Special Article
Objective
:
TTo review the current status of the community mental health system for children and adolescents in Korea.
Method: Computer-aided literature review of articles and documents published by the Korean government.
Results
: In 2004, 24 community mental health centers participated in school mental health programs, and 500 community child centers provided various programs for protection, education, and cultural activities. Child and youth counseling services were supplied by 43 and 137 counseling centers, respectively. Approximately 23,500 children were enrolled in special schools. Throughout the year, about 4,000 cases of child abuse were reported from 38 child abuse centers and 35 probation and parole offices enlisted about 29,000 adolescents. Close to 19,000 children resided in 279 residential facilities of various kinds in the year 2003. Currently, roughly 2,100 adolescents enter training schools per annum.
Conclusion
: The community mental health system should balance mental health promotion, prevention, early intervention, and treatment. Mental health promotion and prevention ought to begin in preschool. A significant level of redundancy in services provided by the government and nongovernmental organizations (NGO) was noted calling for greater collaboration and integration. Community mental health system based on the system of care philosophy should be developed for youth with severe emotional disorders.
Correspondence: Sungdo D. Hong, M.D., Division of Child & Adolescent Psychiatry, Department of Psychiatry Samsung Medical Center, Sungkyunkwan University School of Medicine 50 Irwon-dong, Kangnam-gu, Seoul 135-710, Korea
Tel: +82-2-3410-3585, Fax: +82-2-3410-0050, E-mail : sdhong@smc.samsung.co.kr
Introduction
The burden of mental disorders on children is of great importance. Associated emotional and behavioral problems lower the quality of life and reduce a child's ability to fulfill its potential. No other condition has worse effects on a child's development. Children with mental disorders are at risk of not becoming a fully functional member of the society during adulthood. Because child mental disorders can persist into adulthood, their financial and sociological cost is considerable. As of 2005, there are approximately 12 million children and adolescents (<18 yrs) in Korea, making up 25% of the total population. No definitive statistics exist on youth being at risk of unhealthy and unproductive lives caused by various risk factors. It has been estimated, however, that approximately half a million young individuals may be extremely vulnerable to the negative consequences of multiple high risk behaviors like school failure, runaway, crimes, violence, early sexual experience, and child abuse. About 1.3 million young individuals are at moderate risk, owing to poverty, divorce, and learning difficulty. They may require proper support to be prevented from the negative consequences.
Childhood is an important developmental time, where the foundations for mental health are built. Disruption of this mental health-promoting period can lead to defects that carry into or begin in adulthood. It is critical to establish and maintain preventive measures in childhood to avoid later problems. The field of mental disorder prevention has now developed to a point, where risk reduction and early intervention have become feasible. Mental disorder prevention is increasingly recognized as an effective clinical measure.
Community mental health system in Korea is in a developmental stage. The Korean government began to implement its first measures in the 1990's, commissioning several reports on various aspects of community mental health with the beginning of 1994. A mental health law was legislated in 1995 regulating the care and rehabilitation of mentally ill patients at the community level. In the time thereafter, additional funding went into developing a community mental health service infrastructure.
Although children and adolescents were not excluded from the services of community mental health centers, their needs were not specifically addressed. No requirements were in place ensuring appropriate services tailored to children and adolescents. The demand for mental health services was so large in the adult population alone that all existing funds were depleted, leaving no room for services catering to younger patients.
A major force inhibiting the development of community mental health services for the youth is the focus on adult within the field of mental health itself. This way of thinking, as well as an undeniable unfamiliarity with the young population's needs, keeps the community mental health leadership from implementing specialized services for children.1 Fortunately, however, some child psychiatrists became involved in leadership roles in several community mental health centers and initiated school consultation services for children. Recently, the mental health of children and adolescents in schools has gained more interest as the number of qualified child psychiatrists is growing.
Methods and Materials
Computer assisted keyword-driven database searches were conducted to identify relevant Korean studies. Various documents from the Korean government were also reviewed.
Results
A. The welfare system
1. Community centers (Bokjikwan)
Historically, community centers have offered various services for the mentally ill. The Taiwha Fountain House, which opened in 1986, is considered to be the first to offer a community psychiatric rehabilitation program in Korea. According to the Association of Social Welfare Centers, there are 394 community centers in Korea as of 2005. These centers offer various activities such as rehabilitation, special education, and counseling for children.
2. Community child centers
An increasing number of children in Korea are deprived of protective environment of family due to economic difficulties or disruption of the family. Little is done to remedy this problem. In 2004, the government increased the number of community child centers by converting 244 study halls and providing approximately $600 of monthly funding to each center. The centers provide various programs for protection, education, and cultural activities of children. There are currently 500 community child centers in total.
3. Child abuse centers
In 2000, seventeen centers for the prevention of child abuse were inaugurated, growing to a total of 38 in 2004. These centers operate 24-hour phone support for.34 cases of child abuse. Additionally, the staff members of centers locally investigate scenes of reported child abuse and take necessary preventive actions (e.g., emergency custody of a child). The centers also provide parental education and counseling to prevent possible recurrence. In 2004, approximately 5,000 telephone calls were received, primarily regarding child abuse. Of the reported abuses, approximately 4,000 were confirmed, including cases of neglect (35.1%), physical abuse (9.3%), emotional abuse (9.0%), and sexual abuse (4.5%). Most often the perpetrators were the child's parents (81.4%).2
4. Residential facilities
About 19,000 children resided in 279 residential facilities of various kinds in 2003. The Korean government has made efforts to improve the care quality in these institutions, but all shelters, group homes, and facilities (e.g. for youth prostitutes) have a maximum capacity of 3,000 individuals. With 100,000 new run-aways each year, more of these facilities are urgently needed. As of 2004, about 10,000 children were in government-run foster homes. Plans are underway to increase the financial aid to these programs and facilities.
B. The mental health system
1. Community mental health centers
As of 2004, there were 115 community mental health centers nationwide, funded by central or local authorities. In 2002, some of the community mental health centers started providing services to schools. Two years later, 24 community mental health centers engaged in school mental health services. Throughout the year 2004, about one hundred children and adolescents with psychiatric illness were identified and, half of them were helped by each community mental health center.3
The guidelines of 2005 Mental Health Services say that the purpose of the child and adolescent mental health services were: (a) prevention of mental health problems, (b) early detection and appropriate treatment of mental disorders, and (c) guidance of young individuals toward good citizenship. These goals are to be achieved by constructing the structures of mental health services in the community, with the general focus on early detection, referrals to local resources, and prevention of mental diseases. The financial aid allocated to this program for 2005 was approximately $13,000 per center-an amount arguably too small for the ambitious plan.4
Nonetheless, some programs for school children succeeded as in the Nowon Community Mental Health Center (SI Chun, personal communication). Funds for the project were supplied by the Ministry of Education and Human Resources Development as well as by the Ministry of Heath and Welfare to provide 11 schools with full-time social workers for the children's welfare and mental health. A child psychiatrist trained the involved personnel and offered parental education. He additionally assisted in medical services, group psychotherapy, and networking with local services for children. A summer program for children with behavioral problems was also offered with great success.
2. Child and youth counseling centers
There are 43 child-counseling centers operated by the Ministry of Health and Welfare nationwide. The same ministry also appointed approximately 5,000 advisors in rural areas to give first hand assistance to troubled children and to make referrals to the appropriate services.
Additionally, there are 137 youth counseling centers operated by the National Youth Commission and each center handles about 6,600 cases per year. It appears, however, that the centers are not able to intervene systematically to prevent or detect youth at risk. The National Youth Commission has a yearly budget of approximately $43 million for counseling, emergency rescue, runaway protection, and cultural/educational activities for financially stricken teenagers. It supports youth counseling centers, '1388 Supporters', shelters, study halls, youth centers, and arts centers.
C. The education system
1. Special schools and classes
In 2005, approximately 23,500 children were enrolled in special schools. Children with mental retardation accounted for roughly 15,200, while emotional problems occurred in 1,900. A bigger number of children with cognitive or emotional problems attended regular schools. Special classes in regular schools were provided for 15,700 children with mental retardation, 3,500 children with emotional disorders, and 7,800 children with learning disorders. Approximately 2,700 cases of mental retardation, 400 cases of emotional disorders, and 600 with a learning disorder were on regular classes.5
Less than 15% of 12,000 children (3-5 yrs) with disabilities received free education. Furthermore, there were no educational services for disabled children younger than 3 years. The advancement to a higher level of education was and remains problematic due to the imbalanced distribution of special classes at various educational levels. Eighty-four special classes were counted in kindergartens, 3,119 in elementary schools, 712 in middle schools, and 187 in high schools. Oftentimes, there are too many children in special classes. Because of a remaining stigma against special education, many parents of disabled children refuse to place their children in special classes fearing social disapproval.6
2. Mental health services in schools
Poor academic functioning and inconsistent school attendance have been identified as warning signs for emerging or existing mental health problems during childhood and adolescence.7 Schools commonly identify children with mental health needs only after their emotional or behavioral problems cannot be managed by their regular classroom teacher. According to Ahn et al.,8 teachers play an increasingly important role in identifying children at risk and providing mental health services to schoolchildren. Teachers have indicated that 6.9% of the children in their classes have certain mental health problems. More than 46.5% of these children were deemed to be in need of mental care, yet only 15.1% were referred to the appropriate services.
The Seoul Metropolitan Office of Education operates 12 youth counseling centers. These centers provide various services for students such as counseling, school related problem solving, and information on volunteer activities. The staff comprises 22 teachers, 25 counselors, and 45 volunteer consultants including child psychiatrists and attorneys. These counseling centers handle various aspects for the interested, like telephone reports of school violence and sexual abuse, no-smoking campaigns, and Internet/phone counseling in addition to actual face-to-face counseling.9
In 2004, these centers provided about 100,000 counseling sessions, addressing issues of mental health, school transition, and career counseling. Child psychiatry fellows have been providing consultation services to these counseling centers since 1998, a year before the School Mental Health Committee was formally organized in the Korean Academy of Child and Adolescent Psychiatry (KACAP).
The KACAP has two committees related to school and community mental health services. The School Mental Health Committee has not only conducted consultations in the counseling centers of the Seoul Metropolitan Office of Education, but also offered educational courses for teachers and published books for general populations. The Public Relation Committee has organized public education and services relating to childhood mental illness such as attention deficit hyperactivity disorder (ADHD).
There have been few studies on school consultations.10,11,12,13 However, an increasing number of child psychiatrists shows interest in school consultation. Since 2002, as a part of the public health services, the Child Psychiatry Department of the Seoul City Hospital has provided mental health services for school children, their parents and teachers in a multi-discipline team approach involving child psychiatrists, psychologists, special education teachers, and administrative assistants. In 2005, the program focused on children with ADHD, increased group psychotherapy efforts, and improved parent education, which achieved high approval ratings with children, parents, and teachers (H. J. Byun, personal communication).
School consultation sometimes utilizes the Internet for the guarantee of interaction without social prejudice or limitations on time and space. This form of consultation may contribute to the prevention and early intervention of child and adolescent psychiatric illnesses,14 but it should be limited to a small part of the whole consultation process.
C. The education system
1. Correctional facilities
There were 35 probation and parole offices as of 2004, and about 29,000 under-age individuals were administered under these services. On average, a single officer managed more than 200 cases. It is necessary to separate adult from younger offenders as their needs differ significantly. There were roughly 200 young individuals in 15 halfway houses. To help individuals out from training school or prison to make better adjustment and become valuable members of society, more halfway houses are urgently needed.
Training schools are specialized educational institutes administered by the Ministry of Justice for offenders aged 12-20. Fourteen of these schools have been converted and now specialize in computer science, foreign languages, physical education, or arts and leisure. Substance abuse, as well as psychiatric and developmental disorders is treated in medical training schools. There are also detention centers, where young offenders are detained for up to one month to receive a psychological evaluation and behavioral observation prior to being sentenced. Yearly, close to 6,300 cases are admitted, 3,600 of which receive counseling.
Discussion
Policymakers and service providers in health care, education, social services, and juvenile justice are now focusing more on intervening early in children's lives. They have come to appreciate that mental health is inexorably linked with general health care and success in the classroom, but inversely related to involvement in the juvenile justice system. It is also increasingly accepted that prevention may be cost-effective.
A responsibility for mental healthcare for children and adolescents is dispersed across multiple systems including family, schools, the juvenile justice system, child welfare, hospitals, and other institutions. The services for prevention, early assessment and treatment can be based at these places. To be effective, all the services must be coordinated with other services and programs. For example, a number of studies have documented high rates of serious emotional disturbance (SED) amongst youth in the juvenile justice system, with estimates of approximately 50-70 percent.15 Collaboration between juvenile justice and mental health systems are needed to prevent youth from entering into juvenile justice, and to treat the youth with SED in the juvenile justice system.
1. Prevention strategies
As of 2002, close to 8,300 Korean kindergartens educated approximately 55,200 children. Additional services were provided by 21,300 childcare centers catering to about 770,000 infants and young children. An age group analysis has revealed that 42.8% of all 3- year-olds attended day-care facilities; 4 and 5-year-olds were recorded with 57.8 and 68.7%, respectively.16 There is no recognizable systematic effort to provide for good mental health in very young children, which is undoubtedly a missed opportunity for the prevention and intervention of mental disorders.
Routine developmental and psychosocial assessment of young children and their families using standardized instruments is rarely used in pediatric practices in Korea. Pediatricians and family practitioners should be encouraged to pay more attention to ensure sound mental health in their patients. Aside from playing an important role in mental disorder prevention, they should also refer patients to the appropriate specialists for early intervention and treatment.
2. Comprehensive system of care
Community mental health services for children and adolescents in the US have undergone a major revolution in philosophy, practice, and research in the last 20 years. The traditional community mental health consultation model prevalent from the 1950's to the mid 1980's has yielded to a more comprehensive system of care philosophy model.15 The system-of-care approach is based on a philosophy built on three hallmark tenets: (a) mental health services should be driven by the needs and preferences of the child and family; (b) services are supposed to be community based, and under the management of multiple agencies; and (c) the services offered, the agencies participating, and the programs generated ought to meet the mental health needs of the children and should be responsive to the cultural context and other characteristics of the populations being served.
To develop a system of care consistent with these ideas, a community must focus its program on (a) infrastructure to house, organize, and manage the integrated program elements; and (b) service delivery to provide services, treatment, and support directly to children and their families.17 In summary, adequate infrastructure and service delivery are prerequisites for developing a system of care.
3. Suggestions for a mental health system in korea
Suh18 proposed that the mental health services system should have good coordination not only between medical and welfare services, but also between private and public service providers. In order to improve efficiency and accessibility, mental health services should be regionalized and staged according to the local need and the degree of specialization of providers. Incentives should be made to reduce the length of hospitalizations or institutionalizations at the customer and the service provider level. With these principles, mental health facilities in Korea may focus on the new paradigm of community mental health.
The Korean community mental health system for children has an apparent lack of services for SED. As behavioral and emotional problems of children and adolescents become more serious and complicated, the need for SED services increases. Unfortunately, SED is grossly underserved or served inappropriately by a fragmented mental health services system. Community mental health centers do not have any SED programs.
Mental health services for children and adolescents are administered by various government branches, including the Ministry of Education and Human Resources Development, the Ministry of Health and Welfare, the Ministry of Justice, the Ministry of Labor, the Ministry of Unification, and others. There is a certain degree of redundancy in the services provided by government and NGO. Better collaboration and coordination among these service providers is desirable. It should be noted that, oddly, many services and programs seem to be too politically sensitive, with little attention to recent developments in various disciplines and with lack of consistency and continuity. Lastly, the amount of funding available for mental health care in children is grossly inadequate for the development of a working and efficient service system.
Conclusion
To ensure that our health system meets the needs for child mental
health care, it is necessary to move toward a community mental health system that balances mental health promotion, prevention, early intervention, and treatment. Services for mental health promotion and prevention should start early in preschool. As schools play an important role not only in prevention, but also in treatment of mental disorders in children and adolescents, they should be actively utilized. To decrease service redundancy amongst governmental, NGOs, and private organizations, collaboration should be initiated that helps integrate the offered services. A community mental health services program for SED should be developed based on the system of care philosophy.
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