https://orcid.org/0000-0003-4072-0793
Abstract
Objective
This study utilized the World Health Organization Disability Assessment Schedule version 2 (WHODAS 2.0) to identify vulnerable students and explore the impact of mental and developmental disorders on disability.
Participants
A total of 156 undergraduates who visited support service offices at large-scale universities in Japan between April 2018 and March 2020 were included.
Methods
The 36-item WHODAS 2.0 was administered, and data were gathered regarding mental and developmental disabilities. Mann–Whitney and Kruskal–Wallis tests were conducted.
Results
Parents/guardians typically initiated consultation with student support services. Students whose parents had initiated consultation did not have higher scores in any WHODAS domain except “Life Activities.” In every WHODAS domain except “Cognition,” the “Mental Disorder” group scored significantly higher than the “No Disorder” group. The addition of “Developmental Disorders” significantly increased WHODAS scores, except in “Mobility.”
Conclusions
The WHODAS is a useful tool for identifying vulnerable students.
Introduction
Despite several studies on the increasingly complex needs of university students and difficulties connecting them to supports offered at higher learning institutions,Citation1,Citation2 mental health problems appear to be rising in this population.Citation3–6 A recent World Health Organization (WHO) survey of university students across eight countries found that 34% reported suffering from at least one lifetime mental disorder.Citation7
Japan is no exception to this trend. The Japan Student Services Organization (JASSO) Fact-Finding Survey (FFS 2015, FFS 2019) found that the number of higher education students with mental disorders increased approximately 1.65-fold (5,888 vs. 9,709 students) from 2015 to 2019, and the number of cases of “developmental disorders (with a medical certificate)” increased approximately 2.21-fold (3,436 vs. 7,605 students).Citation3,Citation4
Students who suffer from mental and developmental disorders often experience difficulties in learning, and many lack the ability or motivation to seek help.Citation8–13 One study found that a number of university students who had no special problems upon admission developed learning and other problems due to mental health issues or a mismatch between developmental disorder tendencies and their learning environments.Citation14 In many cases, students only seek help when their problems have begun to severely impact their interpersonal relationships and academic performance.Citation8,Citation14,Citation15
Rapid measures and intra-campus collaboration are crucial for addressing mental health and learning problems; however, creating an atmosphere where students feel safe disclosing their mental health struggles is equally important.Citation16,Citation17 In this context, two main questions arise: (i) How do we encourage students to get the help that they need? (ii) How do we accurately identify those students to begin with?
Regarding the latter question, mental health and developmental disorders have diverse symptoms, and few studies have identified which symptoms signal students’ need for support and assistance.Citation18–20 We believe that there is room for investigation into additional metrics that can be used to determine a student’s likelihood of requiring university-provided psychological services for assistance with a mental or developmental disability.
The WHO Disability Assessment Schedule version 2 (WHODAS 2.0) is a self-administered questionnaire designed to identify mental, neurological, and addictive disorders.Citation21 Although one study found that it may have some item redundancy,Citation22 the WHODAS-2 has been shown to be valid and reliable with solid psychometric properties, broad applications in different groups and settings, and strong and theoretical underpinnings.Citation23,Citation24 It also links directly to the International Classification of Functioning, Disability, and Health (ICF).Citation25
We propose that the WHODAS-2 could be a particularly appropriate instrument to assess students’ mental health vulnerabilities for several reasons. First, it is short and easy to use—the 12-item version takes only five minutes, and the 36-item version takes 20 minutes— Citation26 and it can be easily administered by phone or Internet as in clinical settings.Citation27,Citation28 These elements could be helpful in dealing with students who are inexperienced with or embarrassed to seek mental health services, as studies have indicated that such individuals are often reluctant to connect to campus mental health services in person.Citation29 Moreover, as a patient-reported outcome measure (PROM), it measures patients’ own views of their experiences of impairment and disability rather than those of a clinician. The assessment of impairment and disability is distinct from diagnostic considerations; the WHODAS can reflect any medical or psychiatric illness as well as comorbid conditions.Citation30 Moreover, the questionnaire covers a range of life domains, including interpersonal relations and self-care, which makes it a more holistic tool than instruments designed to identify specific conditions. However, although the WHODAS has been validated among a range of populations, including community and youth samples, its applications for university students have yet to be determined.Citation31,Citation32
This study aimed to (i) explore the feasibility of the WHODAS 2.0 for identifying the functioning of students who are usually difficult to connect to campus support services and (ii) examine differences in disability scores measured by the WHODAS 2.0 according to who arranged for the consultation and the type of disorder. We hypothesized that students whose parents/guardians came for consultation before the students themselves would show higher scores across functional domains than those who had come for a consultation on their own. We further hypothesized that WHODAS scores would be significantly higher if there were mental and, in some cases, developmental disorders.
Methods
Participants
The participants in this study were undergraduate university students who had visited a support service office at a large-scale university between April 2018 and March 2020. All students who visited the office (N = 668) were approached on-site to inform them about the study and solicit their participation.
One hundred and sixty-one people agreed to participate in the study. Five respondents who did not complete the questionnaire were excluded and 156 respondents were included in the final sample.
This study was approved by the Ethics Committee of the authors’ affiliated institution. Informed consent was obtained from all participants.
Assessing disability: the World Health Organization Disability Assessment Schedule 2.0
The Japanese version of the WHODAS 2.0, developed by Tazaki et al, was used for this study.Citation33 The 36-item WHODAS 2.0 measures disability in participants across six functioning domains during the previous 30 days. Score calculation for the WHODAS 2.0 uses item-response, theory-based scoring.Citation21 Each domain score was calculated by adding the item responses (ranging from 1 “no difficulty” to 5 “extreme difficulty/cannot do”). A summary score (overall disability) was also computed for all items (items concerning “life activities at work or school” were excluded for those who did not work or study). The summary and domain scores were transformed into a range from 0 (best) to 100 (worst), with a high score equating to greater disability in any domain. Cronbach’s alpha scores for the Japanese version of the WHODAS 2.0 ranged from .67 to .98 across the six domains. In this study, the Cronbach’s alpha scores ranged from .80 to .84 across the domains.
Various clinical characteristics were also surveyed, including age, year of study, route of visit, main source of difficulty, and diagnosed mental or developmental disorder. The principal investigator, who is a clinical psychologist with experience in psychological evaluation, administered the questionnaire to participants in person at the university’s support services office.
Statistical analysis
Participants were divided into groups according to who initiated the consultation: the students themselves or their parents. The dependent variables were not normally distributed within each group (Shapiro–Wilk test). Thus, group differences were examined using descriptive statistics and either a Mann–Whitney U test or a Kruskal–Wallis test followed by a Bonferroni post hoc test to correct for multiple comparisons. Statistical significance was set at p < .05. Statistical analysis was performed using SPSS version 25.0 (SPSS Inc., Chicago, IL, USA).
Results
Clinical characteristics
shows the characteristics of the participants. The average age of the participants was 22.14 ± 2.86 years and most (84.6%) had parents/guardians assisting with booking their consultation at support services. The students’ chief complaint was related to “learning difficulties” (73.7%). Most students were undiagnosed (53.2%); however, 23.1%, 15.4%, and 5.8% presented with “mental disorders,” “developmental disorders,” and mixed “mental/developmental disorders,” respectively.
Table 1. Characteristics of the participants (N = 156).
Student-initiated versus parent/guardian-initiated consults
We hypothesized that students whose parents/guardians came for a consultation before the students themselves would obtain higher scores across functional domains than those who had come for a consultation on their own initiative. shows the results of the Mann–Whitney U tests for each of the WHODAS domains, wherein the independent variable was “who initiated consult (ie student, parent/guardian/teacher),” and the dependent variable was “functional domain scores.” The scores appeared to be greater for those whose parents/guardians initiated their consultations in all WHODAS domains except for “self-care”; however, the differences were not statistically significant except for “life activities” (U(Nstudent = 25, Nparent = 132) = 1132.00, z = −2.227, p = .026). In summary, for all WHODAS domains except “life activities,” the groups were not significantly different from one another.
Table 2. Quantitative differences in average WHODAS 2.0 scores according to who initiated consultation (N = 156).
Disability increases with mental and developmental disorders
We hypothesized that the presence of mental and developmental disorders would be accompanied by an increase in disability scores on the WHODAS 2.0. In all WHODAS 2.0 domains, except cognition (p = .059), the results of multiple comparisons through Kruskal–Wallis and Bonferroni post hoc tests showed that the median score of the “Mental Disorder” group was significantly higher than that of the “No Disorder” group. Additionally, scores in the “Developmental Disorders” group were significantly higher than the “No Disorder” group in the “Getting along” domain (p < .001). Similarly, those with both mental and developmental disorders (“Multiple” group) scored higher than the “No Disorder” group in the “Life activities” (p < .001) and “Overall disability” (p < .001) domains. However, the scores of the “Developmental Disorder” group were significantly lower than those of the “Mental disorders” group for the “Mobility” domain (p < .01).
Discussion
Initiation of consultation did not predict disability scores
We hypothesized that students whose parents/guardians initiated consultation with student support services rather than going to the office themselves would have higher WHODAS scores. This hypothesis was only valid for the WHODAS domain of “life activities.” WHODAS-2 defines life activities as domestic responsibilities, leisure, work, and school.Citation21 Therefore, students who did not actively seek help from campus psychological services were likely also struggling with these other domestic and life activities. This fits descriptions in the literature wherein individuals experiencing difficulties performing general life activities also struggle with help-seeking behaviors; referred to as the “help negation effect.”Citation20,Citation34
Creating a contact point for arranging consultations with parents/guardians and using a media campaign or more direct communication to ensure parents know that psychological services are available on campus would be helpful for at-risk students. Prompt action is essential. For example, the 2011 National Survey of College Counseling Center Directors found that only 20% of students who committed suicide had visited a counseling center.Citation35
Disability is greater if there are mental disorders
As illustrated in , all WHODAS 2.0 domain scores were higher in students with mental disorders compared with students with no disorders, indicating a greater level of disability in these students. However, this was not the case in the cognition domain, as evidenced by the absence of significant differences between the groups. This metric tests for functions involving communication and thinking activities, including concentrating, remembering, problem-solving, learning, and communicating.Citation21 This finding is in contrast to prior studies that found a strong link between mental disorders and cognitive functions; for example, mental disorders can lead to sleep disturbances that further affect functions in the cognition domain.Citation36
Table 3. Average score and standard deviations by diagnosis and WHODAS domain and results of the dispersion analysis (N = 152).
Mobility, defined in the Manual for WHO Disability Assessment Schedule as moving and getting around, leaving the house, and walking a long distance,Citation21 appears to be a challenge for individuals with mental disorders. Depression and anxiety disorders are known to reduce a person’s willingness or desire to leave the house and take care of their self.Citation37 This indicator also falls into the “Self-care” domain,Citation21 which is defined by personal hygiene, dressing, eating, and staying alone and is also impaired in mentally disordered students compared to their peers. Jao et al examined how mental health disorders tend to cluster with unhealthy lifestyle behaviors, often at odds with self-care behaviors, such as low physical activity, poor diet, binge drinking, and cigarette/marijuana use.Citation38
Students with mental disorders performed statistically worse in the “Getting along” domain than their non-mentally disordered counterparts. This finding implies that they have poorer interactions and relationships with people in their lives, including friends, family, and strangers.Citation21 Many mental disorders, such as anxiety and depression disorders, further make interacting or “getting along” with others more challenging, and bouts of intense irritability can manifest.Citation36–38
Unsurprisingly, the WHODAS-2 scores indicate that “Life activities”—including domestic responsibilities, leisure, work, and school tasksCitation21—are also significantly more challenging for individuals with mental disorders and those with both mental and developmental disorders compared with their typically functioning peers. Furthermore, participants with co-occurring developmental and mental disorders had significantly higher WHODAS scores than those without comorbid disorders. Involvement in daily tasks, including personal responsibilities and extending to community activities, is often hindered by the presence of a mental or developmental disorder. Zong et al found that university students with depressive symptoms were more likely to utilize maladaptive coping mechanisms and were less able to cope with stressful events.Citation39
Individuals with mental disorders also had lower scores in the “Participation” domain, which measures participation in community activities and maintenance of personal dignity.Citation21 Finally, there were strikingly higher “Overall disability” WHODAS 2.0 scores in the group with mental disorders compared with the healthy group. In summary, the WHODAS 2.0 domain scores could serve as an excellent guide to assess students’ disability levels and thereby aid clinical staff in better supporting students with mental disorders based on their disability level.
Disability and developmental disorders
Developmental disorders, such as attention-deficit hyperactivity disorder, autism spectrum disorder, and cerebral palsy, appear to affect the WHODAS domain scores less than mental disorders. For instance, for the “cognition,” “self-care,” and “participation” domains, the presence of a developmental disorder did not appear to affect the WHODAS 2.0 score and, somewhat counter-intuitively, did not result in a greater disability score. Unfortunately, the types and severity of the developmental disorder diagnoses were unknown and thus cannot help explain these results. Further research is needed to verify that developmental disorders do not affect these domains of WHODAS 2.0.
In fact, in the “Mobility” domain, developmental disorders were significantly different from the mental disorder group, indicating that the developmental disorder group had no significant trouble getting around, leaving the house, and going for walks. This may not be true for all patients with developmental disorders. For instance, those with cerebral palsy often have significant trouble with certain movements, including walking; thus, this is likely to be specific to this sample and is not necessarily generalizable.
In many cases, the presence of a developmental disorder increased the likelihood of a higher WHODAS score, indicating greater disability. In several instances, the presence of both developmental and mental disorders led to higher WHODAS 2.0 scores. It seems clear that there is some relationship present; however, further research with a larger sample is needed to delineate it.
Clinical significance of the findings
The results of this study illustrate that an approach to prevent the onset or worsening of mental disorders is crucial in supporting university students, as mental disorders are the biggest threat of disability as measured by the WHODAS 2.0. Mental disorders must be promptly detected and responded to. Targeting parents and guardians and ensuring that they are aware of campus psychological support services may prove beneficial in reaching more students who are usually difficult to connect with these services. Rickwood et al found that families exerted a substantial help-seeking influence; although individuals tended to be more self-directed toward late adolescence, the effect remained considerable,Citation40 which is likely due to the nature of many mental disorders directly affecting a person’s motivation to seek help.Citation34
Resources may be too scarce to cater to every student with a disability; thus, a different model that promptly intervenes with such problems is necessary. The concept of “outreach as intervention,” as discussed in Fu and Cheng’s 2017 Editor’s note, discusses providing services that move toward a community mental health model in the form of prevention programs and personal skills development.Citation41 Shahwan et al had some short-term success with an anti-stigma intervention on mental health help-seeking attitudes among university students.Citation42 The program lost efficacy over time; thus, booster sessions may be necessary to maintain its benefits. However, the underlying principles were strong as they laid a good foundation for future programs. In the same way that exercise and nutrition are crucial in preventing disease, we can offer preventive services to students before they become mentally unwell.
Limitations and future work
Small biological differences may have been missed due to the small sample size. Future studies could analyze which of the WHODAS domains signals the need for intervention and support among students. Future studies could also conduct more in-depth analyses to examine the effects of potential confounding variables. Finally, further work with a larger sample than ours, comprising various developmental disorders, is needed to determine the relationship between developmental disorders and disability scores in the WHODAS 2.0 domains.
Conflict of interest disclosure
The authors have no conflicts of interest to report. The authors confirm that the research presented in this article met the ethical guidelines, including adherence to the legal requirements, of Japan and received approval from the Ethics Committee of the Faculty of Arts and Science, Kyushu University, Japan (approval number: 202003).
Acknowledgments
Editorial support—in the form of medical writing, assembling tables, and creating high-resolution images based on authors’ detailed directions, collating author comments, copyediting, fact-checking, and referencing—was provided by Editage, Cactus Communications.
Additional information
Funding
References
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