggested that externalizing problems, as opposed to internalizing problems, were more prominent among adolescents and children who visited mental health services [20]. Most studies investigating the use of mental health services among children and adolescents rely on information from caregivers. In addition, there is insufficient consolidated research on the need for mental health services and it’s utilization by adolescents. Attention toward the perceived need of mental health services for adolescents needs to be more focused on, as there is often a discrepancy between their self-reported need and their caregivers’ accounts of such a need; this is commonly due to caregivers’ lack of awareness and education of
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adolescents’ mental health problems [21]. The adolescent’s subjective difficulties may indicate an underlying psychiatric disorder or the risk of developing such a disorder [6]. The Korean medical system differs from that of other countries [22]. In the United Kingdom or the Netherlands, for example, general practitioners are the formal point of entry when referring patients to mental health care [12, 17]. In Korea, caregivers seek mental health services directly without referral by a general practitioner. Therefore, adolescents’ utilization of mental health services is at the sole discretion of the adolescents and their caregivers. The degree and patterns of use may be different from other countries. Research on factors associated with the need and use of mental health services may help find ways to reduce and hopefully prevent adolescent mental health problems. However, as most previous studies on this issue have been conducted in Western countries [12, 17, 18, 20, 23, 24], further research using a wider spectrum is necessary. This study investigated (1) the degree of the perceived need for mental health services and their use among Korean adolescents, and (2) the factors associated with such a need and the use based on gender.
Methods Participants Of a total of 1,923 eligible students, 1,857 (96.5 %) students, participated in the study. Of the nonparticipants, 45 (2.3 %) declined to participate, and we excluded 21 (1.0 %) owing to incomplete data. There were no significant Table 1 Socio-demographic characteristics of the adolescents Variables
N (%)
Gender (n = 1,857) Male
910 (49.0)
Female
947 (51.0)
Family structure (n = 1,854) Living with both parents Other Education of the father (n = 1,805) [12 years B12 years
1,798 (97.0) 56 (3.0) 582 (32.2) 1,223 (67.8)
Education of the mother (n = 1,797) [12 years
322 (17.9)
B12 years
1,475 (82.1)
Economic status (n = 1,840) High Middle Low
296 (16.1) 1,428 (77.6) 116 (6.3)
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differences in gender or school between participants and nonparticipants. The group of adolescents included 910 boys (49 %) and 947 girls (51.0 %). The mean ages were 13.75 years (SD = 1.0). We summarize the characteristics of the adolescents in the Table 1. Procedures This study was based on an examination of 1,857 Korean adolescents between the ages of 14–16 from all 6 middle schools throughout the Osan city in October 2006 (one school for the mentally disabled was excluded). The city has a population of 120,000 with similar socioeconomic profile to the national average and is located 30 miles southeast of the capital city of Seoul [25]. The availability and scale of accessible mental health services (two private outpatient clinics, one mid-sized psychiatric hospital) did not differ with other cities in Korea. After explaining the objectives and benefits of this study and giving assurances of confidentiality to teachers, parents and adolescents, written consent was obtained. Each student completed a 45–60 min, inclassroom survey during school hours, under the direction of research assistants. Ethical approval was given by the Ajou University Hospital Institutional Review Board. Measures Socio-Demographic Factors and Perceived Need and Use of Mental Health Services The adolescents completed a general questionnaire covering age, gender, family structure, parental education and economic status. Family structure included the composition (e.g., adolescent living with both biological parents). Economic status was divided into three categories based on family income. Perceived need and use were determined as follows. The first question asked: ‘‘Have you considered seeking mental health service for your emotional or behavioral problems during the past 12 months?’’ For adolescents responding affirmatively, a second question asked: ‘‘Did you receive treatment for those problems during the past 12 months?’’ The responses were recorded as dichotomous variables (e.g., yes or no). Although these specific questions have not been validated, other studies have used similar items [26, 27]. Based on the completed questionnaire, the adolescent’s subjective difficulties may indicate an underlying psychiatric disorder or the risk of developing a disorder [6].
report competence and problem behaviors for the last 6 months. It was developed for adolescents between the ages of 11 and 18 years. The YSR yields age- and genderbased T-scores for 13 empirically derived subscales, such as anxious/depressed, attention problems, aggressive behaviors, externalizing and internalizing problems, etc. The YSR also includes a competence scale reflecting the adolescent’s social and school functioning. The YSR has been reported to have adequate psychometric properties [28]. As is the case for the YSR, the K-YSR has been normed for gender- and age-specific groups and has been used widely for clinical and research purposes in Korea. The Korean version of YSR has good reliability and discriminant validity [29]. It has an internal consistency from 0.63 to 0.85 and test–retest reliability from 0.11 to 0.72. Based on the Korean normative samples, the K-YSR scores were dichotomized into those in the normal range and those in the borderline or clinical range of the scoring distributions. The cut offs were made at a T-score of 63 for the syndrome scales and the Total, Internalizing, and Externalizing Problem scales [29]. Statistical Analysis Chi square analyses evaluated associations among categorical variables (Fisher’s exact test was used when it showed low expected frequencies). First, with the perceived need for mental health services and the actual use of such services serving as dependent variables, and the sociodemographic data and psychopathology serving as independent variables, a logistic regression analysis evaluated the association between the variables based on gender. Odds ratio (OR) and 95 % confidence intervals (95 % CI) were calculated using univariate and multivariate logistic regression analyses for all variables significant at the P \ .05 level. Due to the hierarchical relationship of the eight YSR syndrome scales, the Externalizing, Internalizing, and Total Problem scales, regression analyses performed according to three different sets of variables were necessary: the first set included the total problem score; the second set, the externalizing and internalizing scores; and the third set, the eight syndrome scores [17]. All explanatory variables were dichotomized. We used the Statistical Package for the Social Sciences (SPSS) to analyze the data.
Results
Korean-Youth Self-Report (K-YSR)
Demographic and the Perceived Need and Actual Use of Adolescent Mental Health Services
Korean-Youth Self-Report (K-YSR) is the companion version of Child Behavior Checklist for adolescents to self-
Of the total sample (N = 1,857), 32.2 % had a father with a post-high school education and 322 (17.9 %) had a
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Child Psychiatry Hum Dev Table 2 Multivariate logistic regression analysis: adolescent and family characteristics influencing perceived need and utilization of mental health services in adolescent boys Self-perceived need for help OR (95 % CI)
Table 3 Multivariate logistic regression analysis: adolescent and family characteristics influencing perceived need and utilization of mental health services in adolescent girls
Mental health service use OR (95 % CI)
Including K-YSR total problem
Self-perceived need for help OR (95 % CI) Including YSR total problem
Mother’s low education level (year B 12)
Mother’s low education level (year B 12)
Father’s low education level (year B 12)
Father’s low education level (year B 12)
Living with both parents
Living with both parents
Income high level (reference = lower level)
Income high level (reference = lower level)
Income middle level (reference = lower level)
Income middle level (reference = lower level)
YSR Total problem
1.04*** (1.03–1.06)
YSR Total problem
Including K-YSR internalizing, Externalizing problem
1.04*** (1.03–1.05)
Including YSR internalizing, externalizing problem
Mother’s low education level
Mother’s low education level
Father’s low education level
Father’s low education level
Living with both parents
Living with both parents
Income high level
Income high level
Income middle level Internalizing
Income middle level 1.10*** (1.07–1.13)
0.91* (0.82–0.99)
Externalizing
Internalizing
1.09*** (1.07–1.12)
Externalizing
1.08* (1.01–1.16)
Including K-YSR syndrome Including YSR syndrome
Mother’s low education level Father’s low education level
Mother’s low education level
Living with both parents
Father’s low education level
Income high level
Living with both parents
Income middle level
Income high level
Withdrawn Somatic complaints Anxious/depressed
Mental health service use OR (95 % CI)
0.66* (0.48–0.89) 1.17*** (1.12–1.23)
Income middle level Withdrawn Somatic complaints Anxious/depressed
Thought problems Attention problems
Thought problems
Delinquent behavior
Attention problems
Aggressive behavior
Delinquent behavior
OR odds ratio, CI confidence interval, K-YSR Korean-Youth Self Report * P \ .05; ** P \ .01; *** P \ .001
0.85** (0.76–0.96) 1.25*** (1.19–1.33)
Aggressive behavior
1.10* (1.01–1.21)
OR odds ratio, CI confidence interval, YSR Youth Self Report * P \ .05; ** P \ .01; *** P \ .001
mother with a post-high school education. Most of the participants (97.0 %) lived in two-parent homes, and most families (77.6 %) were of average socio-economic status (Table 1). About 11.6 % of participants (n = 213) perceived a need for mental health services, while only 2.1 % (n = 38) had actually received mental health services
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12 months prior to the study to treat emotional or behavioral problems. In addition, more girls (14.1 %) perceived a need for mental health services than boys (8.9 %), while both boys (2.2 %) and girls (1.9 %) showed equally low rates of actual use. No significant gender differences
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existed (P = 0.09, v2 = 2.79, df = 1). There was a large discrepancy between the perceived need for mental health services and the actual use. Only 3.3 % of the adolescents who perceived a need to use mental health services actually used the services, but there was no significant difference between boys (5.0 %) and girls (2.3 %) with regard to the actual use of these services. Factors Associated with the Perceived Need and Actual Use of Mental Health Services According to Gender The factors associated with the perceived need for mental health services, as well as the factors associated with the actual use of such services, were investigated. In a multiple logistic regression model (adolescent boy), as shown in Table 2, the major predictors of the perceived need were YSR total problem (OR 1.04, 95 % CI 1.03–1.06), internalizing problems (OR 1.10, 95 % CI 1.07–1.13), anxious/depressed problem (OR 1.17, 95 % CI 1.12–1.23). Internalizing problems (OR 0.91, 95 % CI 0.82–0.99) withdrawn problems (OR 0.66, 95 % CI 0.48–0.89) were associated with actual mental health service use. In a multiple logistic regression model (adolescent girl), as shown in Table 3, the major predictors of the perceived need were YSR total problem (OR 1.04, 95 % CI 1.03–1.05), internalizing problems (OR 1.09, 95 % CI 1.07–1.12), anxious/depressed problem (OR 1.25, 95 % CI 1.19–1.33) withdrawn problems (OR 0.85, 95 % CI 0.76–0.96). Externalizing problems (OR 1.08, 95 % CI 1.01–1.16) aggressive behavior (OR 1.10, 95 % CI 1.01–1.21) were associated with actual mental health service use.
Discussion The perceived need for mental health services in the present study was 11.6 %, similar to the rate in other studies. Zwaanswijk et al. [17] reported self-perceived need for mental health services among Dutch adolescents (aged 11–18 years) as having problems that are more serious than other adolescents’ problems (problem recognition or need) was 10.5 %. The present study found that about 2.1 % of the sample had received some kind of mental health professional help or evaluation. This finding is lower to the 3–8 % reported in previous studies, such as from the Netherlands and the US [30]. These results suggest that the threshold for adolescent utilize mental health services is high. Therefore, measurements need to be taken to examine the factors giving rise to the perception These differences may be ascribed to variances in the definitions of the need for mental health services and its utilization, differences in the age of adolescents; the organization of mental health
services in which country the study was conducted in; and the prevalence rates of adolescent psychopathology based on culture [31]. Especially, this may be ascribed to the fact that Korean schools are not equipped with physicians or counselors; thus, adolescents and parents must seek mental health services directly, which may make it difficult for Korean adolescents to seek mental health services. Cultural taboos may in part explain the discrepancy, as Asian cultures are known to prefer informal methods of dealing with mental health problems in lieu of seeking professional mental health services [32, 33]. According to a culture comparative study on societal preconceptions of mental disorders in Australia and Japan, the Japanese culture was found to regard such matters as private affairs to be resolved within the family without outside assistance [34]. The values of conformity to norms, emotional self-control, collectivism, family recognition through achievement, and filial piety are some of the most common traits found throughout Asian culture. Anything that falls outside of these categories including mental illnesses are generally not accepted. Many people of Asian descent outcast people with mental illnesses and class them as dangerous and aggressive [35]. Asian American college students were subjected to a study that explored the impact of Asian cultural values, public stigma, and attitudes toward seeking professional psychological help by Shea and Yeh [36]. In this study, adolescent girls had higher rates of selfperceived need than adolescent boys, but this did not affect the difference in the actual use mental health services based on their gender. Previous research found the females tend to report feelings of depression, anxiety and suicidal ideation more than their male counterparts and were more willing to seek help [37, 38]. This may in part explain woman’s positive attitudes toward seeking help. Our results show that regardless of gender, adolescents with total problems, internalizing problems, anxious/ depressed problems tend to express a self-perceived need to use mental health services. In addition, there was a positive association between aggressive behavior, externalizing problems and actual mental health service use in girls. Sourander et al. (2001) studied concurrent and predictive associations of several child and family factors and service use when they reached the age of 16. This study concluded that parent-reported externalizing, internalizing, and total behavior problems were associated with the students utilizing mental health services. Verhulst and Van der Ende [12] found that not only was there an association with utilization but also with service needs when parents reported on their child’s externalizing and internalizing problems. Our findings are in line with other results proving that self-perceived internalizing problems had a stronger association with perceived problems than externalizing problems [39]. While adolescents experiencing
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internalizing problems tend to recognize the problematic nature of their state, but do not seek further help, which is also reflected in the significant effects of internalizing problems on self-perceived unmet need. Internalizing problems such as depression and anxiety should be considered a major public health issue among adolescents. Research has found that many psychiatric disorders present in adulthood originated in childhood or adolescence. The present rate of depression among Korean adolescents is more than double that of adults, which could be the reason why suicide is the number-one cause of mortality among young people in South Korea [3] and depression is one of the most well-known and preventable cause of adolescent suicidal attempt [40, 41]. Early detection and treatment of childhood and adolescent disorders may be preventive of adult mental disorders. An effective method increasing the mental health access rate of adolescents with internalizing problems could be to make the awareness of mental health problems more widely known. Social support from family and friends is also important, as adolescents usually turn to them first when seeking help [42]. The family education in identifying depression and anxiety disorders of adolescents and close observation by family members are important factors in increasing the access rate of mental health services. Adolescents and children who utilized mental health services, predominantly expressed externalizing problems as opposed to internalizing problems [17, 20]. There was a negative association between withdrawn problems and actual mental health service use in boys whereas the negative association was with perceived need for mental health services for girls. The social withdrawal scale includes one’s behavior of shyness, introverted feelings and withdrawn behavior, and includes items such as ‘‘Preferring to be alone’’; ‘‘Secretiveness’’ and ‘‘Withdrawn’’. These items are all suggestive of difficulties in social interactions. Due to such withdrawal problems adolescents tend to avoid self-disclosure to others which may reduce actual use of mental health services. Social withdrawal has been linked with such internalizing difficulties as anxiety and depression in childhood and adolescence [43]. A recent study on adolescent help-seeking behavior has drawn an important distinction between individual and structural determinants of such behavior [44]. Individual determinants include factors such as knowledge on mental health, attitudes, and perceived stigma relating mental health problems. Structural determinants include family, school or community support systems, referral pathways and health system structures. These factors have on impaction on when and how adolescents seek and access mental health services [42]. Therefore, mental health professionals/service providers must educate problematic
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adolescents with sufficient knowledge of mental health issues and sources of help [45, 46]. This study has several limitations. The first limitation is that this is a cross-sectional report that requires further research from a longitudinal perspective. Second, discrepancy in the health care system of Korea and other countries must be taken into account before any definitive conclusion can be made. Additional sources of information, such as teachers’ reports omitted here, as well as family factors such as parental sensitivity, knowledge and even support for mental health services may provide greater specificity and shed insight on the complexity of factors shaping self perceived need and decisions to solicit psychiatric services for their symptoms. Finally, because the present study relied solely on the subjective reports of adolescents willing to participate, there remains the possibility that not all the data collected may not be accurate, which is one of the major weakness of this study.
Summary This study investigated the status of adolescents’ self-perceived need for and their actual use of mental health services, associated with relevant socio-demographic and psychopathological factors. Although the perceived need for mental health services is high, only a small proportion of adolescents sought mental health services. There is a discrepancy between the perceived need and actual use, in addition to the factors associated with them. To increase the actual use of mental health services more attention needs to be focused on their internalizing problems, such as anxious/depressed and withdrawn problems, in addition to externalizing problems in both genders.
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