Mental health among children of immigrant parents

A large-scale study that enrolled more than 2000 11-year-old immigrant and ethnic Dutch children was conducted in Holland (5), a country with approximately the same percentage of immigrants as Denmark. The study included measures of mental health from multiple sources, such as the Youth Self-Report and the Child Behavior Checklist (6;7). The authors found discrepancies in reported difficulties between the two groups. The young respondents themselves did not report any differences in difficulty levels, whereas immigrant parents reported that their daughters had more mental-health–related internalizing problems than the daughters reported themselves. Furthermore, teachers reported higher levels of externalizing problems in both boys and girls among the immigrant groups than among the ethnic Dutch children. This latter finding is corroborated by another study that found Turkish immigrant adolescents to have a significantly higher total rate of problems than Dutch adolescents (8).

Similar tendencies have been observed among youth samples from other countries. In a Turkish study that compared migrant children (having temporary residence in Turkey) with non-migrant children, Diler and colleagues (9) found that the migrant children had significantly lower self-esteem and higher levels of depression and anxiety. By contrast, externalizing behavior was not significantly elevated in the migrant group. In a review of mental health among migrant children, Stevens and Vollebergh (10) stated in their review that it was difficult to draw any sound conclusions with respect to these children’s risk of mental health problems. Many confounding factors that may affect the risk of children’s mental health are mentioned in these studies, including the family’s socioeconomic status and the parents’ employment status and educational level. In addition, family stress often resulted from the fact that immigrant adolescents generally acculturate to the values of the new society faster than their parents do.

Subjective health among children of immigrant parents

How children inform others about their well-being is often expressed in complaints about their subjective health. In a large study of adolescents living in five Nordic countries, subjective health complaints, which may be conceived as a proxy for psychological and physical well-being, were applied to assess the young persons’ subjective health (11). The study showed that adolescents with foreign backgrounds reported significantly higher levels of subjective health complaints (e.g., headache, back pain, stomach pain, loss of appetite, lower feeling of well-being) as compared with children from the majority of the population. Several similar studies have also been conducted in Denmark. A recent study found immigrant children to suffer from more health-related problems as compared with ethnic Danish children (12). This study included 7,056 students (age groups: 11 years, 37%; 13 years, 34%; 15 years, 29%) and addressed both physical and mental-health–related problems, which were referred to in the article as “nervous symptoms.” The youth were divided into three groups: immigrant (4%), descendants (7%), and ethnic Danes (89%). The outcomes demonstrated no significant differences in self-reported somatic health complaints among the three groups with regard to headache, stomachache, or backache. However, 32% of the immigrant girls and 28% of the immigrant boys reported experiencing nervous symptoms; these were a significantly higher prevalence than those found among the ethnic Danish girls and boys at 23% and 18%, respectively. These findings were supported by a Swedish study that reported higher levels of subjective health-related complaints among girls with foreign backgrounds, who from the seventh grade onward showed an increased risk for subjective health complaints as compared with girls with Swedish backgrounds (13).

Mental health among children of refugees

Children of refugee parents may be perceived as immigrants, and they are often included in the groups of immigrants in studies such as those described previously. However, it is highly possible that parents who are refugees may differ from parents who have immigrated as a result of their own choice with regard to mental-health–related problems (e.g., post-traumatic stress, lack of social network) and other important parameters that affect the upbringing of a child. Therefore, it is important to distinguish between the impact of being a member of an ethnic minority and that of having a refugee background on mental health; studies have been undertaken to address this distinction. According to a review conducted by Reed and colleagues regarding the mental health of displaced and refugee children, protective effects include confounding factors such as stable family life, education, and support received during the process of integration into local communities (14).

Although the literature is limited, the existing findings indicate that being a refugee or being the child of a refugee parent may increase an individual’s risk of experiencing mental health problems (15). Leavey and colleagues examined psychological disorders among refugee and migrant children in London with the use of the Strengths and Difficulties Questionnaire (SDQ) as a self-report measure and found that both migrant and refugee children expressed greater psychological distress on a number of the questionnaire’s subscales (16). A British study of the mental health of refugee children included a classmate control group that consisted of both ethnic minority and indigenous white children (17). The study applied a teacher-rated SDQ. Teachers rated refugee children as having higher levels of emotional difficulties than both of the control group populations.

Gender differences with regard to reported mental health among refugee children

In a review of 44 studies of refugee youth by Fazel and colleagues, boys were reported to experience higher levels of post-traumatic stress disorder symptoms as compared with girls (3). In half of the studies that enrolled both accompanied and unaccompanied refugee children, the prevalence of depression and internalizing difficulties was higher among girls than boys. However, the remaining studies showed no gender-related effects. The overall conclusion presented by the review was that results involving gender differences in relation to mental health were inconsistent. Other studies also found depression and internalizing difficulties to be higher among girls than boys (14). Overall, the differences between genders follow the patterns found in the general population: emotional disorders are more prevalent among females than males and males are more susceptible to externalizing disorders than females (18). One explanation for the lack of firm conclusions within this topic may also be found in the heterogeneity of study samples and the applied measurements of mental health issues.

Purpose of the study

Motivated by the lack of clarity in the literature with regard to the effect of immigration or having a refugee background on mental health in the youth population, we examined mental health problems in three groups of youth between the ages of 8 and 18 years. We looked at three groups: 1) an ethnic Danish group; 2) a group of children with a background as second- or third-generation immigrants; and 3) a group of children whose parents were refugees. On the basis of previous findings, we hypothesized that immigrant children and refugee children would have more somatic and psychological difficulties (both internalizing and externalizing) than children of Danish origin. Furthermore, we expected refugee children to be more burdened by internalizing mental problems than immigrant children were.

Sample

The total sample consisted of 332 children between 8 and 18 years old. Data were collected from different sources. The first source was the OASIS Treatment and Counselling for Refugees, Copenhagen, Denmark. OASIS contacted 51 refugee families with permanent residence in Denmark who had been referred for trauma treatment at the center. The contact was established by mailing permission forms to the families in their native language. The families were selected on the basis of their geographic placement (i.e., living within a radius of approximately 50 km from Copenhagen) and on whether they had children between the ages of 11 and 16 years. The parents were asked to give written consent that allowed their children to fill out a few questionnaires in the classrooms at their schools. Parents of 15 children allowed their children to participate. We included these children’s classmates in the sample group that included immigrant, Danish, and other refugee children. The next step was to contact the children’s respective schools and obtain permission to perform the data collection in their classrooms. In addition to the 15 children previously described, we included another group of refugee children from identified refugee countries in accordance with a formal list obtained from the Danish Foreign Ministry. Finally, we compiled data from children who attended the “homework cafés” run by the Red Cross in Denmark, which are exclusively frequented by immigrant and refugee children. These children received consent forms to be filled out by their parents. The data collection was carried out in Danish. In the classrooms, a teacher was present; in the homework cafés, the supervising teacher was present together with the researchers. The research project was described to the children, and they were free to ask questions about the questionnaires. The questionnaires were read aloud to the children to secure their understanding. Children who had difficulty understanding the text could ask the researchers for assistance.

Outcome measures

Strengths and Difficulties Questionnaire (19;20):

The youth self-report version of the SDQ was applied in the present study. This questionnaire has been found to have sound psychometric properties in both Westernized and non-Westernized countries (21-24). It consists of 25 items that can be scored as “Not true,” “Somewhat true,” and “Certainly true.” The items are scored on five scales: 1) hyperactivity/inattention; 2) conduct disorder; 3) emotional problems; 4) peer problems; and 5) prosocial. Each of these scales contains five items; the hyperactivity/inattention and conduct disorder scales are combined into an externalizing scale, and the emotional and peer problems scales are combined into an internalizing scale (25). The children filled out the two-page version of the SDQ, but it turned out that they had difficulty reporting the impact of their symptoms (e.g., making conclusions about a generalized impact from the types and numbers of symptoms present). Therefore only the answers from the first page of the questionnaire have been analyzed.

Revised Children’s Anxiety and Depression Scale (26):

The Revised Children’s Anxiety and Depression Scale (RCADS) consists of 47 items and measures (DSM-IV) symptoms of anxiety disorders and depression in children and adolescents. It is scored on a four-point scale (i.e., 0 = Never, 1 = Sometimes, 2 = Often, 3 = Always). It has satisfactory psychometric properties, with good internal consistency and adequate reliability and validity, and it has been tested in a Danish population (27). In the present study, the self-report child version of the RCADS was applied.

Health Behavior in School-Aged Children Symptom Checklist (28-30):

The Health Behavior in School-Aged Children Symptom Checklist is an eight-item symptom checklist that assesses how often the young person has suffered from different physical and nervous symptoms within the past 6 months. Good psychometric properties have been found for both one- and two-factor solutions. The one-dimensional scoring adds up to a total health complaint score that excludes sleep problems (28). The two-factor solution also includes a three-item psychological health complaint scale as well as a five-item somatic health complaint scale (30). Both of these models have been included as outcome measures in the present study.

Statistical analyses

All analyses were carried out with the use of SPSS Statistics software (version 20.0). The total sample consisted of 332 children. On the basis of information about their parents’ migrant status, the children were classified into three broad groups. The Danish sample included children with two Danish parents (N = 148); the immigrant sample consisted of children with two immigrant parents (N = 81), whereas the refugee sample was comprised of children with two refugee parents (N = 67). Half of the immigrant group was made up of children with two Turkish parents (N = 41), with other large ethnic groups including Pakistani children (N = 13) and Filipino children (N = 7). Children of immigrants from Western countries (N = 7) and children of parents with different statuses (e.g., one immigrant parent and one refugee parent, one immigrant parent and one Danish parent) were excluded from all analyses (N = 24). Five children with missing values for their countries of origin were also excluded from the analyses.

With regard to the refugee children, the largest ethnic groups consisted of Iraqi children (N = 19), Afghan children (N = 11), and children from Palestine (N = 7). The remaining groups were composed of less than five children from each nationality.

Because the distribution of SDQ scores has been found to be skewed (25), the internalizing and externalizing scale scores were log transformed before they were used as continuous variables in the analysis of variance probability testing. The four problem scales (i.e., hyperactivity/inattention, conduct disorder, emotional problems, and peer problems) were used in logistic regressions, with appropriate cutoffs used to identify the 20% of the sample with the highest problem scores.

Demographic data

A total of 296 children and adolescents were included in the study. They had a mean age of 13.2 years (range, 8 to 16 years), and 158 (53.3%) were boys. With regard to language use, 54.2% of the children reported speaking Danish only at home, whereas 19.4% reported that no Danish was spoken at home. Overall, significant age differences were observed among the three groups (Table 1); however, Bonferroni post hoc testing revealed that none of the intergroup comparisons were significant. No significant differences were observed among the groups with regard to gender, but, expectedly, large differences were observed with regard to language use among the groups. The refugee group had the highest frequency of speaking non-Danish languages only (48.5%).

No significant differences were observed for any of the health complaint scale scores among the three groups (Table 2). However, borderline significance was observed for the somatic health complaint scale. However, this observation was the opposite of what was expected (i.e., fewer somatic health complaints were reported by the refugee group, whereas it was believed that this group would have more such complaints).

As shown in Table 3, no significant differences were observed for the continuous SDQ externalizing and internalizing scale scores.

Furthermore, Table 4 shows that no significant differences were observed for the above and below cutoffs for the SDQ emotional and hyperactivity scales.

Alternatively, significant differences were observed for the SDQ conduct disorder and peer problems scales, with the most favorable outcomes seen among the Danish children. Post hoc testing revealed significant differences with regard to the conduct scale scores of the Danish children and the immigrant children (P = .004) and the Danish children and the refugee children (P = .026). Significant differences were also found for the peer problem scores between the Danish children and the refugee children (P = .013).

Overall, significant differences among the three groups were observed for the separation anxiety disorder scale and the obsessive-compulsive disorder (OCD) scale of the RCADS (Table 5).

The most favorable outcomes were observed among the Danish children, and the least favorable outcomes were seen among the refugee children. Bonferroni post hoc testing revealed significant differences between the Danish and refugee groups with regard to their OCD scale scores (P = .007) and their separation anxiety disorder scale scores (P = .017).

Subjective health complaints among immigrant and refugee children

Our first hypothesis was that immigrant and refugee children would experience more somatic and psychological complaints than children of Danish origin. We tested this hypothesis with the use of the Health Behavior in School-Aged Children Symptom Checklist to assess somatic, psychological, and overall complaints. Much to our surprise, we found fewer differences than expected. In fact, we found no statistically significant differences among the groups. This finding is partly supported by the work of Nordahl Jensen and Holstein (12), who reported no differences between immigrants and ethnic Danish youth on the somatic complaints subscales or the total scale. They did, however, report that immigrant boys and girls in general experienced a higher degree of nervous symptoms as compared with ethnic Danish youth. One explanation for the lack of differences among the groups in our study may be found in the use of a self-report. It is plausible that, had we applied a multi-informant approach, our results would have been different. Another reason for these small differences may be the limited size of the sample, or it may be found in the applied measure. The Health Behavior in School-Aged Children Symptom Checklist consists of only eight items. Despite the fact that this tool demonstrated adequate psychometric qualities, it may not pick up on mental-health–related complaints to the same degree that a more specialized assessment tool would.

Mental health complaints among immigrant and refugee children

To further explore our hypothesis, we assessed the mental health of our sample by applying the SDQ. By applying this more refined measure to assess psychological difficulties, we found significant differences among immigrant children, refugee children, and Danish children. The immigrant children reported higher levels of conduct problems and the refugee group had higher levels of both conduct and peer problems as compared with Danish children. The significant conduct problems among the immigrant and refugee children may be reinforced by the fact that both immigrant and refugee families prefer to use their native languages at home, which gives rise to a lack of mastery of the Danish language. Among the immigrant children, 29.6% used no Danish at home; among the refugee families, 48.5% used no Danish at home. The lack of Danish language skills in these groups may cause misunderstandings and perhaps conflicts when these children are in contact with others (e.g., peers, teachers), thereby contributing to their elevated levels of conduct symptoms. In a study performed in London, Leavey and colleagues (16) already reported that not having English as a first language appears to be a significant risk factor for psychological stress for both refugee and migrant children.

We further explored differences in mental health status as measured by the SDQ scores. For all three groups, we found a minimum of 30% of youth scoring above the clinical cutoff. Although 27% of refugee children had previously been shown to meet case criteria (17), our numbers were surprisingly high for all three groups. This may in part be due to the samples being recruited from low-income areas of residence; such areas have previously been associated with higher levels of mental health problems among youth (31). However, the SDQ is not based on the DSM-IV and therefore does not tap directly into anxiety and depression symptoms at a pathological level.

We then assessed internalizing mental health issues with the use of self-report measures that were based on the DSM-IV criteria via the use of the RCADS. Significant differences were observed in the refugee group with regard to separation anxiety disorder and OCD. Despite the face value of the symptom level indicating that refugee children experienced more anxiety than immigrant children, who in turn experienced more anxiety than Danish children, no significant differences emerged between the immigrant children and Danish children. The finding that refugee children experienced higher levels of anxiety supports the previous literature, which reported higher levels of emotional difficulties (32). A study by Montgomery and Foldspang (33) suggested that exposure to discrimination in Denmark is associated with internalizing behavior among refugee adolescents.

To the best of our knowledge, no other studies have assessed OCD symptoms in refugee children. However, studies of OCD symptoms in different ethnic groups may inform our understanding of the findings. For example, Williams and colleagues (34) reported that non-clinical black and Hispanic groups reported contamination symptoms at the same mean level as whites with clinical levels of OCD. It is thus likely that culture and ethnicity may play a role in the expression of OCD and related disorders; however, at present, little is known about these mechanisms (35). In the present study, the high level of OCD in the immigrant group - and, in particular, in the group of refugee children - may also be caused by ethnicity or unknown factors rather than a product of a true difference in anxiety level. Therefore, further studies are required to address this question.

Overall, our study has confirmed that children of refugee parents, as a group, have specific vulnerabilities when it comes to mental health issues. This is particularly striking because the majority of the refugee group in this study may be considered quite resourceful: these children actively sought assistance at homework cafés and were willing to participate in the study. However, the vulnerabilities may be caused by the fact that part of the sample of refugee children was recruited from a treatment center for traumatized refugees and therefore may have parents with mental health problems. It is not possible from the result of this study to reveal aggravating or improving factors that may affect the family conditions of these children, because the refugee children were not examined in relation to whether their parents were or were not traumatized. This issue was discussed in an article by Daud and colleagues (36) that addressed resilience and vulnerability among refugee children of traumatized and non-traumatized parents. In that study, children without traumatized parents had more favorable values on the SDQ and other tests as compared with the group of children whose parents had been traumatized. The fact that children of refugees presented with more mental problems than the immigrant and Danish groups should encourage educational staff to be more aware of the backgrounds of ethnic minority children.

Limitations of the study

The largest limitation of this study is that our sample was a convenience sample. It was difficult to establish contact with the refugee group, which resulted in a very low response rate: only 15 parents (out of 51 invitations to participate) agreed to their children’s participation. These parents were rewarded by means of a modest gift token (i.e., 20 Euros). The children from this part of the refugee sample (i.e., those recruited from OASIS) comprised what was likely the most burdened group, with parents who may still suffer from trauma. To expand the group, we included children of refugees who attended homework cafés and who were not in contact with the OASIS treatment centre, thereby adding a group of refugee children with unknown backgrounds.

The information in this study is based on the students’ self-reported data. This gives rise to the question of whether these children were able to provide reliable data, particularly with regard to their background data. In a study undertaken by Nordahl and colleagues (37), the percentage of student–parent agreement about the language usually spoken at home was high. The proxy measure for ethnic background should therefore be considered robust. With regard to the self-reported data about possible psychological problems, we did not include the parents in the study, which is a limitation regarding the ability to obtain more detailed multi-informant data. However, even if a screening instrument such as the SDQ had been translated into many languages, there is scarce evidence to support its validity among cross-cultural populations. In addition, the refugee parents were very hard to enroll in the study. Other studies, such as the one by Daud and colleagues (36), have found that refugee parents felt the interview situation to be stressful. Including only a few parents would have compromised the generalizability of the study, which is why we opted for the use of self-report data. We may have found more significant differences if we had used a group of ethnic Danish children from more advantaged backgrounds. Alternatively, our less advantaged sample should be considered a strength of the design, because it provides a community control sample that compares peers of different ethnicities who, in some respects, share the same living conditions. Other studies have shown that agreement among informants is low for children, parents, and teachers with regard to internalizing difficulties (38). This suggests that it is important to explore youth self-reports of subjective experience in further detail at it relates to internalizing symptoms.

Only a few children were less than 11 years old. The SDQ self-report is validated for children 11 years old and older; RCADS has been validated for the entire span of ages included in the study. To compensate for the possible influence of reading difficulty as it related to the understanding of the questionnaires, the questions were read aloud to the children during test administration, and administrators were circulating in the classrooms to allow the children to ask questions if they were in doubt.