Table 2 shows the help-seeking behavior in each country by gender (see Table S2 for the total sample, available online). Because of the significant effects of gender and country on help-seeking behavior, the results are presented separately for girls and boys. Of the 13,184 adolescents included in the analyses, 19.2% of adolescents (girls, 21.9%; boys, 16.3%) considered getting help, 6.3% of adolescents (girls, 7.7%; boys, 4.8%) sought help from informal sources, and merely 3.3% of them (girls, 4.9%; boys, 1.7%) sought help from formal sources. The proportion of adolescents who considered getting help between countries ranged from 10.3 to 36.4% (girls, 15.5–38.5%; boys, 5.0–34.4%). In most countries, formal help-seeking was limited. Despite the high perceived need ranging from 28.3 to 48.5% (girls, 25.8–53.6%; boys, 30.9–43.6%), 0.8–0.9% (girls, 0.6–0.9%; boys, 0.9–1.2%) in middle-income countries (India, Vietnam, China) sought formal help. In high-income countries, Greece, Israel, and Japan, only 2.0–2.5% (girls, 2.2–3.1%; boys, 0.9–2.9%) sought formal help. The two exceptions were Norway and Finland, where 6.4% and 6.9% (girls, 10.1% and 11.5%; boys, 2.2% and 2.8%, respectively) sought formal help. Girls were significantly more likely to seek help than boys in most countries, while in no country boys had higher help-seeking behavior than girls.

Table 3shows the proportion of different sources of help used by adolescents who had sought help in each country by gender. In this descriptive analysis, informal sources of help was included, even if the adolescent had also sought a formal source of help. Adolescents reported various sources of help for the ‘someone else’ option, including siblings, significant others, and internet friends. The most common ‘someone else’ source was ‘friends’, while in Israel, there was no data available on ‘someone else’ option. Non-human sources of help such as pets and God were excluded. Among adolescents who sought help, approximately 90% sought informal help in all Asian countries, ranging from 91.7% (India) to 96.1% (China) for girls and 87.7% (India) to 95.8% (China) for boys. In India, Vietnam, and China, more girls sought help from friends than boys, and help from relatives were more common among boys than girls in China and Japan. In India, more boys sought help from teachers than girls. On the other hand, formal help in Asian countries ranged from 3.9% (China) to 21.2,% (Japan) for girls and 7.1% (Vietnam) to 17.5% (Japan) for boys. A significant gender difference was found only in China with more boys seeking help from school nurses and medical doctors than girls. Formal sources of help were used more frequently in European countries, especially Finland, Israel, and Norway. In Greece, 81.4% of girls and 75.6% of boys sought informal help, whereas formal assistance was sought by 20.3% of girls and 31.1% of boys. Adolescents sought help from both informal and formal sources, but more from formal sources of help in Finland (informal, 42.5% for girls and 57.1% of boys; formal, 76.9% of girls and 57.1% of boys), Israel (informal, 52.0% of girls and 66.7% of boys; formal, 68.0% of girls and 44.4% of boys), and Norway (informal, 48.5% of girls and 63.8% of boys; formal, 69.7% of girls and 55.3% of boys). A significant gender difference was found in Finland with more girls seeking help from formal source of help, especially from psychologists and school counsellors, than boys. Moreover, seeking help form school nurses were more common among girls than boys in Norway.

Table 4 shows the proportion of adolescents with a high level of emotional and behavioral problems based on the SDQ total scores above the 90th percentile. A total of 11.1% of adolescents (girls, 13.2%; boys, 9.0%) had a high level of problems, that is, above the 90th percentile SDQ total scores (see Table S3 for the total sample, available online). In middle-income countries (India, Vietnam, China), 1–2% (girls, 1.8–2.3%; boys, 0.0–2.5%) of those with a high level of problems sought formal help in the past six months. In high-income countries, including Greece, Israel, and Japan, 5.5–7.1% (girls, 5.9–9.2%; boys, 2.6–8.9%) of those with a high level of problems sought formal help. In the two Nordic welfare countries, Finland and Norway, formal help-seeking was higher: 25.4% (girls, 32.8%; boys, 9.1%) and 20.6% (girls, 26.4%; boys, 10.3%) respectively of those with a high level of problems. Among boys, formal help-seeking was at the same level as in other high-income countries (9.1% and 10.3%, respectively). Girls had exceptionally high level of formal help-seeking and low unmet need in these two Nordic countries (32.8% and 26.4% respectively). Although help-seeking was more common among girls than boys in general, the significant difference was found only in Finland and Norway.

Figure 1 illustrates the differences in unmet need between countries. The odds of not seeking formal help among those with a high level of emotional and behavioral problems was estimated in the different countries, compared to the reference country with the lowest unmet need (Finland). All countries had increased odds of unmet need, except in Norway for girls. The greatest odds were in China (OR 28.49, 95% CI 6.67 − 121.61). For boys, there was no significant difference between countries and the odds ranged from 0.68 (95% CI 0.25–1.90) in Norway to 3.61 (95% CI 0.74–17.56) in India. There were no OR estimates for boys in China and Vietnam because none of the boys in these countries with a high level of problems had sought any formal help.

Odds ratios and 95% confidence intervals for not seeking formal help among those scoring above 90th percentile total difficulties scores

In the additional analysis (Table S4, available online), the associations of those who reported a high level of emotional and behavioral problems with self-report of perceived difficulties measured by the impact supplement question of SDQ were examined. Among those scoring above the 90th percentile on SDQ total scores, 70.9% (India) to 93.5% (Vietnam) of girls and 65.8% (India) to 89.4% (Vietnam) of boys had at least mild perceived difficulties.