Psychosocial problems among immigrant and non-immigrant children--ethnicity plays a role in their occurrence and identification

Migrant adolescents' experience of depression as they, their parents, and their health-care professionals describe it: a systematic review and qualitative meta-synthesis

Migrant youth are vulnerable and face a risk of internalised disorders such as depression. This qualitative meta-synthesis explores migrant adolescents' experience of depression. 14 studies (7 qualitative studies and 7 case reports) were selected after a systematic search of PubMed, Embase, Scopus and PsycInfo. Their quality was assessed with the Critical Appraisal Tool (CASP) for qualitative studies and the Joanna Briggs Institute (JBI) checklist for case reports. The analysis identified six themes describing the experience of depression among migrant adolescents: (1) the vulnerability factors underlying depressive distress, before, during and after migration; (2) the subjective experience of depression, combining symptoms associated with a form of depression common in the West with symptoms more common in other cultures; (3) two types of aetiological hypotheses to make sense of their distress; (4) attitudes adopted in response to distress; (5) experience of care, especially reasons discouraging investment in care; and (6) impairment of identity construction by breaks in cultural transmission and intergenerational conflicts. The threat of losing their connections both at the interpersonal (connection to family, peers and community) and intrapsychic levels (construction of identity) is inherently linked to migrant adolescents' experience of depression. We propose to adapt Brandenberger's 3C model (communication, continuity of care, and confidence) for the care of young migrants to promote a therapeutic alliance, foster construction of a coherent bicultural identity, and support the family.

Individual and cumulative risk factors in developmental language disorder: A case-control study

Many mental disorders (MD) share common etiology, fuelling debates about the specificity of clinical categories and whether the presence of specific risk factors (RF) can distinguish among them. The study of developmental language disorder (DLD), more specifically, has been further hindered by a lack of consensus regarding its definition. These limitations increase the risk of under-detection and lifelong consequences for affected children. This paper aims (1) to document which individual RF allow differentiating DLD from other MD and (2) to compare the cumulative RF between children with DLD versus other MD. This case-control design study used medical records of a psychiatric sample of 795 preschoolers (mean age 4:11, 75% boys). A logistic regression measured the predictive value of potential RF on DLD. Later first sentences, maternal immigration and family history of language delay were identified as significant in explaining 30% of the variance for DLD diagnosis. An ANCOVA revealed that children with DLD were exposed to a significantly higher number of RF than were children with other MD. Public health policies informed with the knowledge of specific RF associated with DLD, and their cumulative impact, could improve early detection and reduce the cascade of negative consequences associated with DLD.

The Strengths and Difficulties Questionnaire Parent Form: Dutch norms and validity

Objective

This study provides Dutch national norms for the parent-reported Strengths and Difficulties Questionnaire (SDQ) for children aged 3-14 years, and assesses the test performance of the SDQ Total Difficulties Scale (TDS) and impairment Scale. We further compared Dutch SDQ norms with those of the United Kingdom (UK), to determine potential variation in country-specific norms.

Study design

We analyzed data of 3384 children aged 3 to 14 years. The data were obtained in schools, and in the context of Preventive Child Healthcare. Parents completed the SDQ parent form and the Child Behavior Checklist (CBCL). We determined clinical (10% elevated scores) and borderline (20% elevated scores) SDQ TDS norms. We assessed the test performance (validity) of the SDQ TDS and Impairment Score using the CBCL as criterion.

Results

The clinical SDQ TDS norms varied between > 10 and > 14 depending on the age group. The SDQ TDS discriminated between children with and without problems, as measured by the CBCL, for all age groups (AUCs varied from 0.92 to 0.96). The SDQ Impairment Score had added value (beyond the SDQ TDS) only for the age group 12-14 years. For the Netherlands we found lower clinical SDQ TDS norms than those previously reported for the UK (i.e. > 16).

Conclusion

The clinical SDQ TDS norms varied between > 10 and > 14 depending on the age groups. We found good test performance at these proposed norms. Dutch norms differed somewhat from UK norms. In the Netherlands, the SDQ performed better with Dutch-specific norms than with UK-specific norms.

Emotional School Engagement and Psychiatric Symptoms among 6-9-Year-old Children with an Immigrant Background in the First Years of School in Finland

The aim of this study is to examine emotional school engagement and psychiatric symptoms among 6-9-year-old children with an immigrant background (n = 148) in their first years of school compared to children with a Finnish native background (n = 2430). The analyzed data consisted of emotional school engagement measures completed by children and Strengths and Difficulties Questionnaires completed by both parents and teachers. Children with an immigrant background had lower self-reported emotional school engagement than children with a native background with reference to less courage to talk about their thoughts in the class and more often felt loneliness. Further, they reported that they had more often been bullies and seen bullying in the class. Children with an immigrant background had more emotional symptoms and peer problems reported by parents than children with a native background. However, teachers did not report any significant differences.

Assessment of transcultural psychotherapy to treat resistant major depressive disorder in children and adolescents from migrant families: Protocol for a randomized controlled trial using mixed method and Bayesian approaches

OBJECTIVES

Cultural variations complicate psychiatric care, especially for migrant children. Transcultural psychotherapy (TCP) is an original psychotherapeutic technique developed to address complex situations of resistant mental disorders in the context of migration. This research will aim to assess the efficacy, the acceptability, and describe the therapeutic processes of TCP for the treatment of depression in first or second generation of migration children and adolescents.

METHOD

Mixed method study using a multicenter, Bayesian randomized clinical trial with blinded evaluation of the primary outcome. Two parallel groups of 40 children or adolescents from 6 to 20 years old and their family will be included. In the experimental group, patients will attend six sessions of transcultural therapy in addition to usual care.

RESULTS

The improved Clinical Global Impression scale scores at 6 months will be compared across groups. Qualitative analysis of families and therapists' interviews will allow to specify the therapeutic processes and acceptability of the therapy.

CONCLUSION

The findings will encourage the development and routinization of TCP for second-line use and its adaption as a first-line technique in this population.

The mental health of immigrant mother's offspring in Taiwan: A national epidemiological study

BACKGROUND/PURPOSE

With globalization, transnational marriages become more and more common in the world. The mental health of the offspring of immigrants is a significant public health issue. The present study aimed to investigate whether children of immigrant mothers demonstrate more emotional and behavioral problems than those of native mothers in Taiwan.

METHODS

In a sample of 6242 children in grade 3, grade 5, and grade 7 from a national epidemiological study of child mental disorders, 617 (9.9%) children were born by immigrant mothers (Chinese, Vietnam, Indonesia, and other countries) and 5625 children by Taiwanese parents. The children reported on Achenbach Youth Self-report, and their parents reported about them on the Child Behavior Checklist, Parental Bonding Inventory, and Family APGAR for assessing emotional and behavioral problems, mother's parenting style, and perceived family support.

RESULTS

Compared with children of native mothers, children of immigrant mothers reported themselves and were reported by their parents to have more externalizing and internalizing problems. However, after considering the effects of sociodemographics, parenting style, and family function, only significant differences in externalizing problems between children with native or immigrant mothers were found.

CONCLUSION

Our findings indicate that right parenting style and family support; may offset emotional and behavioral problems in children of immigrant mothers, and suggest that improving maternal parenting and family function is beneficial to child development, regardless of immigrant or native mothers.

Factors associated with the identification of child mental health problems in primary care-a systematic review

Background: Although common and often with long-lasting effects, child mental health problems (MHPs) are still under-recognized and under-treated. A better understanding of the factors associated with the identification of MHPs in primary care may improve the recognition of MHPs.

Objectives: To review studies on factors associated with the identification of child MHPs in primary care.

Methods: Six leading databases were systematically searched until 1 October 2018. Two independent researchers selected articles and extracted data on study characteristics and factors associated with MHP identification. Inclusion criteria were the investigation of factors associated with MHP identification by primary care professionals (PCPs) in children aged 0–18 years.

Results: Of the 6215 articles identified, 26 were included. Prevalence rates of PCP-identified MHPs varied between 7 and 30%. PCPs identified 26–60% of children with an increased risk of MHPs as indicated by MHP assessment tools, but associated factors were investigated in relatively few studies. MHPs were more often identified in children with a family composition other than married parents, with worse mental health symptoms, prior MHPs, among boys in elementary school, when contact with PCPs was related to parental psychosocial concerns or routine health check-ups, when PCPs were recently trained in MHPs or when PCPs felt less burdened treating MHPs.

Conclusion: MHP identification varied substantially between studies and PCPs and was related to several child, family and practice factors. Future studies should systematically investigate factors associated with MHP identification by PCPs and specifically in children with an increased risk of MHPs according to mental health assessment tools.

Mental Health Diagnostic Considerations in Racial/Ethnic Minority Youth

Misdiagnoses of racial/ethnic minority youth's mental health problems can potentially contribute to inappropriate mental health care. Therefore, we conducted a systematic review that focuses on current theory and empirical research in an attempt to answer the following two questions: 1) What evidence exists that supports or contradicts the idea that racial/ethnic minority youth's mental health problems are misdiagnosed? 2) What are the sources of misdiagnoses? Articles were reviewed from 1967 to 2014 using PsychINFO, PubMed, and GoogleScholar. Search terms included "race", "ethnicity", "minority", "culture", "children", "youth", "adolescents", "mental health", "psychopathology", "diagnosis", "misdiagnosis", "miscategorization", "underdiagnosis", and "overdiagnosis". Seventy-two articles and book chapters met criteria and were included in this review. Overall, evidence was found that supports the possibility of misdiagnosis of ethnic minority youth's emotional and behavioral problems. However, the evidence is limited such that it cannot be determined whether racial/ethnic differences are due to differences in psychopathology, mental health biases, and/or inaccurate diagnoses. Cultural and contextual factors that may influence misdiagnosis as well as recommendations for research and practice are discussed.

The Effectiveness of the BITSEA as a Tool to Early Detect Psychosocial Problems in Toddlers, a Cluster Randomized Trial

Objective

Effective early detection tools are needed in child health care to detect psychosocial problems among young children. This study aimed to evaluate the effectiveness of the Brief Infant-Toddler Social and Emotional Assessment (BITSEA), in reducing psychosocial problems at one year follow-up, compared to care as usual.

Method

Well-child centers in Rotterdam, the Netherlands, were allocated in a cluster randomized controlled trial to the intervention condition (BITSEA—15 centers), or to the control condition (‘care-as-usual’- 16 centers). Parents of 2610 2-year-old children (1,207 intervention; 1,403 control) provided informed consent and completed the baseline and 1-year follow-up questionnaire. Multilevel regression analyses were used to evaluate the effect of condition on psychosocial problems and health related quality of life (i.e. respectively Child Behavior Checklist and Infant-Toddler Quality of Life). The number of (pursuits of) referrals and acceptability of the BITSEA were also evaluated.

Results

Children in the intervention condition scored more favourably on the CBCL at follow-up than children in the control condition: B = -2.43 (95% confidence interval [95%CI] = -3.53;-1.33 p<0.001). There were no differences between conditions regarding ITQOL. Child health professionals reported referring fewer children in the intervention condition (n = 56, 5.7%), compared to the control condition (n = 95, 7.9%; p<0.05). There was no intervention effect on parents’ reported number of referrals pursued. It took less time to complete (parents) or work with (child health professional) the BITSEA, compared to care as usual. In the control condition, 84.2% of the parents felt (very) well prepared for the well-child visit, compared to 77.9% in the intervention condition (p<0.001).

Conclusion

The results support the use of the BITSEA as a tool for child health professionals in the early detection of psychosocial problems in 2-year-olds. We recommend future studies in large and varied populations to replicate these findings.

Trial registration

Current Controlled Trials NTR2035

Mild psychotic experiences among ethnic minority and majority adolescents and the role of ethnic density

PURPOSE

Despite evidence of the increased risk of psychotic disorders among ethnic minority adults, little is known about the effect of ethnic minority status to mild psychotic experiences among adolescents. This study investigated mild psychotic experiences in ethnic minority and majority adolescents in a Dutch representative general population sample, and tested the ethnic density effect in the classroom.

METHODS

The CAPE was used to assess mild psychotic experiences among Dutch (n = 3,606) and non-Western ethnic minority pupils (n = 769).

RESULTS

Ethnic minority adolescents showed higher levels of grandiosity and delusions than their ethnic majority peers, whereas no differences were found for hallucinations, paranormal beliefs and paranoia between both groups of adolescents. The ethnic density effect was partly confirmed for the ethnic majority: a decrease of ethnic majority pupils in class increased their feelings of paranoia.

CONCLUSIONS

Because only some dimensions of mild psychotic experiences were affected by ethnic minority status or the interaction between ethnic minority status and ethnic class composition, our findings emphasize that mild psychotic experiences are multifactorial in origin, with different underlying processes.

Internalizing and externalizing problems in immigrant boys and girls

This longitudinal study explores differences between native Dutch and immigrant Moroccan adolescents in the relationship between internalizing and externalizing problems across time. By using generalized estimating equations (GEE), the strength and stability of associations between internalizing and externalizing problems in 159 Moroccan and 159 Dutch adolescents was studied over a period of 4 years. No differences in strength of co-occurring problems were found between Moroccan and Dutch adolescents. However, for Moroccan adolescents, associations between problems increased over time, whereas in Dutch adolescents, associations remained stable. The increase of co-occurring problems may be a result of undertreatment and increasing complexity of problems in Moroccans during adolescence. The results of this study imply that investigating processes leading to co-occurring problems in subgroups of adolescents, such as immigrant youths, is needed to optimize prevention and intervention efforts.

Prisoners' assessments of mental health problems among their children

High rates of imprisonment among American men and women have motivated recent research on the well-being of children of incarcerated parents. Despite advances in the literature, little is known regarding the mental health status of children who experience maternal relative to paternal incarceration. Accordingly, we examine whether there are differences in mental health needs among children of incarcerated parents. Specifically, we assess whether incarcerated mothers are more likely than incarcerated fathers to report that their children suffer from mental health problems. Using cross-sectional data on children (N = 1,221) compiled from a sample of parents confined in the Arizona Department of Corrections, we find that children of incarcerated mothers are significantly more likely to be identified as suffering from mental health problems. This effect remained even after controlling for additional parent stressors and child risk factors such as exposure to violence, in utero exposure to drugs/alcohol, and parental mental illness. Policy implications and directions for future research are discussed.

An incidence study of diagnosed autism-spectrum disorders among immigrants to the Netherlands

OBJECTIVE

To estimate the risk of developing autism-spectrum disorder (ASD) in children born to immigrants as compared with children of Dutch-born parents.

METHOD

Retrospective, population-based cohort study of all live births (n = 106 953) between 1998 and 2007 in a circumscribed geographical region in the Netherlands. Cohort members were linked to the Psychiatric Case Register to identify diagnosed cases.

RESULTS

A total of 518 cases of ASD were identified, including 150 children with autism and 368 children with Asperger syndrome or Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS). Children born to migrants from developing countries were at significantly lower risk of ASD [rate ratio (RR) = 0.6, 95% confidence interval (CI) 0.5-0.9] than children of Dutch-born parents. Within the ASD group, the risk for the subgroup with Asperger syndrome and PDD-NOS was reduced (RR = 0.4, 95% CI 0.3-0.6), whereas that for narrowly defined autism was non-significantly increased (RR = 1.4, 95% CI 0.9-2.4). Migrant groups did not differ in age at diagnosis.

CONCLUSION

The results echo Swedish findings indicating a reversal of risk gradient in children of parents from developing countries, specifically a decreased risk for high-functioning and increased risk for low-functioning autism.

Instruments measuring externalizing mental health problems in immigrant ethnic minority youths: a systematic review of measurement properties

BACKGROUND

Little is known about reliability and validity of instruments measuring externalizing mental health problems in immigrant ethnic minority youths.

AIMS

To provide an overview of studies on measurement properties of instruments measuring these problems in immigrant ethnic minority youths, their methodological quality and results.

METHODS

A systematic review of the literature in MEDLINE, EMbase, PsycINFO and Cochrane Library was performed. Evaluation of methodological quality of studies found was done by using the 'COSMIN-checklist'. Full text, original articles, published in English after 1990 were included. Articles had to concern the development or evaluation of the measurement properties of self-reported, parent-reported and/or teacher- or clinician-reported questionnaires assessing or screening externalizing mental health problems in immigrant ethnic minority youths. Specific results of analyses on (an) immigrant ethnic minority group had to be given.

RESULTS

Twenty-nine studies evaluating 18 instruments met our criteria. Most studies concerned instruments with known validity in Western populations, tested mainly in African Americans. Considering methodological quality, inequivalences between ethnicities were found, self-reports seemed to perform better, and administration of an instrument influenced reliability and validity.

CONCLUSION

It seems that the majority of instruments for assessing externalizing problems in immigrant ethnic minority youths is currently not sufficiently validated. Further evaluating existing instruments is crucial to accurately assess and interpreted externalizing problems in immigrant ethnic minority youths.

How are immigrant background and gender associated with the utilisation of psychiatric care among adolescents?

PURPOSE

To investigate how parental country of birth and individual gender affect utilisation of psychiatric care in adolescents.

METHODS

On the basis of data from the Longitudinal Multilevel Analysis in Scania database, the article employs logistic regression to analyse the utilisation of psychiatric care among adolescents aged 13-18 (n = 92203) who were living in the southern Swedish county of Scania in 2005.

RESULTS

Adolescents whose parents were born in middle- or low-income countries presented lower levels of psychiatric outpatient care utilisation than those with native parents. Initially, no associations were found between the utilisation of psychiatric inpatient care and parental country of birth. Following adjustment for socio-demographic variables, it was found that adolescents with parents born in low-income countries were less likely to utilise psychiatric inpatient care. Girls presented higher levels of psychiatric care utilisation, but controls for possible interactions revealed that this was true primarily for girls with parents born in Sweden or other high-income countries.

CONCLUSIONS

The different utilisation patterns found among adolescents with different backgrounds should be taken into consideration when planning and designing psychiatric care for adolescents, and when allocating resources. Our results may indicate lower levels of mental health problems among adolescents with parents born in middle- or low-income countries implying that protective factors compensate other stressors implicated in mental health problems. On the other hand, our findings may indicate an unmet health-care need as a result of problems accessing care.

AMOR II: an effort to eradicate psychosocial barriers induced by immigration phenomenon in children with cancer

BACKGROUND

Immigration in the childhood cancer population constitutes a stressor factor because of high biopsychosocial vulnerability. In recent years the incidence of immigrant children in our unit has increased. Since 2005 we have developed a psychosocial program to overcome this challenge. Our objective is to assess its impact on the immigrant pediatric population.

PROCEDURE

We have compared new cases (n=114) from 2005 to 2010 with historical cases (n=95) from 1995 to 2004. We administered a long-term follow-up questionnaire allowing for the assessment of symptoms associated with biopsychosocial variables.

RESULTS

Most of our immigrant patients came from Latin America and we observed a significant increase of cases coming from Morocco and Romania. The most common diagnosis was hematological malignancies. From 2005 to 2010 the disease status was mainly initial, whereas in the period 1995 to 2004 most of the patients arrived with advanced disease. Socioeconomic variables amongst these patients tended towards low incomes, high unemployment, and economic difficulties. The implementation of the biopsychosocial protocol AMOR II improved adaptation (P=0.012), the amount and understanding of information received (P=0.002), and family emotional support (P=0.004).

CONCLUSIONS

In brief, our biopsychosocial protocol had significantly increased some psychosocial variables. However, immigration in Spain is still associated with economic difficulties, "aculturism" and failure to adapt.

Mental health in migrant schoolchildren in Italy: teacher-reported behavior and emotional problems

The migration process is a cause of physical and social stressors that may lead to mental health problems, particularly in children. In Italy, there are few studies about migrant children's mental health; thus, the aim of this study is to compare the prevalence and types of emotional and behavioral problems in migrant schoolchildren to those of native Italian children. The research involved migrant (first- and second-generation) and native schoolchildren attending kindergarten, primary, and secondary school. A questionnaire was administered to parents to collect information about the sociodemographic characteristics of the children. All teachers filled in the Teacher's Report Form for migrant and native children. The findings show that teachers detect academic and adaptive problems more easily in migrant schoolchildren, but they are probably less aware of the children's psychological problems. The observations made in this study provide a starting point in understanding the psychological status and main problems noted among migrant children.

Characteristics of the strengths and difficulties questionnaire in preschool children

OBJECTIVES

Validated questionnaires help the preventive child healthcare (PCH) system to identify psychosocial problems. This study assesses the psychometric properties and added value of the Strengths and Difficulties Questionnaire (SDQ) for the identification of psychosocial problems among preschool-aged children by PCH.

METHODS

We included 839 children (response 66%) 3 to 4 years of age undergoing routine health assessments in 18 PCH services across the Netherlands. Child healthcare professionals interviewed and examined children and parents. Before the interview, parents completed the SDQ and the Child Behavior Checklist (CBCL). We assessed the internal consistency, the scale structure, and validity (correlation coefficients, sensitivity, and specificity), with CBCL and treatment status as criteria, and the degree to which the SDQ could improve identification solely on the basis of clinical assessment.

RESULTS

The internal consistency of the SDQ total difficulties score was good (Cronbach's α, 0.78), but it was worse for some subscales of the SDQ (range, 0.50-0.74). The area under the receiver operating characteristic curve using the CBCL as a criterion was 0.94 (95% confidence interval 0.91-0.97), and sensitivity and specificity were 0.79 and 0.93, respectively. The SDQ added information to the clinical assessment; the odds ratio was 36.48 for added information by using the CBCL as a criterion.

CONCLUSIONS

The SDQ is a valid tool for the identification of psychosocial problems in preschool-aged children by PCH. However, the low reliability of some SDQ subscales does not justify use of these subscales for decisions about further treatment.

Reliability and validity of the KIPPPI: an early detection tool for psychosocial problems in toddlers

BACKGROUND

The KIPPPI (Brief Instrument Psychological and Pedagogical Problem Inventory) is a Dutch questionnaire that measures psychosocial and pedagogical problems in 2-year olds and consists of a KIPPPI Total score, Wellbeing scale, Competence scale, and Autonomy scale. This study examined the reliability, validity, screening accuracy and clinical application of the KIPPPI.

METHODS

Parents of 5959 2-year-old children in the Rotterdam area, the Netherlands, were invited to participate in the study. Parents of 3164 children (53.1% of all invited parents) completed the questionnaire. The internal consistency was evaluated and in subsamples the test-retest reliability and concurrent validity with regard to the Child Behavioral Checklist (CBCL). Discriminative validity was evaluated by comparing scores of parents who worried about their child's upbringing and parent's that did not. Screening accuracy of the KIPPPI was evaluated against the CBCL by calculating the Receiver Operating Characteristic (ROC) curves. The clinical application was evaluated by the relation between KIPPPI scores and the clinical decision made by the child health professionals.

RESULTS

Psychometric properties of the KIPPPI Total score, Wellbeing scale, Competence scale and Autonomy scale were respectively: Cronbach's alphas: 0.88, 0.86, 0.83, 0.58. Test-retest correlations: 0.80, 0.76, 0.73, 0.60. Concurrent validity was as hypothesised. The KIPPPI was able to discriminate between parents that worried about their child and parents that did not. Screening accuracy was high (>0.90) for the KIPPPI Total score and for the Wellbeing scale. The KIPPPI scale scores and clinical decision of the child health professional were related (p<0.05), indicating a good clinical application.

CONCLUSION

The results in this large-scale study of a diverse general population sample support the reliability, validity and clinical application of the KIPPPI Total score, Wellbeing scale and Competence scale. Also, the screening accuracy of the KIPPPI Total score and Wellbeing scale were supported. The Autonomy scale needs further study.

Work experience and style explain variation among pediatricians in the detection of children with psychosocial problems

OBJECTIVE

To assess whether variation in the proportion of children identified as having psychosocial problems by individual preventive pediatricians can be explained by pediatrician characteristics, over and above variations in the mix of children. Furthermore, to assess whether the characteristics of preventive pediatricians were related to the quality of problem identification.

METHODS

We used data from approximately 3070 children ages 5 to 6 years who were assessed during a routine well-child visit by a preventive pediatrician in the Netherlands (response rate 85.2%). We obtained data about parent-reported child problems by using the Child Behavior Checklist (CBCL), sociodemographic background of the family, and characteristics of the preventive pediatrician. After each assessment, preventive pediatricians reported whether they had identified any psychosocial problem in the child. Multilevel logistic regression analyses were used to assess whether variation in the proportion of children identified by preventive pediatricians as having a psychosocial problem could be explained by the characteristics of preventive pediatricians and whether these characteristics were related to the quality of problem identification.

RESULTS

Preventive pediatricians varied widely in the proportion of children identified as having psychosocial problems. Pediatrician characteristics such as work experience and work style (for example, on indication use of behavior questionnaires like the CBCL in routine care) explained about a quarter of this inter-pediatrician variation; child characteristics did not explain this variation even though characteristics like gender and parental education level were associated with likelihood of problem identification. More use of the CBCL and less use of the Teacher Report Form in routine care resulted in a better problem identification by preventive pediatricians. Work experience was not related to better problem identification.

CONCLUSIONS

Preventive pediatricians identify psychosocial problems in children in a standardized way, but important inter-pediatrician variation remains. This variation may be reduced further and quality improved by changing their work style and targeted training.

Reliability and validity of the Dutch version of the Brief Infant-Toddler Social and Emotional Assessment (BITSEA)

Background

The Brief Infant-Toddler Social and Emotional Assessment (BITSEA) is a relatively new and short (42-item) questionnaire that measures psychosocial problems in toddlers and consists of a Problem and a Competence scale. In this study the reliability and validity of the Dutch version of the BITSEA were examined for the whole group and for gender and ethnicity subgroups.

Methods

Parents of 7140 two-year-old children were invited in the study, of which 3170 (44.4%) parents completed the BITSEA. For evaluation of the score distribution, the presence of floor/ceiling effects was determined. The internal consistency (Cronbach's alpha) was evaluated and in subsamples the test-retest, parent-childcare provider interrater reliability and concurrent validity with regard to the Child Behavioral Checklist (CBCL). Discriminative validity was evaluated by comparing scores of parents that worry and parents that do not worry about their child's development.

Results

The BITSEA showed no floor or ceiling effects. Psychometric properties of the BITSEA Problem and Competence scale were respectively: Cronbach's alphas were 0.76 and 0.63. Test-retest correlations were 0.75 and 0.61. Interrater reliability correlations were 0.30 and 0.17. Concurrent validity was as hypothesised. The BITSEA was able to discriminate between parents that worry about their child and parents that do not worry. The psychometric properties of the BITSEA were comparable across gender and ethnic background.

Conclusion

The results in this large-scale study of a diverse sample support the reliability and validity of the BITSEA Problem scale. The BITSEA Competence scale needs further study. The performance of the BITSEA appears to be similar in subgroups by gender and ethnic background.

Early detection of psychosocial problems in children aged 5 to 6 years by preventive child healthcare: has it improved?

OBJECTIVE

To assess whether the quality of identification of psychosocial problems by preventive child healthcare professionals (CHPs) in children aged 5-6 years has improved after a series of nationwide interventions.

STUDY DESIGN

We analyzed data about 8440 children aged 5-6 years who were assessed during routine well-child visits by CHPs (response rates, 85%-90%). Of these children, 4339 were assessed before the interventions. Parents completed the Child Behavior Checklist (CBCL) and CHPs reported on psychosocial problems that they identified in children. The agreement between identification of psychosocial problems by CHPs and parent-reported problems on the CBCL were assessed before and after the nationwide interventions.

RESULTS

CHPs identified psychosocial problems in 22%-28% of all children. Identification of psychosocial problems by CHPs was much more likely in children with an elevated CBCL total problems score than in others (OR: 4.65, 95% CI: 3.28-6.58). The quality of identification by CHPs did not improve after the interventions, the OR for improvement was 0.81 (95% CI: 0.57-1.15).

CONCLUSIONS

The quality of problem identification by CHPs has not improved. CHPs still miss many cases with parent-reported problems on the CBCL. Additional efforts are needed to improve early identification of psychosocial problems.

Prevalence of psychosocial problems in Dutch children aged 8-12 years and its association with risk factors and quality of life

AIMS

To determine the prevalence of psychosocial problems among Dutch children aged 8-12 years and studying its association with risk factors and quality of life.

METHODS

This study was conducted within the framework of a community-based health study in the north-west region of the Netherlands. The cross-sectional study sample consisted of 2703 children (1392 boys and 1311 girls). Psychosocial problems and quality of life were measured with the extended version of the Strengths and Difficulties Questionnaire (SDQ) and KIDSCREEN-10, respectively. Questionnaires and data about risk factors (parental education level, ethnicity, family structure, income, chronic diseases and life events) were completed by the parents or caregivers.

RESULTS

The prevalence of psychosocial problems (SDQ score > or =14) in the total sample was 10.4%. The prevalence was higher in boys compared with girls (13.9% v. 6.6%, OR= 2.28; 95% CI = 1.75-2.97). Boys had significantly more hyperactivity/inattention, conduct, peer relationship and prosocial behaviour problems compared with girls. Risk factors associated with psychosocial problems were: one or more chronic disease(s), life event(s), a low parental educational level (for boys only) and an income under a modal level. Psychosocial problems were significantly inverse related with quality of life in the total sample (rho = -0.47).

CONCLUSIONS

Psychosocial problems are common in children, especially among boys, and are inversely related with children's quality of life. The identified risk factors in this study can be useful for developing targeted prevention strategies aimed at children at high risk for psychosocial problems.

National origin and behavioural problems of toddlers: the role of family risk factors and maternal immigration characteristics

In many societies the prevalence of behavioural problems in school-aged children varies by national origin. We examined the association between national origin and behavioural problems in 1½-year-old children. Data on maternal national origin and the Child Behavior Checklist for toddlers (n = 4943) from a population-based cohort in the Netherlands were used. Children from various non-Dutch backgrounds all had a significantly higher mean behavioural problem score. After adjustment for family risk factors, like family income and maternal psychopathology, the differences attenuated, but remained statistically significant. Non-Dutch mothers with immigration risk factors, such as older age at immigration or no good Dutch language skills, reported significantly more behavioural problems in their offspring. In conclusion, the present study indicated more behavioural problems in immigrant toddlers from various backgrounds. Researchers and policymakers aiming to tackle disparities in behavioural problems should take into account that risks associated with national origin are intertwined with unfavourable family and immigration characteristics.

Professional identification of psychosocial problems among children from ethnic minority groups: room for improvement

OBJECTIVE

To assess the effectiveness of child health care professionals (CHP) in identifying psychosocial problems among children originating from industrialized and nonindustrialized countries and to assess whether parental concerns enhance CHP problem-identification.

STUDY DESIGN

During routine well-child visits data were collected from a sample of children aged 5 to 12 years of Dutch, Moroccan, Turkish, Surinam, and Antillean origin (response: 82%). CHP reported on psychosocial problems that they identified in children. Parents completed the Child Behavior Checklist (CBCL) and a questionnaire on concerns regarding their child's psychosocial development. Interpreter services were used to support parents in filling out questionnaires.

RESULTS

Elevated CBCL total and internalizing problem scores were more prevalent among children from nonindustrialized countries (10% and 17%, respectively) than among children from industrialized countries (3% and 5%, respectively). About 30% of the Turkish and Moroccan children with an elevated CBCL score were identified by CHPs compared with 60% of the children from industrialized countries. Parental concerns on their child's psychosocial well-being were related to elevated CBCL scores. Concerns were not related to CHP problem-identification.

CONCLUSIONS

Better methods to support parents in disclosure of their concerns regarding the psychosocial development of their children may enhance CHP-identification of problems, especially among groups from nonindustrialized countries.

Ethnic density in school classes and adolescent mental health

OBJECTIVE

The present study set out to examine the association between ethnic composition of school classes and prevalence of internalising and externalising problem behaviour among ethnic minority and majority students.

METHODS

Data were derived from the Dutch 2002 Health Behaviour in School-aged Children (HBSC) survey, a nationally representative cross-sectional study with a total of 5,730 adolescents, aged 11-18 and attending secondary school, of which 931 belong to ethnic minority groups. The data were analysed using a multilevel regression model.

RESULTS

The study revealed that, after taking individual characteristics like age, gender, educational level and family affluence into account, ethnic minority students on average report higher levels of externalising but not internalising problems. Ethnic density on the level of school classes modified this difference, as a negative association between the proportion ethnic minority students in class and externalising problem behaviour was found, but only for ethnic minority students. No effect of ethnic composition was found with respect to internalising problem behaviour.

CONCLUSION

The data revealed that ethnic minority students report higher levels of externalising problem behaviour, but only in classes with a minority of ethnic minority students and not in classes with a culturally diverse composition. This points towards a possible beneficial effect of a more culturally diverse environment for minority students. Majority students appeared to be insensitive for the ethnic density effect. Future studies should investigate the role of the ethnic composition of the school class more in-depth.

Sociocultural disadvantage, traumatic life events, and psychiatric symptoms in preadolescent children

Previous research has demonstrated impact of psychosocial adversity on the mental health of children. This cross-sectional study examined specific influences of psychosocial adversity on internalizing versus externalizing symptoms, as explained by relative neighborhood disadvantage, sociocultural disadvantage, and exposure to interpersonal and non-interpersonal traumatic life events. Participants included 258 children aged 6 to 12 years from two Swedish elementary schools located in two socioeconomically distinct neighborhood settings. Information was obtained from their parents by means of questionnaires (a demographic form including information about parental occupation and country of origin, the Strengths and Difficulties Questionnaire and the Life Incidence of Traumatic Events checklist). Neighborhood differences in mental health were explained by variability in psychosocial adversity. While controlling for gender, age, and the other symptom dimension, sociocultural disadvantage was associated with internalizing but not with externalizing symptoms. In contrast, traumatic life events and especially interpersonal traumas were related to externalizing but not to internalizing symptoms. These findings provide some support for specificity of psychosocial adversities in the impact on child mental health.

Psychosocial adaptation of adolescent migrants in a Swiss community survey

OBJECTIVE

The aim of this study was to compare psychosocial adaptation in adolescent (first generation) migrants, double-citizens (mainly second generation with one migrant parent), and native Swiss, and to compare migrants from various European regions.

METHOD

Data from a community survey were based on 1,239 participants (mean age 13.8, SD = 1.6 years) with 996 natives, 55 double-citizens, and 188 migrants. The adolescents completed the youth self-report measuring emotional and behavioural problems, and various questionnaires addressing life events, personality variables, perceived parental behaviour (PPB), family functioning, school environment, and social network.

RESULTS

Adolescent migrants had significantly higher scores for internalizing and externalizing problems. There was a pattern of various unfavourable psychosocial features including life events, coping, self-related cognitions, and PPB that was more common among adolescent migrants than natives. Double-citizens were similar to natives in all domains. Young adolescents from South and South-East Europe differed from natives in terms of more unfavourable psychosocial features. Migrant status was best predicted by adverse psychosocial features rather than emotional and behavioural problems.

CONCLUSION

There is some indication that certain migrant adolescents are at risk of psychosocial mal-adaptation. Obviously, ethnic origin is an important moderator.

Social competence and emotional/behavioral problems in a birth cohort of Sami and Norwegian preadolescents in Arctic Norway as reported by mothers and teachers

In a 7-year follow-up birth cohort from the general population in the Sami core area in Finnmark, Arctic Norway, we examined mothers' and teachers' reports of social competence and emotional/behavioral problems among 71 indigenous Sami and 77 Norwegian 11-12-year-olds. The instruments used were the Child Behavior Checklist (CBCL) for parents and the Teacher Report Form (TRF). No ethnic differences were found on competence scales. Total Problems reported by Sami and Norwegian mothers were low in comparison with the overall mean found in multicultural meta-studies. Sami mothers reported lower Total Problems and Attention Problems than did Norwegian mothers. There were no ethnic differences on the TRF measures. Consistent with other international studies, mothers and teachers rated girls higher than boys on social competence and boys higher than girls on Externalizing and Attention Problems. Gender differences were larger on the TRF than on the CBCL. The very low problem ratings made by the Sami mothers indicate that there is a need for specific clinical cut-off points to distinguish between clinically referred and non-referred children in this indigenous Arctic population.

Predictive Validity of Symptoms-Based Approaches to the Adjustment of High-Risk Children at School and in the Community

Objective: To compare the predictive validity of different diagnostic classifications for disruptive behavioral disorder (DBD) in youths aged 9 to 15 years of age: the DSM-IV categorical diagnosis, the number of DSM-IV DBD symptoms and Achenbach’s taxonomy (Child Behaviors Checklist scores for social problems, rule-breaking behaviors, aggressive behaviors, and attention problems). The incremental validity, after including clinical structured interviews with parents and children into models that contained CBCL scores, is reported. Method: Longitudinal study in a Spanish high-risk population, comparing each classification in 1 and 2-year follow-ups. Both predictors and criteria pertain to measures of the same class of behaviors: clinical information regarding impairment at school and community. Results: Predictive accuracy was dependent on the specific outcomes and the children’s age. The CBCL scores obtained the best predictive results. Dimensional approaches (the number of DSM-IV DBD symptoms and CBCL) obtained higher R2 values than categorical DSM-IV diagnosis. Assessment based on clinical interviews with family significantly increased the predictive validity of Achenbach’s taxonomy. Conclusions: These results provide guidance for detecting early disruptive behaviors and planning measures for the prevention of subsequent antisocial conduct. This work may provide direction to future validation studies of classifications and diagnostic systems for behavioral adjustment in youths.

Underdiagnosis and referral bias of autism in ethnic minorities

This study examined (1) the distribution of ethnic minorities among children referred to autism institutions and (2) referral bias in pediatric assessment of autism in ethnic minorities. It showed that compared to the known community prevalence, ethnic minorities were under-represented among 712 children referred to autism institutions. In addition, pediatricians (n = 81) more often referred to autism when judging clinical vignettes of European majority cases (Dutch) than vignettes including non-European minority cases (Moroccan or Turkish). However, when asked explicitly for ratings of the probability of autism, the effect of ethnic background on autism diagnosis disappeared. We conclude that the use of structured ratings may decrease the likelihood of ethnic bias in diagnostic decisions of autism.

Parents' concerns about children are highly prevalent but often not confirmed by child doctors and nurses

BACKGROUND

The aim of this study was to assess the prevalence in the general population of parents' concerns about the development of their child, to identify groups at risk and to assess the association between parents' concerns and professional judgement.

METHODS

We obtained cross-sectional data on a Dutch nationally representative sample of children aged 14 months, 3 3/4, 5-6 and 8-12 years within the setting of routine well-child visits provided to the entire population. A total of 4,107 participated (response rate 85.3%). Data were about concerns that parents reported by questionnaire before the visit regarding behavioural and emotional problems, developmental delay, consequences of disease and contact with peers that needed professional assistance, and about the assessment of these domains by doctors and nurses during the visit. Moreover, we obtained data on parent-reported psychosocial problems using the Infant-Toddler Social and Emotional Assessment and the Child Behavior Checklist.

RESULTS

Of all parents, 49.3% reported some concerns and 8.7% reported frequent concerns, most frequently on child behaviour. Frequent concerns were most likely to refer to young children, children from labour immigrant families, with fathers of medium educational level and in low-income families. The prevalence rates of professional-assessed parenting problems were much lower than parent-reported ones. The rates of psychosocial problems were highest in the case of shared concerns, but also higher if parents expressed concerns that were not confirmed by professionals.

CONCLUSION

A very large proportion of parents of young children have concerns regarding their child, but agreement on these concerns with child health professionals is relatively low.

Mental health in migrant children

Many factors have been identified to explain differences in mental health problems between migrant and native children: the process of migration, the ethnic minority position of migrants, their specific cultural background and the selection of migrants. In this paper, the international literature regarding mental health of migrant children is reviewed using strict selection criteria. An extensive search was carried out to locate journal articles on the subject of mental health in migrant youth published since the 1990s. Only 20 studies met all inclusion criteria. Besides the conclusion that the studies did not unequivocally find an increased risk of mental health problems in migrant children, it proved to be very difficult to draw any sound conclusions with respect to these children's risk of mental health problems, since the impact of migration on children's mental health varied with the informants used and the characteristics of the migrant group and of the host country. The lack of univocal definitions of key terms further complicated generalised conclusions in this research field. As such, this research field is in urgent need of more research using standardised research designs, methodology and definitions. A proposition for this research design is made.

The association of behavioural and emotional problems with tobacco use in adolescence

Smoking is a highly addictive behaviour, often initiated during adolescence. It is suggested that smoking is associated with behavioural and emotional problems. This study aims to assess the impact of psychosocial problems on smoking initiation and vice versa.

METHOD

We obtained data on self-reported psychosocial problems and smoking of adolescents at the age of 13 years and 2 years later. The baseline questionnaire was completed by 1789 students. 68% of the baseline questionnaire could be linked to a questionnaire of the second measurement.

RESULTS

15% smoked at baseline and 29% two years later. Respectively 8% and 9% had a clinical Externalizing problem score or a clinical Internalizing problem score at baseline, 14% had these problems two years later. Externalizing problems at baseline predicted the onset of smoking two years later. Internalizing problems only predicted smoking among girls. This association between psychosocial problems and smoking is most obvious for the onset of regularly smoking and less for the onset of experimenting. Reversibly smoking at baseline is only associated with the onset of externalizing problems two years later.

CONCLUSION

Clinical Externalizing and Internalizing problems make the initiation of regular smoking more likely. The effects on experimental smoking are less obvious.

Development of ethnic disparities in internalizing and externalizing problems from adolescence into young adulthood

BACKGROUND

Little is known about changes in ethnic disparities in mental health during the development of adolescents into young adults. The aim of this study was to study the development of disparities in internalizing and externalizing problems between Dutch natives and Turkish migrant children from adolescence into adulthood.

METHODS

Turkish migrants (n = 217) and Dutch natives (n = 723) completed two comparable questionnaires about internalizing and externalizing problems: the Youth Self-Report at age 11-18 and the (Young) Adult Self-Report ten years later, at age 21-28. We used mixed linear regression models to model development of mental health problems and to test changes in disparities in mental health between Turkish migrants and Dutch natives.

RESULTS

Both in adolescence and in adulthood migrants reported more internalizing and externalizing problems than natives, most pronounced for internalizing problems. Disparities decreased from adolescence into adulthood for both internalizing problems (-52%, p < .0001) and externalizing problems (-67%, p = .01), independently of gender, age, country of birth of Turkish adolescents, and parental socio-economic position. The favorable changes in the disparities over time were due to more favorable development among Turkish migrants than among natives.

CONCLUSIONS

In this prospective study, ethnic disparities in internalizing and externalizing problems decreased as adolescents entered adulthood. Different explanations are discussed.

Behavioural and emotional problems in very preterm and very low birthweight infants at age 5 years

BACKGROUND

Children born very preterm (VP; <32 weeks' gestation) or with very low birth weight (VLBW, <1500 g; hereafter called VP/VLBW) are at risk for behavioural and emotional problems during school age and adolescence. At school entrance these problems may hamper academic functioning, but evidence on their occurrence at this age in VP/VLBW children is lacking.

AIM

To provide information on academic functioning of VP/VLBW children and to examine the association of behavioural and emotional problems with other developmental problems assessed by paediatricians.

DESIGN, SETTING AND PARTICIPANTS

A cohort of 431 VP/VLBW children aged 5 years (response rate 76.1%) was compared with two large national samples of children of the same age (n = 6007, response rate 86.9%).

OUTCOME MEASURES

Behavioural and emotional problems measured by the Child Behavior Checklist (CBCL), and paediatrician assessment of other developmental domains among VP/VLBW children.

RESULTS

The prevalence rate of a CBCL total problems score in the clinical range was higher among VP/VLBW children than among children of the same age from the general population (13.2% v 8.7%, odds ratio 1.60 (95% confidence interval 1.18 to 2.17)). Mean differences were largest for social and attention problems. Moreover, they were larger in children with paediatrician-diagnosed developmental problems at 5 years, and somewhat larger in children with severe perinatal problems.

CONCLUSION

At school entrance, VP/VLBW children are more likely to have behavioural and emotional problems that are detrimental for academic functioning. Targeted and timely help is needed to support them and their parents in overcoming these problems and in enabling them to be socially successful.

Continuous admission to primary school and mental health problems

Background

Younger children in a school class have higher rates of mental health problems if admission to primary school occurs once a year. This study examines whether this relative age effect also occurs if children are admitted to school continuously throughout the year.

Methods

We assessed mental health problems based on parent-reports (using the Child Behavior Checklist, CBCL) and on professional assessments, among two Dutch national samples of in total 12,221 children aged 5–15 years (response rate: 86.9%).

Results

At ages 5–6, we found a higher occurrence of mental health problems in relatively young children, both for mean CBCL scores (p = 0.017) and for problems assessed by child health professionals (p < 0.0001). At ages 7–15, differences by relative age did not reach statistical significance.

Conclusion

Continuous admission to primary school does not prevent mental health problems among young children, but may do so at older ages. Its potential for the prevention of mental problems deserves further study.