Correspondence: Dong Hyun Ahn, M.D., Ph.D., Department of Psychiatry, Hanyang University Hospital, College of Medicine, Hanyang University, Seoul, Korea
Tel: +82-2-2290-8425, FAX: +82-2-2298-2055, E-mail: ahndh@hanyang.ac.kr

Introduction

Several years ago, I introduced and discussed the major topics important to children's well-being in Korea.¹ The topics were 1) high prevalence of child abandonment and overseas adoption, 2) high prevalence of illegal abortion and unbalanced sex-ratio at birth, 3) the high-school senior syndrome ("education fever" or "Ko-sam-pyung"), 4) intra-familial violence and child abuse, and 5) "parent-child joint suicide"-special form of child maltreatment". In this manuscript I will re-address some of these topics, but also focus on the clinical aspects of child and adolescent mental health. Recently Hong et al.² discussed the most disconcerting problems among Korean children and ado-lescents, such as "the high school senior syndrome", suicide, school bullying ("Wang-tta"), parent-directed violence of adolescents, social isolation of adolescents (hikkigomori phenomenon), Internet addiction, and looking autism in children lacking appropriate parental care. Four of the above mentioned problems will be reviewed here including intra-familial violence and child maltreatment, Internet addiction, hikkigomori phenomenon, and education fever.

Intra-familial Violence and Child Maltreatment

Legal prevention of child abuse in Korea was inaugurated by the Child Welfare Law of 1961. Subsequently, no further legal amendment was passed to help build a prevention and professional help system until 1989, when the Korean Association for the Prevention of Child Abuse and Neglect (KAPCAN), a civil organization under the leadership of Professor Michael K Hong, was founded. Several clinical and social studies on physical child abuse have been carried out by social workers and psychiatrists, but it was not until the late 1980s that many researchers in the fields of psychiatry, social welfare, feminism, and paedology became involved in research addressing children's rights.
There are two early reports of professional questionnaire surveys. One study³ surveyed 2,000 general practitioners and 1,700 pediatricians with a short questionnaire, and found that 46% of the respondents had encountered excessively beaten children in their practice, including 6 cases of death. The research reveals that mild beating was prevalent in school-age children. The age of the children correlated inversely with the physical effects of the beating This can lead to the misconception that serious beating per se is prevalent in younger children, which is not the case, as same-level beating leads to more serious injury in a young child. Seventy-one kindergarten teachers identified seriously beaten children in close to 7.8% of a pool of 2,792 children in 21 slum area kindergartens.⁴
Another well-designed survey was carried out by Kim and Ko.⁵ Twenty-two 3rd and 4th grade classes of two elementary schools in Seoul were selected as a sample population for a questionnaire survey. According to the severity and the frequency of being beaten during the previous year, three child groups were identified: children without physical punishment (33.8%), children with mild beating (58%), and children with serious beating (8.2%). The severity of the beating in the last group exceeded the degree "N", as defined by the Straus' Conflict Resolution Technique Scale (12+episodes per year).⁶ Five years later, Ko⁷ surveyed the same schools with the same methods and found that child beating had markedly increased to 72.5 and 23.9% for mild and severe levels of beating, respectively.
In 1998, an abused child's sad story was broadcasted on the Seoul Broadcasting System television program "I want to know about it", raising attention across the nation. In the following year, the Child Welfare Law was revised to emphasize prevention of child abuse and neglect. In 2000, eighteen Child Abuse and Neglect Prevention Centers(CANPC) were established, which have increased in number to 39 at the current time.⁸
Along with other organizations, the Korean Medical Association (KMA) initiated the campaign against child abuse and neglect in the medical field. The KMA organized a committee for the prevention of child abuse and neglect, and published the Clinical Guidelines for The Prevention and Treatment of Child Abuse and Neglect⁹ and the Resource Book of Child Sexual Abuse¹⁰ in 2003. The KMA program has been steadily growing and will also reach into new areas, following a 2005 revision of the Clinical Guidelines and expanding the campaign to school teachers, medical personnel, medical students, as well as medical doctors.
Until the late 1990s, most families and society in general seemed to tolerate physical violence to children. According to an opinion survey among teachers, parents, and elementary school children, 97% acknowledged a necessity for physical punishment to correct a misbehaving child.¹¹ Surprisingly, most of the school children themselves accepted physical punishment. It is also common that parents beat their children to anger.¹² In such context, violence-prone parents have a notion to batter their children repeatedly and intentionally due to anger, or under the pretext of educational punishment or parental love. In fact, it has been reported that 58% of all kindergarten teachers ignored physical punishment of a child treating it as a mild problem and thus did not report it to child abuse centers or the police.⁴
Nonetheless, a different survey¹³ found that a large percentage of the general population and professionals considered child maltreatment, including neglect, a serious problem. Fortunately, our society has community support systems and public educational programs to reduce and discourage violence against children since 2000. However, there is room for additional improvement regarding legal support and community networks for protective services. The development of community child support networks should be supported. The fact that governmental agencies, as well as non-governmental children's and women's rights organizations, have recently turned their attention to children's rights gives this idea a good perspective.

"Education Fever"-A Syndrome in Senior High-School Students ("Ko-sam-pyung").

Korea has had an exam-based selection (Kwa-gu) for bureaucratic positions for several hundred years. A similar system was in place during the Japanese occupation, and it was further strengthened with the establishment of an independent Korean government. Graduating from college or university, passing the selection examination, and becoming a bureaucrat is generally deemed necessary to become a successful and financially independent member of the society. As a result, Koreans have developed a unique "education fever" that has detrimental effects on the younger generation. Fierce competition, an achievement-oriented curriculum, lack of appropriate discipline and activity in school, overwork (high school studying times of at least 10-12 hours per day, and tutoring. all lead to serious stress in children, hindering normal development and ultimately destroying a child's personality. Recently, the U.N. Children's Right Committee recommend to the Korean government to correct the educational system according to the Convention of Children's Rights¹⁴ . Millions of Koreans suffer repeatedly from the consequences of 'education fever' or "Ko-sam-pyung"-the high school senior syndrome. Students and parents directly involved in the preparations for college entrance examinations endure this situation for up to two years. About 500,000 high school graduates take the same test at the same time, which has far-reaching consequences on daily life: airplane arrivals and departures, for example, are prohibited during the examinations.
Almost all Korean citizens have completed elementary school education after the 1980s. The rate of students entering next-level education institutions is increasing very rapidly (Figure 1). Most Koreans wish to graduate from college, which generates early and unrealistic expectations of child education. Education fever has become an obstacle in Korean child development. The existing pressure is exemplified by the popular phrase "Performance makes happiness", which is also the title of a recent movie.
The Ministry of Education should address the current preoccupation with higher education. The selection system for college candidates has been changed fifteen times within the last 50 years¹⁶ and children are increasingly suffering the effects of the system. The television tutoring controversy, the liberalization of the university administration from bureaucracy, economic concerns, and people's excessive concern with education only aggravate the situation. The saying "Three is success, four is failure" (i.e., if one sleeps for three hours, he can pass the entrance examination; an additional hour of sleep will result in failure) has become an accepted catch phrase amongst college candidates. Kim and Lee (1991) found that Korean students were more anxious about the test than foreign students. And their anxiety mainly originated from the expectation of their parents and society.
Recently, the Korean government encourages foreign study travel of students to help alleviate the education pressure. However, there are insufficient data about education fever and its effects, and it is known that some children cannot adjust to the Korean education system resulting in runaways to foreign schools¹⁷. Some of the latter succeed, but others also fail to adjust to the foreign school system, giving rise to delinquency, drug abuse, suicide, and fractured families (kirog-" wild geese").¹⁷ Education fever is a serious problem that requires a timely solution.

Internet Addiction

Beginning in the late 1990s many children and adolescents started spending considerable time on the Internet, especially with multiplayer role-playing online games. This "Internet addiction" has become a concern with Korean children and adolescents. Most, who devote comparatively long hours to "being online", become socially withdrawn, bullied, depressed, neglected by their parents, or fall behind in school.¹⁸
Interestingly, when doing a Medline search for "Internet addiction", one will find a high concentration of studies covering this topic originating from Korea^19,20 and Taiwan.^21,22 In Korea alone, 289 research results were published, most of them between 2003 and 2004. Many psychiatric studies were also conducted since 2000. Eastern Asian countries, including Korea, are leaders in information technology, especially in the design of multiplayer role-playing online games, which may in part explain why Internet addiction is so prevalent in these countries.
Internet addiction is not an officially accepted condition and consequentially subject to controversy. Yet, Kim et al.²³ has successfully used Young's Diagnostic Questionnaire of Internet Addiction as operational criteria for internet addiction. Other researchers^19,20,24 have used the 20-item Young Internet Addiction Scale in their studies.
Despite the debate, many Korean children and adolescents devote a lot of time to the Internet. There are numerous personal computer game rooms ("PC bang"), and PCs are also found in virtually every household. Professional gamers in their 'teens' or early 20s become Hollywood movie star-like idols for adolescents. Most studies^19,20,24,25 agree that close to 30% of Korean adolescents are Internet 'overusers', while 2-5% may be considered internet addicts. These individuals have clear psychopathologies, including anxiety, depression, attention deficit, relationship difficulties, and little family support. A more recent development is accidents and crime related to internet addiction, such as sudden death following excessive (~40 hours) computer entertainment in a PC bang and homicides between gaming partners after unsatisfactory game outcomes.
As a consequence, the Prime Ministry Youth Commission has begun developing a program for the "Treatment of Severely Internet Addicted Adolescents" in cooperation with the Korean Association of Adolescent Psychiatry (KAAP) in the year 2005.²⁶ Four university-based hospitals participated in the development of this program. Special, networked forms of treatment are now being designed to cater to Internet-addicted. Many teachers and psychologists are also interested in preventing Internet misuse and counseling of adolescents and parents at risk is now gaining more attention. A collaborative effort is desired, where teachers educate their students in proper Internet usage, psychologists counsel adolescents at risk, and psychiatrists treat severely addicted adolescents. The KAAP will expand this system in the future with the help of the Prime Ministry Youth Commission.

Socially Withdrawn Adolescents(the Hikkigomori Phenomenon)

Behavioral disturbances similar to what is seen in internet addiction are on the rise in many adolescents and young adults, who are socially withdrawn and not willing to participate in school or social activities. Entertainment is rejected and all available time is spent on computer maintenance in avoidance of social contact. So far, this kind of withdrawal is not a clinically defined behavioral, social, or emotional childhood or adolescence disorder,²⁷ but the phenomenon is predominant enough to have coined the associated terms NEET ("Not in Education, Employment or Training"),²⁸ "hikkigomori",²⁹ and "socially withdrawn lonely adolescents".³⁰ It has been estimated that the number of affected individuals in Korea now exceeds 33,000 (Figure 2).³⁰
In Korea, socially withdrawn lonely youth (SWLY) who are very similar to the Japanese hikkigomori are operationally defined by 1) staying at home without minimal social contact for 3+months, 2) not participating in social activities (e.g., education or employment), 3) having only one or no friends, 4) being anxious or fearful about the withdrawal, 5) not engaging in productive activities, 6) not being psychotic or having an I.Q. below 50.^30,31
Rubin et al.²⁷ has distinguished self-initiated isolation from the peer group from withdrawal by the peer group. Additionally social withdrawal as symptomatic phenomenon would include anxiety, phobia, major depression, schizophrenia, or avoidant personality. Some SWLY cases have been clinically diagnosed, but others have not. Hu and colleagues³¹ reported that 63.1% of all SWLY patients are without clinical diagnosis, whereas 36.9% of them were diagnosed with depres-sion, attention deficit-hyperactivity disorder, anxiety, adjustment disorder, social phobia, and others. Social withdrawal is also associated with intra- and inter-personal difficulties. Socially withdrawn adolescents are more aggressive toward other family members (especially parents), more suicidal, more prone to self-inflected injury, and more negative about their own personality. Recently Yeo³² developed a SMAY ("socially maladjusted youth") support plan in collaboration with researchers in Japan with promising results in a pioneer 5-day SMAY rescue camp. Despite a growing body of research, our understanding of social withdrawal during childhood and adolescence is still in need for better-designed research. One such effort is The International Consortium for the Study of Social and Emotional Development (with representatives from Australia, Brazil, Canada, China, India, Italy, Korea, and the United States), which has initiated cross-replicated longitudinal studies on the develop-ment of social competence, behavioral inhibition, and dysregulated temperament.²⁷

Conclusion

Korea has experienced war, civil revolution, and two military coups in the last sixty years. The Korean society has gone through dynamic changes associated with traditional problems. Poverty, illiteracy, slavery, and frequent military invasions are hence of no concern for today's children and adolescents. At the present time, issues that are serious in less developed countries do not apply to most Korean children and adolescents. The quality of life has considerably improved with the economic growth starting in the 1970s. Recent socioeconomic changes brought further improvement to Korean children and adolescents, but problems from urbanization and industrialization are little recognized threats.
The main problems affecting child and adolescent mental health in Korea are changes in the familial environment and the highly competitive education system. Korea has become a nation with a high divorce rate, but a low birth rate. The family and the society seem to have conflicting values regarding parenting, with one side being tolerant of corporal punishment for children, while the other is fully devoted to affectionate child care. The Korean society has undergone many economic, political, and sociocultural changes in the last six decades. Answers must be found to why and how children and adolescents have mental health problems during their development. Overcoming the difficulties changing family environments and society values clearly remains a task for the youth that needs to be addressed.

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2. Hong KE, Yamazaki K, Banaag CG, Yasong D. Systems of Care in Asia. IN. Facilitating Pathways: Care, Treatment and Prevention in Child and Adolescent Mental Health. Ed. by Remschmidt H, Belfer ML, Goodyer I, Berlin, Springer 2004, pp58-70.

3. Ahn DH, Hong KE. A survey of child abuse in Korea. Mental Health Research (in Korean) 1987; 6: 53-65.

4. Kim JJ. Child abuse observed in the kindergartens of the slum area. in Family violence: The fact and management Ed. by Kim KI, Seoul, Tamgudang 1988, pp340-392.

5. Kim KI, Ko BJ. An incidence survey of battered child in the two elementary schools of Seoul. Mental Health Research 1987; 6: 66-81.

6. Straus MA, Gelles RJ, Steimetz SK. Behind closed doors: Violence in the American family. Garden City, New York, Doubleday/Anchor 1979.

7. Ko BJ. An incidence survey of battered child in the two elementary schools of Seoul-A follow-up in 5 years-. J Korean Acad. Child Adolesc Psychiatry 1992; 3: 56-72.

8. Ministry of Health and Welfare, National Center for the Prevention of Child Abuse, www.korea1392.org.

9. Korean Medical Association. Clinical Guideline for Prevention and Treatment of Child Abuse and Neglect. Seoul, Korean Medical Association, 2003.

10. Korean Medical Association. Resource Book of Child Sexual Abuse. Seoul, Korean Medical Association 2003.

11. Lee HY. An attitude study of teacher, parents, and children toward physical punishment. Unpublished M.A. Dissertation, Sungshim (Sacred-Heart) Women's University 1988.

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14. Ministry of Foreign Affairs and Trade. Concluding Observations for the Second Report. http://www.mofat.go.kr/mofat/ICSFiles/afieldfile/2003/02/15/cmk_c103_17881.hwp.

15. Prime Ministry Youth Commission. 2005 White Paper on Adolescence. Seoul, Prime Ministry Youth Commission, pp327.

16. Yoon JI, Song KC, Cho DS, Kim BJ, Rhu MH. Education policy in Korea. Seoul, Education Science Co, 1991.

17. A Wrenching Choice. The Washington Post. Jan 9, 2005.

18. Kim HS. Internet Addiction. Seoul, Nanum Press, 2000.

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21. Ko CH, Yen JY, Chen CC, Chen SH, Yen CF. Gender dif-ferences and related factors affecting online gaming addiction among Taiwanese adolescents. J Nerv Ment Dis 2005; 193 (4): 273-277.

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25. Lee MS, Oh EY, Cho SM, Hong MJ, Moon JS. An assessment of adolescent Internet addiction problems related to depression, social anxiety and peer relationship. J Korean Neuropsychiatr Assoc 2001; 40 (4): 616-626.

26. Kim SB. National Plan of Severely Internet Addicted Adolescents Treatment Program. Presented at Annual Academic Meeting of Korean Association of Adolescent Psychiatry in Seoul on Nov 25, 2005.

27. Rubin KH, Burgess KB, Kennedy AE, Stewart SL. Social withdrawal in childhood. IN. Child Psychopathology, 2nd edition, Ed. by Mash EJ, Barkley RA, New York, The Gulford Press 2003, pp372-406.

28. The Social Exclusion Unit. Bridging the Gap: New Opportunities for 16-18 Years Olds Not in Education, Employment or Training. 1999.

29. http://www.pref.hokkaido.jp/hfukusi/ hfkitah/soumu/nhk/hikkikomori/hi..

30. Whang SK, Kwon HS, Chang MK. Socially Maladjust Youth Support Plan of Korea. Proceeding of Korea-Japan International Symposium held in Seoul on Nov 30, 2005, pp47-63.

31. Hu MY. Clinical features of socially mal-adjusted youth of Korea. Proceeding of Korea-Japan International Symposium held in Seoul on Nov 30, 2005, pp65-95.

32. Yeo IJ. Socially Mal-Adjust Youth (SMAY) Support Plan. Proceeding of Korea-Japan International Symposium held in Seoul on Nov 30, 2005, pp97-104.