Introduction

Filial piety, the Chinese tradition of Xiao, is a fundamental tenet of Confucian culture (Bedford & Yeh, 2019). This cultural value has a significant impact on East Asian and Southeast Asian populations that are influenced by Confucianism (Hashimoto & Ikels, 2005). It involves essential ideas about how children should treat their parents. Filial piety requires younger generations to honor and obey their elders (Ho, 1994). In return, elderly people provide advice, comfort, and teachings and help others in need (Chow, 1996). In Confucian societies, filial piety is a crucial aspect of adolescents’ socialization and can significantly impact adolescents’ social and psychological development (Chao, 2000; Rao et al., 2003). Despite the potential significance of filial piety for adolescents’ mental health, researchers have yet to systematically review the literature that addresses this importance. This article provides a comprehensive review of the literature on the association between filial piety and mental health among adolescents.

Research on the role of filial piety in modern Confucian societies has generated conflicting findings and debates regarding its impact on individuals (Yeh, 2003). Some studies suggest that filial piety can positively affect personal growth and relationships with others. Filial piety promotes love, unity, and close family ties and can make it easier for generations to get along (Ishii-Kuntz, 1997; Sung, 1990). However, other researchers have found that filial piety can negatively affect individual development, such as harming creativity and cognitive development and fostering a negative attitude (Bedford & Yeh, 2019; Ho, 1994; Jen et al., 2019). These debates highlight the need for a nuanced understanding of the relationship between filial piety and individual development. Simplifying the role of filial piety may not provide a comprehensive understanding of the phenomenon.

To address this issue, Yeh conducted historical and factor analyses that led to the development of the dual filial piety model (Yeh & Bedford, 2003), which distinguishes between reciprocal filial piety and authoritarian filial piety. Reciprocal filial piety is characterized by loving and caring behaviors guided by spontaneous affection resulting from long-term interaction with parents (Yeh, 2003). This is supported by moral guidelines in social domain theory derived from the principle of reciprocity and the emphasis on intimate relationships in Confucianism (Nucci & Turiel, 1978; Yeh, 2003). In contrast, authoritarian filial piety is characterized by obedience and respect for authority guided by adherence to role obligations based on family hierarchy with a focus on the father’s role (Yeh, 2003). This is supported by social conventions (Nucci & Turiel, 1978; Yeh, 2003) and is derived from the nature of Asian Chinese authoritarianism (Chang, 1994). This pioneering work provides a framework for understanding the complex nature of filial piety and its potential impact on individual development in modern Confucian societies (Bedford & Yeh, 2019).

The dual filial piety model has been used in many studies of adolescents. Because filial piety pertains to the relationship between parents and children, studies have explored concepts associated with family dynamics and social functioning (Leung & Shek, 2016; Li et al., 2014; Shek et al., 2022). Research has found that children’s reciprocal filial piety can reduce family conflict, contribute to better family functioning, and improve social relationships and outcomes (Leung & Shek, 2016; Li et al., 2014; Shek et al., 2022). Reciprocal filial piety is positively related to social competence (Leung et al., 2010). Yeh et al. (2010) suggested that reciprocal filial piety and authoritarian filial piety are related to different problem strategies.

Family factors have been identified as transdiagnostic predictors of mental disorders and symptoms among adolescents (Lynch et al., 2021). As a unique cultural family belief, filial piety may also be associated with various mental disorders/symptoms. This study provides a comprehensive review of the relationship between dual filial piety and mental disorders/symptoms among adolescents.

Current Study

Due to the lack of a systematic review, the specific mental disorders/symptoms that may be associated with filial piety and the nature of these associations remain unclear. To address this gap, this study investigated the relationship between dual filial piety and mental disorders or symptoms among adolescents influenced by Confucianism. To achieve this goal, a systematic review of relevant articles on East Asian and Southeast Asian populations was conducted.

Methods

Definition of Keywords

Dual Filial Piety 

Although the term “filial piety” is also used in other regions, such as Poland (Różycka-Tran et al., 2020, 2021), Malay (Tan et al., 2019) and the Arabic region (Khalaila, 2010), in this review, filial piety was defined as attitudes toward parents among people living in East and Southeast Asia, as well as East and Southeast Asians living abroad, derived from Confucian tradition. The dual filial piety model serves as the basis for defining filial piety in this review. Filial piety was consciously divided into two dimensions: reciprocal filial piety and authoritarian filial piety. Studies that did not use this model were categorized according to the dual filial piety model based on whether the description or measurement of filial piety emphasized love and support for parents (categorized as reciprocal filial piety) or sacrifice and oppression toward parents (categorized as authoritarian filial piety) (Yeh, 2003; Yeh & Bedford, 2003). The description of filial piety as a cultural norm is identified as Asian Chinese authoritarianism, also categorized as authoritarian filial piety, as noted by Chang (1994).

Mental Disorders/Symptoms

In reference to Downs et al. (2018), a mental disorder was defined as a psychiatric condition that is clinically diagnosed using standardized classifications for mental or behavioral disorders. Articles that described clinical populations, such as populations with diagnosed eating disorders, were considered to include participants with mental disorders.

Mental symptoms were defined as issues identified through a behavioral screening questionnaire that encompassed emotion, conduct, and peer problems. For example, abnormal scores on Ko’s Mental Health Questionnaire (Ko, 1998) and the Center for Epidemiologic Studies-Depression Scale (CES-D) (Radloff, 1977) are believed to indicate possible psychopathology.

Search Method

This systematic review of filial piety among adolescents was conducted in 2022 and used a finalized protocol (registration number in PROSPERO: CRD42022384536). Academic articles published before December 2022 were searched using 7 databases, namely, PubMed Central (PubMed), ProQuest LLC (ProQuest), Journal Storage (JSTOR), Web of Science, EBSCO Industries (EBSCO), the Chinese Social Sciences Citation Index (CSSCI), and China Journal Net (CJN). Google Scholar and Baidu Scholar were utilized for supplementary searches.

The keywords (filial* OR “filial piety” OR “filial obligation” OR “filial duty” OR “filial responsibility” OR “cultural value” OR “cultural norm*”) AND (adolescen* OR student*) were used to search each database individually. The search terms were informed by relevant literature reviews (Dong & Xu, 2016; Pan et al., 2022; Wu et al., 2018). Considering the cultural context in which filial piety is typically discussed as a fundamental component of cultural values or norms (Tsao & Yeh, 2019), it is advisable to include culture-related search terms. Chinese translations of the above English search terms were used when searching the Chinese databases CSSCI and CJN. Because “mental disorders/symptoms” is a broad concept, no search terms were set for this at the time of the search.

Inclusion and Exclusion Criteria

The population, phenomenon of interest, context, and study design (PICoS) strategy was used to define the eligibility criteria.

Population

The study included East Asian or Southeast Asian adolescents aged 10–24 years or those residing overseas. The age range was chosen to align with adolescent growth and allow extended investments across broader settings (Sawyer et al., 2018). Studies were considered if they provided empirical information on adolescents.

Phenomenon

The phenomenon of interest was the relationship between dual filial piety and mental disorders/symptoms.

Context

The context could be any country or region where filial piety has a significant influence.

Study Design

This review focused solely on academic research and excluded other genres, such as novels and news articles. The review included qualitative and quantitative studies but excluded review articles, scale translations, and theoretical articles. Studies that conceptualized filial piety using the dual filial piety model or studies that could be classified as either reciprocal filial piety or authoritarian filial piety based on the measurement scales or textual content were included in the review. Studies that used the dual filial piety scale (Yeh & Bedford, 2003) but reported reciprocal filial piety and authoritarian filial piety as an indicator were not considered to use the dual filial piety model and were not included in the review.

Data Extraction

Titles and abstracts were screened by two reviewers (Authors 1 and 2) to assess their relevance. Subsequently, the full texts and references were reviewed. The eligibility criteria were applied to select the target studies. The reviewers resolved any differences in appraisal through consensus. For missing data, the authors of the articles were contacted via email or ResearchGate. Endnote software was used to manage the documentation.

Data Synthesis Strategy

A narrative review was conducted for scattered themes using different methods or examining different theoretical concepts, constructs and relationships (Baumeister, 2013) to link studies on different topics for reinterpretation or interconnection to develop or evaluate a new theory (Baumeister & Leary, 1997). Meta-analyses were also conducted for the focused outcome (i.e., depression and anxiety). The data were analyzed using the “meta” and “metafor” packages in R. Pearson’s r was the effect size metric used in this meta-analysis. Fisher’s z-transformation was performed to obtain accurate weights for each study. The WPS Process diagram plugin was used to design the flowchart, while the forest plot was generated using R software.

Results

Search Outcomes

Figure 1 shows the number of articles retrieved from each database and the selection process. A total of 1002 articles were preliminarily identified (PubMed 85, ProQuest 18, EBSCO 410, Web of Science 391, JSTOR 3, CSSCI 29, CJN 60, Baidu Scholar 4, and Google Scholar 2). A total of 17 articles were included, all of which met the inclusion criteria. The studies included participants from mainland China, Hong Kong, Taiwan, Korea, and North America. Twelve quantitative studies and 5 qualitative studies were included. Of the 12 quantitative studies, all except for Zhang and Liu (2012) were conducted using community samples obtained from schools, while all qualitative studies used clinical samples.

Fig. 1
figure 1

PRISMA flowchart depicting the study inclusion/exclusion process

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Quality Appraisal

To evaluate the risk of bias and overall research quality of each study, the Quality Assessment Tool for Observational Cohorts and Cross-Sectional Studies (National Institute of Health, 2022) was used to evaluate quantitative studies. The assessment tool included 14 criteria covering design, selection bias, data collection, and confounders. The Critical Appraisal Skills Program Qualitative Checklist was used to evaluate qualitative studies (Critical Appraisal Skills Programme, 2018), which included 10 criteria, such as study design, data collection, credibility of the research results, and generalizability of the findings. Two researchers assessed each study and provided an overall quality rating of “good”, “fair”, or “poor”. If the ratings differed, the two researchers discussed the article with a third researcher to reach a consensus.

Of the 17 studies included, 16 were rated as “good” or “fair” in terms of quality. One article by Yang and Sun (2022) was excluded from the analysis due to poor quality. Filial piety was conceptualized inconsistently among the 17 studies. Specifically, nine out of 12 quantitative studies utilized the dual filial piety model to measure filial piety and applied filial piety to reciprocal filial piety and authoritarian filial piety. The authors classified the remaining three quantitative studies and five qualitative studies as either reciprocal filial piety or authoritarian filial piety based on the content of the scales and descriptions in the text (please refer to Tables 1 and 2). For detailed information on the quality assessment, please refer to Tables 3 and 4.

Table 1 Summary of quantitative studies
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Table 2 Summary of qualitative studies
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Table 3 Quality assessment table for quantitative research studies
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Table 4 Quality assessment table for qualitative research studies
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Dual Filial Piety and Mental Disorders/Symptoms

Depression

Five studies examined the relationship between filial piety and depression (Cho & Lee, 2019; Juang & Cookston, 2009; Pan & Tang, 2021; Yeh, 2006; Yeh et al., 2010). A meta-analysis of cross-sectional data by Pan and Tang (2021), Yeh (2006), and Yeh et al. (2010) revealed a significant negative correlation between reciprocal filial piety and depression (r= − 0.20, 95% confidence interval [CI] [− 0.37; -0.01], p < .05). The meta-analysis exhibited high heterogeneity, indicating substantial variability in effect sizes across studies (I2 = 89%, p < .01) (details in Table 5). Based on the forest plot, it appears that the study by Pan and Tang (2021) had a larger effect size and a wider confidence interval than the other two studies (Yeh, 2006; Yeh et al., 2010). Upon further examination, it was discovered that all three studies utilized samples of middle and high school students; however, the study by Pan and Tang was conducted in mainland China, while the other two were conducted in Taiwan (Yeh, 2006; Yeh et al., 2010). Reciprocal filial piety was positively associated with depression with a greater correlation coefficient than the other two studies (Yeh, 2006; Yeh et al., 2010).

Table 5 Summary forest plot: meta-analysis of correlations between dual filial piety with depression/anxiety
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A meta-analysis of cross-sectional data by Cho and Lee (2019), Juang and Cookston (2009), Pan and Tang (2021), and Yeh (2006) showed a nonsignificant negative correlation between authoritarian filial piety and depression among adolescents (r =  − 0.0221, CI [− 0.0943; 0.0504], p = .551). The meta-analysis demonstrated low heterogeneity (I2 = 47%, p = .13).

Pan and Tang (2021) and Juang and Cookston (2009) also reported a lagged association between filial piety and depression. Notably, both reciprocal filial piety and authoritarian filial piety are negatively associated with depression, but the strength of this relationship changes over time. Specifically, the 1-year lagged association is strongest and gradually diminishes (Juang & Cookston, 2009; Pan & Tang, 2021).

Anxiety

The association between filial piety and anxiety was discussed in four studies: including Wei et al. (2022), Yeh (2006), Yeh et al. (2010), and Zhou (2020). These studies were subjected to meta-analysis, which revealed a significant negative correlation between reciprocal filial piety and anxiety (r = − 0.11, 95% CI [− 0.15, − 0.08], p < .001). The meta-analysis exhibited low heterogeneity, indicating little variability in effect sizes across studies (I2 = 0%, p = .96) (details in Table 5). These findings suggest that there is a stable and significant negative correlation between reciprocal filial piety and anxiety. A nonsignificant positive correlation between authoritarian filial piety and anxiety was observed (r = 0.07, 95% CI [− 0.07, 0.20], p = .33). The meta-analysis demonstrated high heterogeneity (I2 = 90%, p < .01) (details in Table 5), suggesting substantial variability in effect sizes across the three studies. The forest plot was analyzed, revealing that the study by Wei et al. (2022) showed more significant differences than the other two studies. Authoritarian filial piety and anxiety were significantly positively correlated in Wei et al. (2022), while a significant correlation was not found by Yeh (2006) or Zhou (2020). Upon comparison, it was found that Zhou (2020) and Wei et al. (2022) samples were from mainland China, while Yeh (2006) sample was from Taiwan. However, both Zhou (2020) and Yeh (2006) samples consisted of middle school students, while Wei et al. (2022) Sample consisted of university students.

Aggression/Deviant Behaviors

Two studies investigated the relationship between filial piety and externalizing behaviors, such as aggression and deviant behaviors (Yeh, 2006; Yeh et al., 2010). Reciprocal filial piety was negatively associated with aggression and deviant behaviors (Yeh, 2006; Yeh et al., 2010). In contrast, authoritarian filial piety was unrelated to either behavior (Yeh, 2006).

Internet Addiction

A negative correlation was found between reciprocal filial piety and internet addiction. However, the relationship between authoritarian filial piety and internet addiction was found to be negative in Wei et al. (2019b) and positive in Wei et al. (2019a), 2020), although the authors acknowledged a high level of overlap between the datasets (Wei, 2023).

Self-Harm

Zhou (2020) investigated the relationship between dual filial piety and self-harm and found that reciprocal filial piety was negatively correlated with self-harm, while authoritarian filial piety showed no significant correlation. There appears to be a link between reciprocal filial piety and a lower likelihood of adolescents engaging in self-harm.

Suicide

Zhang and Liu (2012) conducted a case‒control study to investigate the differences in filial piety between a suicidal group and a control group of rural Chinese adolescents and youths. The measurement of filial piety included only four items, and participants were inclined toward authoritarian filial piety. According to Zhang and Liu (2012), the two groups exhibit significant differences in authoritarian filial piety, suggesting that young people who strongly adhere to authoritarian filial piety are less likely to experience suicidal thoughts or behaviors.

Eating Disorders

Five qualitative studies explored the relationship between filial piety and eating disorders (Chan & Ma, 2004; De Montgrémier et al., 2015; Montgrémier et al., 2022; Ma and Chan, 2004; Ma, 2007). In descriptive terms, reciprocal filial piety provides greater motivation for recovery among patients with eating disorders (Ma and Chan, 2004; Ma, 2007), while authoritarian filial piety is associated with more significant family distress and does not contribute to recovery (Chan & Ma, 2004; Ma, 2007). De Montgrémier et al. (2015, 2022) discussed the challenges faced by patients with eating disorders in relation to their parents’ expectations and their own desire for independence. The authors suggested that this disorder may be a way for children to express anger and discomfort. Additionally, the authors highlighted the difficulties that arise from parents’ sense of children’s obligation to prioritize family time, which can make it challenging for parents to comprehend the disorder (De Montgrémier et al., 2022).

Summary

Table 6 shows the associations between dual filial piety and various mental disorders/symptoms.

Table 6 Summary of the relationships between filial piety and mental disorders/symptoms
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Discussion

Research has helped to build a link between filial piety and mental health in adolescents. However, a systematic review is still needed to explore what mental disorders or symptoms would be associated with filial piety, as well as the specific direction and strength of this association in this population. This study aimed to explore the relationship between filial piety and mental disorders and symptoms by analyzing 17 articles, including 12 quantitative and 5 qualitative studies, that examined the association between filial piety and various mental disorders/symptoms, such as depression, anxiety, aggression/deviant behavior, internet addiction, suicide, self-harm, and eating disorders. The participants were from mainland China, Hong Kong, Taiwan, Korea, and the U.S. and included Chinese and Korean individuals.

Previous investigations have demonstrated variation in filial piety among individuals from different geographical regions and age cohorts. For example, a comparative study of filial piety in contemporary Chinese societies revealed that filial piety values differed in Taiwan, Hong Kong, and mainland China (Chen et al., 2020; Yeh et al., 2013). Tsao and Yeh (2019) argued that examining differences in the levels of filial piety across individuals or cultures is insufficient; instead, it is essential to consider the varying impact of filial piety on individuals. The review focused on the relationship between filial piety and mental disorders/symptoms and found that the heterogeneity in the relationship between filial piety and mental disorders/symptoms may be attributed to differences in the age and geographic location of the sample. Specifically, mainland Chinese adolescents had a greater association between reciprocal filial piety and depression than Taiwanese individuals. Yeh et al. (2013) argued that even within the same cultural background, there may be significant differences in values of filial piety and their impact on individuals across different countries and regions, such as mainland China and Taiwan/Hong Kong, due to differences in modernization and political systems. This observation may also contribute to the varying impact of filial piety across different societies. Additionally, the association between authoritarian filial piety and anxiety was significantly negatively correlated among university students compared to high school students. Research has suggested that individuals may be more likely to consider their social and familial responsibilities during the university stage (Wood et al., 2018). An emphasis on the obligation of authoritarian filial piety may also lead to more pressure and stress among college students. However, further research is needed to fully understand the complex interplay between filial piety, cultural values, and specific mental disorders/symptoms in different populations and contexts.

It is widely recognized that there is a strong relationship between symptoms and the environment. Although different symptoms may have different etiologies (Uher & Zwicker, 2017), family factors are transdiagnostic predictors of general and specific psychopathologies in young people (Lynch et al., 2021). This explains why reciprocal filial piety, described as a kind of family relationship in Confucian culture, may play a role in different symptoms among adolescents. Studies provide different explanations of regarding this relationship: reciprocal filial piety is associated with better family relationships (Yeh, 2006; Yeh et al., 2010), social support and social interactions (Wei et al., 2022; Zhou, 2020), and cognitive autonomy (Pan & Tang, 2021), which can help adolescents cultivate positive emotions and a healthy mindset and reduce negative emotions and stress (Zhou, 2020).

Regarding the link between authoritarian filial piety and mental disorders, meta-analyses have shown that authoritarian filial piety is not associated with depression or anxiety. The relationship is unstable in internet addiction despite showing a very small effect size (Wei et al., 2019a, b, 2020). Zhang and Liu (2012) proposed that authoritarian filial piety may play a role in reducing the risk of suicide by promoting an obligation to care for parents and enhancing social support and a sense of belonging. According to the descriptions of individuals with eating disorders, authoritarian filial piety produces more significant pressure and conflict between family expectations and personal achievement, increasing the complexity of recovery. Yeh (2003) provides a possible explanation for this relationship and heterogeneity, suggesting that authoritarian filial piety can have both functional and harmful aspects. Authoritarian filial piety can be used as a social strategy or as a means of social control and is used by Chinese individuals to maintain psychological homeostasis (Hwang, 1999). However, authoritarian filial piety may also suppress the development of individual will, which can negatively affect mental health (Yeh, 2003). Therefore, it is essential to understand the context and the groups for which authoritarian filial piety may have functional or harmful effects.

Several limitations should be acknowledged and addressed in future research. First, this review is limited by the search terms, databases included, and the temporal window during which the searches for articles were conducted, which is a common limitation in all systematic reviews. Second, the available evidence on the relationship between dual filial piety and mental disorders is primarily based on cross-sectional and longitudinal investigations, which can identify only correlation and temporal associations but not causation. However, it is still important to present the evidence to comprehensively understand the study’s findings and their implications.

Conclusion

Despite the potential link between filial piety and adolescents’ mental disorders and symptoms, there has been a notable absence of systematic reviews examining this relationship. The current study addresses this gap by systematically reviewing the relationship between dual filial piety and mental disorders/symptoms among adolescents. Based on the existing evidence, reciprocal filial piety appears to be negatively associated with various mental disorders/symptoms, including depression, anxiety, aggression, deviant behaviors, internet addiction, self-harm and eating disorders. In contrast, authoritarian filial piety is not associated with mental disorders/symptoms but rather with specific outcomes such as suicide and eating disorders. The findings suggest that filial piety is significantly related to various mental disorders and symptoms, and that different types of filial piety may have unique associations with mental health.