search for


 

Sex Differences in Risk Factors for Generalized Anxiety Disorder in Korean Adolescents
J Korean Acad Child Adolesc Psychiatry 2024; 35(4): 258-265
Published online October 1, 2024
© 2024 Korean Academy of Child and Adolescent Psychiatry.

Yea-Ju Jin and JooYong Park

Department of Big Data Medical Convergence, Eulji University, Seongnam, Korea
Correspondence to: JooYong Park, Department of Big Data Medical Convergence, Eulji University, 553 Sanseong-daero, Sujeong-gu, Seongnam 13135, Korea
Tel: +82-31-740-7160, Fax: +82-31-740-7568, E-mail: judepark0501@gmail.com
Received August 15, 2024; Revised September 5, 2024; Accepted September 10, 2024.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Objectives: This study aimed to examine sex differences in the risk factors associated with generalized anxiety disorder (GAD) among Korean adolescents to provide insights for drafting more effective prevention strategies.
Methods: Data from 51845 middle and high school students in the 18th Korea Youth Risk Behavior Web-based Survey were analyzed. GAD was assessed using the 7-item Generalized Anxiety Disorder tool, and factors such as grade, academic performance, economic status, living arrangements, smoking, drinking, sexual experience, and physical activity were included. The prevalence of GAD and its association with these factors were compared between male and female students using chi-square tests and logistic regression. Odds ratios were compared statistically to identify sex-specific differences.
Results: GAD prevalence was higher among girls (42.1%) than boys (30.1%). Both sexes showed increased GAD risk with lower academic performance, lower economic status, smoking, drinking, and sexual experience. Boys living apart from their families had a higher GAD risk, but this was not significant for girls. Additionally, smoking and drinking were associated with a higher increase in GAD risk in girls than in boys.
Conclusion: This study underscores the importance of considering sex differences in the prevention of GAD among adolescents. Tailored sex-specific interventions are crucial for effective prevention and management of GAD in Korean adolescents.
Keywords : Adolescents; Mental health; Risk factors; Health risk behaviors; Sex differences
INTRODUCTION

Adolescent mental health issues are becoming increasingly severe in modern society. According to the 18th Korea Youth Risk Behavior Web-based Survey (KYRBS) conducted in 2022, mental health indicators such as perceived stress levels, depression experiences, suicidal ideation, feelings of loneliness, and moderate-to-severe generalized anxiety disorder (GAD) have increased among both male and female students compared to the previous year [1]. In particular, the prevalence of moderate-to-severe GAD, which was added as a survey item in 2020, has increased from 11.2% in 2020 to 12.7% in 2022 [1].

GAD is a subtype of anxiety disorder characterized by pervasive and persistent anxiety that is not limited to specific situations or environments and causes significant distress and impairment in social and occupational functioning. Anxiety symptoms that occur during adolescence can be considered early signs of various psychopathologies, potentially leading to other anxiety disorders and mental health conditions [2]. Therefore, early detection and prevention of anxiety symptoms during adolescence are important.

Previous studies have reported risk factors associated with mental health, such as sex, economic status, stress, and emotional states, such as sadness, loneliness, suicidal thoughts, and physical activity [2,3]. Additionally, specific experiences during adolescence, such as substance use, smartphone overdependence, and exposure to violence are associated with mental health [4]. However, previous cross-sectional studies have examined associations without considering the temporal characteristics reflected in the survey questionnaires, making it impossible to rule out the possibility of reverse causation. Additionally, these studies have analyzed the overall population without accounting for sex differences despite recognizing sex as a factor related to mental health [2-4]. Males and females may differ in the factors associated with mental health due to biological, psychological, and social differences. Therefore, it is essential to consider that different factors may influence mental health differently in each sex.

This study examined the risk factors associated with mental health among Korean adolescents according to sex. We found sex-differences in risk factors affecting the mental health of Korean adolescents by comparing the differences in risk factors by sex and ultimately suggested the need for different approaches in the prevention of mental health issues based on sex.

METHODS

Study population

This study was performed using the 18th KYRBS (2022), a nationwide cross-sectional survey assessing the health status of adolescents in Korea. The Korea Disease Control and Prevention Agency conducts this survey annually using a stratified multistage cluster sampling method to obtain a nationally representative sample of middle- and high-school adolescents in Korea [5]. For this study, 2022 data, which were the most recent data available at the time of planning, were used. The target population was defined as students enrolled in middle and high schools nationwide as of April 2022, and the sampling frame for the sample design used data from nationwide middle and high schools as of April 2021. The sample comprised 400 middle schools and 400 high schools. Initially, five middle schools and five high schools were allocated to each of the 17 provinces and metropolitan areas. Proportional allocation was applied to ensure consistency between the population and sample composition using stratification variables, distributing the sample schools according to province, city size, region, and school type. Among the 800 selected schools, including 400 middle and 400 high schools, and 56213 sample students, 51850 (92.2%) students from 798 (99.8%) schools participated in the survey that year. After excluding those with missing information on academic performance (n=2) and economic status (n=3), 51845 students (26393 boys and 25452 girls) were included in the analyses. Although five participants had missing values for living arrangements, they overlapped with those with missing values for academic performance and economic status. A trained teacher distributes an information sheet to each student and, using instructional materials (such as an animation or PowerPoint presentation), explains the purpose and procedures of the survey in a school computer laboratory equipped with Internet access. Students then log in with the certificate number provided on the information sheet and complete the online informed consent process. This study was reviewed and approved by the Institutional Review Board of Eulji University (EUIRB2024-007). Informed consent was waived since secondary data were used in this study.

Measurements

Mental health

Adolescent mental health was assessed using the 7-item Generalized Anxiety Disorder (GAD-7) tool [6]. This tool evaluates the frequency of seven issues experienced over the past two weeks: worry, nervousness, anxiety, discomfort, irritability, fear, and disturbance [6]. Responses were scored as follows: “not at all” (0 points), “several days” (1 point), “more than half of the days” (2 points), and “nearly every day” (3 points). The scores for all the items were summed to obtain a total score. A total score of 0–4 points indicated “normal” anxiety levels, 5–9 points indicated “mild anxiety,” 10–14 points indicated “moderate anxiety,” and 15–21 points indicated “severe anxiety.” Individuals scoring 0–4 were categorized as having no GAD, while those scoring 5 or above were categorized as having GAD according to “2020 Standard Guidelines for Mental Health Screening Tools and Their Use” [7]. Although the study participants were patients with migraine, validation of the GAD-7 at a cutoff score of 5 for the Korean population has been reported in a previous study [8].

General characteristics

Variables related to the general characteristics of the adolescent subjects, including grade, academic performance, economic status, and living arrangements, were used. Grade level was surveyed from the first year of middle school to the third year of high school and used as a variable reflecting age. Academic performance was assessed over the past 12 months and categorized into five levels: high, middle-high, middle, middle-low, and low. The economic status of households was categorized into five levels: high, middle-high, middle, middle-low, and low. Living arrangements were surveyed with five options: “living with family,” “living with relatives,” “boarding or living alone (including living with friends),” “dormitory,” and “care facility (orphanage, social welfare facility, childcare facility).” These were reclassified into a binary variable indicating whether students lived with their families.

Risk behaviors

To examine the association between major risky lifestyle behaviors such as smoking, drinking, sexual activity, physical inactivity, and GAD in adolescents, we used risk behavior variables such as smoking experience, drinking experience, sexual activity experience, and the number of days with at least 60 minutes of physical activity. Assuming that lifetime experiences of smoking or drinking have a more significant impact on current mental health by explaining the temporal relationship better than current smoking and drinking status, we used variables reflecting whether students had ever smoked or drank alcohol during their lifetime. Smoking experience was assessed based on whether the individual had ever consumed even a few puffs in their lifetime, whereas drinking experience was assessed based on whether the individual had ever consumed at least one drink in their lifetime. Sexual activity experience was assessed by asking, “Have you ever had sexual intercourse?” and the responses were recorded as a binary variable (yes or no). The physical activity variable was measured by the number of days in the past seven days that the individual engaged in at least 60 minutes of moderate to vigorous physical activity, causing increased heart rate or shortness of breath. Considering that the weekly lifestyle patterns of middle and high school students in Korea are relatively consistent, we assumed that although the survey measured only the number of days in the past week with at least 60 minutes of moderate-to-vigorous physical activity, which increases the heart rate or causes shortness of breath, it would reflect the students’ overall physical activity habits. According to the World Health Organization guidelines, sufficient physical activity is defined as at least 150 minutes per week [9]; thus, individuals were considered to have sufficient physical activity if they reported engaging in such activity for at least three days per week.

Statistical analysis

We first compared the general characteristics, risk behaviors, and prevalence of GAD between adolescent males and females in Korea to highlight the need for separate analyses by sex owing to differences between them. Differences between male and female students were tested using the Rao-Scott chi-square test, reflecting the weights of the complex sample survey.

Based on the differences between male and female students, factors associated with GAD for each sex were identified using the Rao-Scott chi-square test and multiple logistic regression analysis by considering the weights of the complex sample survey. Based on the estimated odds ratios (ORs) for boys and girls, significant differences between the sexes were analyzed to determine which risk factors were more significant for each sex [10].

Z=log(ORmen)log(ORwomen)SEmen2+SEwomen2

All analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC, USA).

RESULTS

Statistically significant differences between male and female students, except for grades, are shown in Table 1. No difference in grade distribution by sex indicated that sampling was conducted equally across grades for both sexes; however, significant differences between male and female students were observed for all other variables, suggesting the need for separate analyses for boys and girls. In terms of academic performance, boys were relatively more prevalent in the extreme categories of high and low than girls, whereas girls were more represented in the middle-low to middle-high range. Boys tended to have better economic status than girls, and a slightly higher percentage of girls lived with their families. Boys had higher rates of smoking, drinking, and sexual experience and also engaged in sufficient physical activity more frequently than girls. The prevalence of GAD was significantly higher in girls (42.1%) than in boys (30.1%).

Comparison between male and female students regarding general characteristics, risk behaviors, and generalized anxiety disorder

Characteristics Male Female p*
Value SE Value SE
Total 26393 (51.6) 1.21 25452 (48.4) 1.21
Mean age of middle school students 13.8±0.01 13.8±0.01
Mean age of High school students 16.7±0.01 16.7±0.01
Grade 0.9998
Middle school 1st grade 4745 (16.4) 0.52 4493 (16.5) 0.52
Middle school 2nd grade 4736 (17.1) 0.53 4610 (17.2) 0.53
Middle school 3rd grade 4700 (18.0) 0.60 4729 (18.1) 0.58
High school 1st grade 4234 (16.4) 0.57 4224 (16.4) 0.54
High school 2nd grade 4164 (15.6) 0.52 3818 (15.4) 0.58
High school 3rd grade 3814 (16.6) 0.59 3578 (16.4) 0.59
Academic performance <0.0001
High 3903 (14.9) 0.31 3032 (12.0) 0.29
Middle-high 6524 (24.9) 0.32 6591 (25.8) 0.35
Middle 7610 (28.9) 0.31 7873 (31.3) 0.35
Middle-low 5664 (21.2) 0.33 5715 (22.4) 0.34
Low 2692 (10.2) 0.23 2241 (8.6) 0.23
Economic status <0.0001
High 3426 (13.3) 0.32 2558 (10.3) 0.32
Middle-high 8392 (32.3) 0.41 7512 (30.5) 0.42
Middle 11702 (43.9) 0.47 12439 (48.3) 0.49
Middle-low 2298 (8.4) 0.24 2509 (9.3) 0.25
Low 575 (2.1) 0.10 434 (1.6) 0.09
Living arrangements 0.0060
With family 24836 (94.8) 0.51 24346 (96.7) 0.34
Apart from family 1557 (5.2) 0.51 1106 (3.7) 0.34
Smoke experience <0.0001
No 23306 (88.0) 0.36 23994 (94.4) 0.21
Yes 3087 (12.0) 0.36 1458 (5.6) 0.21
Drink experience <0.0001
No 16184 (61.2) 0.55 18046 (70.8) 0.52
Yes 10209 (38.8) 0.55 7406 (29.2) 0.52
Sexual experience <0.0001
No 24471 (92.4) 0.25 24286 (95.3) 0.17
Yes 1922 (7.6) 0.25 1166 (4.7) 0.17
Sufficient physical activity <0.0001
No 13549 (51.8) 0.42 18682 (74.0) 0.46
Yes 12844 (48.2) 0.42 6770 (26.0) 0.46
Generalized anxiety disorder <0.0001
No 18593 (69.9) 0.34 14772 (57.9) 0.40
Yes 7800 (30.1) 0.34 10680 (42.1) 0.40
<fn id="t1fn1">

Data are presented as mean±standard error or n (%). *Rao-Scott chi-square test following complex sample survey; weighted percent and standard error were estimated based on a complex sample design. SE, standard error



Table 2 shows the distribution of general characteristics and risk behaviors according to the presence of GAD for each sex. Significant differences in GAD prevalence were observed across grades in both boys and girls. For both sexes, lower academic performance and lower economic status were associated with a higher prevalence of GAD. Additionally, boys living apart from their families experienced GAD in more cases (6.5%) than girls did (3.8%). Smoking, drinking, and sexual experiences were associated with a higher prevalence of GAD in both boys and girls.

General characteristics, risk behaviors according to the generalized anxiety disorder by sex

Characteristics Generalized anxiety disorder (male) Generalized anxiety disorder (female)
No Yes p* No Yes p*
n (%) SE n (%) SE n (%) SE n (%) SE
Grade <0.0001 <0.0001
Middle school 1st grade 3518 (17.3) 0.48 1227 (14.3) 0.55 2720 (17.2) 0.51 1773 (15.6) 0.53
Middle school 2nd grade 3404 (17.4) 0.49 1332 (16.4) 0.61 2627 (16.8) 0.51 1983 (17.8) 0.56
Middle school 3rd grade 3280 (17.9) 0.55 1420 (18.2) 0.69 2691 (17.8) 0.55 2038 (18.5) 0.61
High school 1st grade 2945 (16.2) 0.51 1289 (16.8) 0.65 2462 (16.6) 0.52 1762 (16.0) 0.55
High school 2nd grade 2892 (15.4) 0.48 1272 (15.9) 0.59 2312 (16.2) 0.60 1506 (14.3) 0.56
High school 3rd grade 2554 (15.9) 0.55 1260 (18.4) 0.71 1960 (15.4) 0.54 1618 (17.8) 0.68
Academic performance <0.0001 <0.0001
High 2804 (15.3) 0.34 1099 (14.0) 0.46 1857 (12.6) 0.39 1175 (11.1) 0.36
Middle-high 4623 (25.0) 0.36 1901 (24.8) 0.55 3901 (26.2) 0.44 2690 (25.1) 0.51
Middle 5528 (29.8) 0.37 2082 (26.7) 0.50 4726 (32.3) 0.45 3147 (29.9) 0.52
Middle-low 3913 (20.8) 0.37 1751 (22.1) 0.55 3219 (21.8) 0.41 2496 (23.2) 0.47
Low 1725 (9.2) 0.24 967 (12.4) 0.44 1069 (7.1) 0.26 1172 (10.8) 0.36
Economic status <0.0001 <0.0001
High 2531 (13.9) 0.36 895 (12.0) 0.46 1621 (11.3) 0.37 937 (9.1) 0.38
Middle-high 6044 (32.9) 0.44 2348 (30.8) 0.64 4527 (31.3) 0.49 2985 (29.3) 0.55
Middle 8315 (44.3) 0.50 3387 (42.8) 0.71 7307 (48.9) 0.58 5132 (47.4) 0.58
Middle-low 1397 (7.2) 0.24 901 (11.0) 0.42 1148 (7.4) 0.25 1361 (11.9) 0.39
Low 306 (1.6) 0.10 269 (3.3) 0.23 169 (1.1) 0.11 265 (2.3) 0.15
Living arrangements <0.0001 0.6728
With family 17599 (95.4) 0.40 7237 (93.5) 0.69 14159 (96.4) 0.38 10187 (96.2) 0.33
Apart from family 994 (4.6) 0.40 563 (6.5) 0.69 613 (3.6) 0.38 493 (3.8) 0.33
Sufficient physical activity 0.1429 0.2730
No 9466 (51.5) 0.45 4083 (52.6) 0.67 10882 (74.2) 0.49 7800 (73.6) 0.59
Yes 9127 (48.5) 0.45 3717 (47.4) 0.37 3890 (25.8) 0.49 2880 (26.4) 0.59
Smoke experience <0.0001 <0.0001
No 16641 (89.3) 0.33 6665 (85.3) 0.51 14176 (96.1) 0.21 9818 (92.1) 0.32
Yes 1952 (10.7) 0.33 1135 (14.7) 0.51 596 (3.9) 0.21 862 (7.9) 0.32
Drink experience <0.0001 <0.0001
No 11765 (63.0) 0.56 4419 (56.9) 0.71 11064 (74.9) 0.56 6983 (65.3) 0.63
Yes 6828 (37.0) 0.56 3381 (43.1) 0.71 3708 (25.1) 0.56 3698 (34.7) 0.63
Sexual experience <0.0001 <0.0001
No 17375 (93.1) 0.25 7096 (90.6) 0.39 14262 (96.5) 0.18 10024 (93.8) 0.26
Yes 1218 (6.9) 0.25 704 (9.4) 0.39 510 (3.5) 0.18 656 (6.2) 0.26
<fn id="t2fn1">

*Rao-Scott chi-square test following complex sample survey; weighted percent and standard error were estimated based on a complex sample design. SE, standard error



The results of the multivariate logistic regression analysis, adjusted for the influence of each factor, showed that lower academic performance, lower economic status, smoking experience, drinking experience, and sexual experience were associated with an increased risk of GAD in both male and female (Table 3). In particular, boys in the third year of middle school (OR=1.15, 95% confidence interval [CI]: 1.03–1.28) and the third year of high school (OR=1.16, 95% CI: 1.02–1.32) had a higher risk of GAD compared to those in the first year of middle school. In contrast, girls showed a decreased risk of GAD in the second year of high school (OR=0.82, 95% CI: 0.73–0.92) compared to the first year of middle school. However, no significant differences were observed between boys and girls in these comparisons. The risk of GAD increased only for boys who were living apart from their families (OR=1.30, 95% CI: 1.13–1.49), showing a significant difference between boys and girls (p=0.0006). Smoking and drinking experience increased the risk of GAD for both boys (OR=1.18, 95% CI: 1.07–1.30 for smoking experience and OR=1.17, 95% CI: 1.09–1.25 for drinking experience) and girls (OR=1.53, 95% CI: 1.34–1.76 for smoking experience and OR=1.40, 95% CI: 1.31–1.51 for drinking experience), however the risk was found to be particularly higher in girls when comparing the ORs between them (Table 3).

Sex differences in factors associated with generalized anxiety disorder

Male Female p
OR* 95% CI OR* 95% CI
Grade
Middle school 1st grade 1.00 Reference 1.00 Reference
Middle school 2nd grade 1.10 0.99-1.23 1.10 1.00-1.22 >0.9999
Middle school 3rd grade 1.15 1.03-1.28 1.05 0.94-1.16 0.2383
High school 1st grade 1.10 0.99-1.23 0.93 0.84-1.04 0.0307
High school 2nd grade 1.05 0.94-1.18 0.82 0.73-0.92 0.0028
High school 3rd grade 1.16 1.02-1.32 1.04 0.92-1.17 0.2246
Academic performance
High 1.00 Reference 1.00 Reference
Middle-high 1.06 0.97-1.17 1.05 0.94-1.16 0.8951
Middle 0.93 0.85-1.02 1.00 0.89-1.11 0.3206
Middle-low 1.04 0.93-1.15 1.07 0.96-1.19 0.7120
Low 1.20 1.06-1.37 1.36 1.20-1.55 0.1758
Economic status
High 1.00 Reference 1.00 Reference
Middle-high 1.09 0.99-1.21 1.18 1.07-1.30 0.2660
Middle 1.10 1.00-1.22 1.20 1.09-1.33 0.2253
Middle-low 1.68 1.48-1.91 1.85 1.64-2.09 0.2830
Low 1.96 1.59-2.42 2.15 1.69-2.75 0.5727
Living arrangement
With family 1.00 Reference 1.00 Reference
Apart from family 1.30 1.13-1.49 0.90 0.77-1.06 0.0006
Sufficient physical activity
No 1.00 Reference 1.00 Reference
Yes 0.96 0.90-1.02 1.02 0.96-1.09 0.1826
Smoke experience
No 1.00 Reference 1.00 Reference
Yes 1.18 1.07-1.30 1.53 1.34-1.76 0.0024
Drink experience
No 1.00 Reference 1.00 Reference
Yes 1.17 1.09-1.25 1.40 1.31-1.51 0.0004
Sexual experience
No 1.00 Reference 1.00 Reference
Yes 1.15 1.02-1.30 1.26 1.09-1.44 0.3322
<fn id="t3fn1">

*multivariate logistic regression based on a complex sample design adjusting for grade, academic performance, economic status, living arrangements, sufficient physical activity, smoke experience, drink experience, sexual experience; p-values are derived from Z-tests comparing the log-transformed odds ratios between male and female. CI, confidence interval; OR, odds ratio


DISCUSSION

This study examined the risk factors associated with GAD in Korean adolescents and found significant differences in several factors between males and females. The prevalence of GAD was higher among female students (42.1%) than male students (30.1%). Although common risk factors were observed in both sexes, including lower academic performance, lower economic status, smoking experience, drinking experience, and sexual experience, females showed a higher risk of GAD related to smoking and drinking experience than males. Moreover, living apart from family was identified as a specific risk factor for GAD among males.

Statistics from the 18th KYRBS estimated the prevalence of moderate or higher GAD, reporting 8.0% for male students and 14.7% for female students in 2020, and 9.7% for male students and 15.9% for female students in 2022 [1]. However, in our study, GAD was defined as the presence of mild or higher anxiety using a cutoff score of 5, based on the 2020 Standard Guidelines for Mental Health Screening Tools and Their Use [7]. Consequently, its prevalence is estimated to be high. In a previous study, when a cutoff score of 5 was used, the GAD prevalence in 2020 was 27.3% in males and 40.4% in females [11]. Given the slight increase in the prevalence of moderate or higher GAD from 2020 to 2022, the prevalence of GAD, defined as mild or higher anxiety in our study, also showed a slight increase to 30.1% in males and 42.1% in females compared with 2020.

Consistent with earlier studies, this study found that a higher risk of GAD was observed in both male and female students with lower academic performance, lower economic status, smoking experience, drinking experience, and sexual experience [2-4]. However, we focused on sex-specific differences to provide additional insight into how these factors differentially affect boys and girls. While both smoking and drinking were associated with an increased risk of GAD in males, the risk was significantly higher in females with similar experiences. Specifically, female smokers are at a greater risk of developing GAD than male smokers, and the same pattern is observed in females who drink alcohol compared with their male counterparts. This suggests that, although boys are generally more likely to engage in behaviors such as smoking and drinking [1], the mental health consequences of these behaviors may be more severe for girls [12,13]. The stigma and social pressures associated with smoking and drinking in girls, along with physiological differences in how substances affect the female body, likely contribute to this increased vulnerability [14-16].

For boys, the risk of GAD was particularly elevated during the third year of middle school and the third year of high school, which are critical academic transition periods in the Korean educational system. Although previous studies have not reported differences between boys and girls in terms of anxiety related to academic pressure [17], the results of this study imply that these periods are marked by intense academic pressure, which appears to disproportionately affect boys, leading to higher anxiety levels. Additionally, boys who lived away from their families exhibited a higher risk of developing GAD. These findings suggest that boys may be more susceptible to anxiety in the face of environmental changes, such as the pressures of academic transitions and stress associated with living independently from their families [18-20].

Sex differences in mental health are crucial, especially during adolescence, a period marked by significant biological, psychological, and social changes [21]. Our findings indicate that boys are more likely to experience heightened anxiety during major life transitions and when separated from familial support, whereas girls are more vulnerable to the adverse mental health effects of risky behaviors such as smoking and drinking. These differences are influenced by various factors, including hormonal changes, gender roles, and societal expectations [22]. In Korea, traditional gender roles and the pressure to conform to societal norms can exacerbate these issues differently for boys and girls [17,23,24]. Understanding these differences is crucial for developing targeted interventions that address the specific needs of each sex. For instance, it may be helpful for males to increase their communication time with their families through family-participatory activities to strengthen family bonds and relieve anxiety through active counseling support with a psychologist [25,26]. For females, it may be helpful to provide step-by-step and systematic preventive education on the risks of smoking and drinking, centered on schools and communities [27-29].

The current study had several limitations. First, adolescents may under-report or over-report their mental health status and behavior because of social desirability or recall bias. Second, to measure smoking and drinking behaviors, we categorized the subjects into those with and without smoking experience, and those with and without drinking experience. However, this simple classification may not fully capture the frequency or intensity of smoking and drinking. Third, the GAD-7 is a screening tool consisting of seven questionnaire items designed to quickly screen for GAD. Therefore, the diagnosis of GAD was limited. Finally, the cross-sectional design limits the ability to establish causal relationships between the identified risk factors and GAD. However, we also considered the temporal characteristics of the questionnaire. For example, the GAD questions referred to experiences in the past two weeks, while the variables selected as potential risk factors reflected more general or long-term states to ensure that they preceded the timeframe covered by the GAD assessment. Although physical activity was assessed based on the past week, we assumed that the physical activity patterns of Korean middle and high school students were consistent. Thus, the past week’s activity reflected the student’s overall pattern. Therefore, although this was a crosssectional study, we attempted to interpret the temporal relationship using variables that reflected periods prior to GAD as potential risk factors. However, the limitation remains that it is difficult to establish a clear temporal relationship because of the possibility that GAD symptoms can persist beyond two weeks and the influence of experiences from other variables occurring within the same two-week period. Nevertheless, this study has several strengths, including its large, nationally representative sample, which enhances the generalizability of the findings, and its focus on sex-specific factors, which provide valuable insights into how boys and girls experience mental health risks differently.

CONCLUSION

This study highlighted the importance of considering sex differences when addressing mental health issues among adolescents. These findings suggest that boys and girls have different risk factors for mental health problems. These insights underscore the need for tailored interventions that consider sex-specific factors to effectively prevent and manage anxiety disorders among Korean adolescents. Future research should explore these differences and investigate other factors that may contribute to young people’s mental health during this critical developmental period.

Acknowledgments

None

Availability of Data and Material

The raw dataset analyzed during the current study are available at http://www.kdca.go.kr/yhs/.

Conflicts of Interest

The authors have no potential conflicts of interest to disclose.

Author Contributions

Conceptualization: Yea-Ju Jin, JooYong Park. Data curation: Yea-Ju Jin. Investigation: Yea-Ju Jin, JooYong Park. Supervision: JooYong Park. Writing—original draft: Yea-Ju Jin, JooYong Park. Writing—review & editing: JooYong Park.

Funding Statement

None

References
  1. Korea Disease Control. 18th (2022) Korean Youth Health Risk Behavior On-Line Survey Statistics. Cheongju: Korea Disease Control and Prevention Agency;2023.
  2. Woo KS, Ji Y, Lee HJ, Choi TY. The association of anxiety severity with health risk behaviors in a large representative sample of Korean adolescents. J Korean Acad Child Adolesc Psychiatry 2021;32:144-153.
    CrossRef
  3. Kim ML, Shin K. Exploring the major factors affecting generalized anxiety disorder in Korean adolescents: based on the 2021 Korea Youth Health Behavior Survey. Int J Environ Res Public Health 2022;19:9384.
    Pubmed KoreaMed CrossRef
  4. Lim S. The associated factors with generalized anxiety disorder in Korean adolescents. Korean Public Health Res 2021;47:197-208.
  5. Kim Y, Choi S, Chun C, Park S, Khang YH, Oh K. Data resource profile: the Korea Youth Risk Behavior Web-based Survey (KYRBS). Int J Epidemiol 2016;45:1076-1076e.
    Pubmed CrossRef
  6. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006;166:1092-1097.
    Pubmed CrossRef
  7. National Center for Mental Health. 2020 Standard Guidelines for Mental Health Screening Tools and Their Use. Seoul: National Center for Mental Health;2020.
  8. Seo JG, Park SP. Validation of the generalized anxiety disorder-7 (GAD-7) and GAD-2 in patients with migraine. J Headache Pain 2015;16:97.
    Pubmed KoreaMed CrossRef
  9. World Health Organization. Global Recommendations on Physical Activity for Health: EXECUTIVE SUMMARY [Internet]. Geneva: World Health Organization 2010 [cited 2024 Aug 6]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK305060/.
  10. Altman DG, Bland JM. Interaction revisited: the difference between two estimates. BMJ 2003;326:219.
    Pubmed KoreaMed CrossRef
  11. Kwak JY. Association between stress factors and generalized anxiety disorder(GAD) of Korean adolescents: using GAD-7 [dissertation]. Seoul: Graduate School of Public Health Yonsei University;2023.
    CrossRef
  12. Yue Y, Hong L, Guo L, Gao X, Deng J, Huang J, et al. Gender differences in the association between cigarette smoking, alcohol consumption and depressive symptoms: a cross-sectional study among Chinese adolescents. Sci Rep 2015;5:17959.
    Pubmed KoreaMed CrossRef
  13. Verplaetse TL, Smith PH, Pittman BP, Mazure CM, McKee SA. Associations of gender, smoking, and stress with transitions in major depression diagnoses. Yale J Biol Med 2016;89:123-129.
    Pubmed KoreaMed
  14. Ozbay N, Shevorykin A, Smith P, Sheffer CE. The association between gender roles and smoking initiation among women and adolescent girls. J Gend Stud 2020;29:664-684.
    CrossRef
  15. Beltz AM, Berenbaum SA, Wilson SJ. Sex differences in resting state brain function of cigarette smokers and links to nicotine dependence. Exp Clin Psychopharmacol 2015;23:247-254.
    Pubmed KoreaMed CrossRef
  16. Cosgrove KP, McKay R, Esterlis I, Kloczynski T, Perkins E, Bois F, et al. Tobacco smoking interferes with GABAA receptor neuroadaptations during prolonged alcohol withdrawal. Proc Natl Acad Sci U S A 2014;111:18031-18036.
    Pubmed KoreaMed CrossRef
  17. Sung JM, Kim YJ. Sex differences in adolescent mental health profiles in South Korea. Arch Psychiatr Nurs 2020;34:563-571.
    CrossRef
  18. Jiang Y, Xiao H, Yang F. Accompanying your children: living without parents at different stages of pre-adulthood and individual physical and mental health in adulthood. Front Public Health 2023;11:992539.
    Pubmed KoreaMed CrossRef
  19. Behere AP, Basnet P, Campbell P. Effects of family structure on mental health of children: a preliminary study. Indian J Psychol Med 2017;39:457-463.
    Pubmed KoreaMed CrossRef
  20. Deng Y, Cherian J, Khan NUN, Kumari K, Sial MS, Comite U, et al. Family and academic stress and their impact on students' depression level and academic performance. Front Psychiatry 2022;13:869337.
    Pubmed KoreaMed CrossRef
  21. Christie D, Viner R. Adolescent development. BMJ 2005;330:301-304.
    CrossRef
  22. Farhane-Medina NZ, Luque B, Tabernero C, Castillo-Mayén R. Factors associated with gender and sex differences in anxiety prevalence and comorbidity: a systematic review. Sci Prog 2022;105:368504221135469.
    Pubmed KoreaMed CrossRef
  23. Kim H, Park KH, Park S. Gender differences in lifestyle and mental health among senior high school students in South Korea. Int J Environ Res Public Health 2021;18:10746.
    Pubmed KoreaMed CrossRef
  24. Kim H, Park KH, Park S. Gender differences in sexual behaviors and their relevance to mental health among high school students with sexual experience in South Korea. Int J Environ Res Public Health 2021;18:11295.
    Pubmed KoreaMed CrossRef
  25. Farmakopoulou I, Lekka M, Gkintoni E. Clinical symptomatology of anxiety and family function in adolescents-the self-esteem mediator. Children (Basel) 2024;11:338.
    Pubmed KoreaMed CrossRef
  26. Guo L, Tian L, Scott Huebner E. Family dysfunction and anxiety in adolescents: a moderated mediation model of self-esteem and perceived school stress. J Sch Psychol 2018;69:16-27.
    CrossRef
  27. Lee NK, Cameron J, Battams S, Roche A. W hat works in schoolbased alcohol education: a systematic review. Health Educ J 2016;75:780-798.
    CrossRef
  28. Botvin GJ, Griffin KW. School-based programmes to prevent alcohol, tobacco and other drug use. Int Rev Psychiatry 2007;19:607-615.
    CrossRef
  29. Hwang JH, Ryu DH, Park SW. Influence of school-based smoking prevention education on reducing gap in exposure to anti-tobacco media message among Korean adolescents. Int J Environ Res Public Health 2020;17:8742.
    Pubmed KoreaMed CrossRef


October 2024, 35 (4)
Full Text(PDF) Free
PubMed Central
Google Scholar Search

Social Network Service
Services
Close ✕


Stats or Metrics
  • CrossRef (0)
  • View (321)
  • Download (94)

Author ORCID Information