Immigrant Status and Gender Effects on Psychopathologyand Self-Concept in Adolescents:

A Test of the Migration-Morbidity Hypothesis

S. Klimidis, G. Stuart, I.H. Minas, and AW. Ata

Evidence for a relationship between immigrant statusand psychological morbidity (which we Shall refer toas the "migration-morbidity" hypothesis) in adoles­cents is variable and inconclusive. The present studytests this hypothesis and also explores gender differ­ences in self-reported psychopathology and self­concept measures. Native-born Australians, Australian-

THE COMPREHENSIVE review by the Ca­nadian Task Force on Mental Health Is­

sues Affecting Immigrants and Refugees l iden­tified immigrant children and adolescents as agroup particularly at risk for the development ofpsychological morbidity. For the sake of brevity,we shall refer to the proposition that immigrantstatus is associated with greater psychologicalmorbidity as the "migration-morbidity" hypoth­esis. Studies investigating the effect of immigra­tion on mental health have produced mixedand inconclusive evidence for higher rates ofmorbidity in immigrant children and adoles­cents. Several studies have suggested a relation­ship between immigrant status and greater psy­chological morbidity. Rodriguez? in Switzerlandand using very general indices of morbidity,noted that although Spanish and Italian immi­grant adolescents represented only 10% of thegeneral adolescent population, these groupswere overrepresented in child therapy clientloads (20%) and in child assistance statistics(50%). The Malmo Social Welfare Departmentstudy (cited in Aronowitz3) in Sweden notedthat whereas 5.2% of immigrant adolescentswere subject to social welfare interventions,only 1.4% of native-born children were subjectto such interventions. These studies are difficultto interpret given that there are many factorsassociated with migration that may predisposeimmigrant samples in general to health andwelfare interventions, especially low socioeco­nomic status.4,5 In Canada, Goldenberg (cited inAronowitz3) found that 41% of a sample ofrecently arrived immigrant children had identi­fiable social and emotional problems. Also inCanada, Minde and Minde6 reported that forchildren from 51 Asian immigrant families therate of psychiatric disturbance was 26%. Psychi-

born adolescent children of immigrants, and immigrantand refugee adolescents are compared on a number ofrelevant measures. The results do not support themigration-morbidity hypothesis. However, Vietnam­ese refugee adolescents had poorer self-concept thanthe other groups.Copyright © 1994 by W.B. Saunders Company

attic disturbance was particularly high in thosefamilies that were said to be less "assimilated"to the Canadian culture. From a sample of over2,100 immigrant children in Sweden, 17% hadsocial problems and 14% had emotional prob­lems.? However, these studies lacked controlsamples of native-born children. It is thereforeunclear to what extent these results are due tothe method of measurement of psychologicaland social disturbance or to actual high rates ofdisturbance.

Aronowitz3 reports results from two compara­tive studies: the 1976 study by Takac in Swedenand the 1981 study by Gaertner-Harnach inGermany. Takac reported that teacher ratingsreflected higher scores on measures of anxietyand aggression, lower frustration tolerance,lower self-esteem, higher dependency, andpoorer interpersonal relationships in immigrantchildren compared with native-born children.Gaertner-Harnach in Germany reported thatimmigrant children (n = 1,107) had more se­vere and more frequent behavioral disordersthan native-born children (n = 1,455). Rutter etal.,8 in a British study, compared 354 WestIndian children with 1,689 native-born children.Teacher ratings indicated that 49% of immi­grant boys as compared with 24% of native-bornboys and 34% of immigrant girls as comparedwith 13% of native-born girls had some form of

From the Victorian Transcultural Psychiatry Unit, St. Vin­cent's Hospital, Fitzroy, Victoria, Australia.

Supported in part by a grant from LaTrobe University,Albury-Wodonga Campus.

Address reprint requests to I.H. Minas, M.B.B.S., B.Med.Sc.,D.P.M., Director, The Victorian Transcultural Psychiatry Unit,12 Gertrude St, Fitzroy, Victoria 3065, Australia.

Copyright © 1994 by WB. Saunders Company001O-440X/94/3505-00I0$03.00/0

ComprehensivePsyr:hiatry, Vol. 35, No.5 (September/October), 1994: pp 393-404 393

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disorder. However, when a random subsampleof 110 subjects were subjected to psychiatricassessment through parental interviews, no dif­ferences were evident between immigrant andnative-born subjects. These results call intoquestion the validity of teacher ratings as amethod of identifying rates of morbidity inimmigrant child and adolescent samples. Thediscrepancies may also reflect different sensitivi­ties between teacher assessments and psychiat­ric assessments that may identify different levelsof severity of disturbance or different classes ofdisturbance. Alternatively, as suggested by Rut­ter et al.,s children may have presented differ­ently to parents and teachers. It should also benoted that parental tolerance for different be­havioral disorders in children may differ cross­culturally,9 thus producing different rates ofdisorder depending on who provides the infor­mation on which the assessment is based (i.e.,teacher or parent).

In Britain, Cochrane lO compared psychiatricadmission rates of West Indian, Indian, Paki­stani, and native-born children. The highestrates were for West Indian children, followed byBritish, and then by Indian and Pakistanisamples.. In another British study, Kallarackaland Herbert ll reported that 10% of Indianchildren had some form of disorder, as com­pared with 26% of native-born children. There­fore, neither of these studies supports the propo­sition that mig!"ation has a uniformly adverseeffect on the mental health of immigrant chil­dren. Other studies have failed to find anydifference between immigrant and native-bornsamples. Osborn,12 in the United States andusing the Bell Adjustment Inventory, failed tofind any difference between matched samples ofimmigrant and native-born children. Touliatosand Lindholm13 in the United States failed tofind differences between immigrant and native­born samples. In a more direct test of themigration-morbidity hypothesis. Fichter et al. 14

compared 867 Greek adolescents living in Mu­nich with 2,702 Greek adolescents living inGreece and 2,780 Turkish adolescents living inTurkey, using the 28-item version of the Gen·eral Health Questionnaire. This study foundthat the Greek immigrant groups scored lowerthan the nonimmigrant groups, which did not

KLiMIDIS ET AL

differ from each other. These results directlycontradict the migration-morbidity hypothesis.

The present study compares native-born ado­lescents in Australia with second-generation(Australian-born children of immigrant par­ents), immigrant, and refugee adolescentsamples. This report focuses on whether thereare any differences between these four samplesin self-report measures of psychopathology. Therefugee adolescents in this study were Vietnam­ese. Refugees constitute a group generally con­sidered to be in need of special attention, giventheir premigration experiences and the circum­stances of forced displacement from their home­land. IS-IS For example, Harding and LooneyIsnoted many psychiatric complaints in childrenin refugee camps, including somatic complaints,sleep disturbances, marked withdrawal, aggres­siveness, psychosis, and tantrums, particularlyin those separated from their families. Themajority of studies of refugees after resettle­ment have concentrated on adult Indochineserefugees or on age-undifferentiated samples. Ofthese, studies taking age into account havesuggested poorer adjustment in the older ratherthan younger groupS.19-21 Krupinski and Bur­rows22 in Australia reported findings of a longi­tudinal study investigating the prevalence ofdiagnosable disorders in Vietnamese refugeeyouth. Their results indicated a substantial re­duction in the prevalence of morbidity over a2-year follow-up period. Nevertheless, given themany traumatic experiences of this group priorto migration and the stresses associated with theprocess of acculturation, it was thought reason­able to explore the psychological adjustment ofthis group separately in the present study.

This study also investigates gender differ­ences in self-reported psychopathology. Thereis ample evidence to suggest the importance ofgender in relation to the prevalence of psycho­pathology. Reinherz et alP noted a 2:1 risk ingirls compared with boys for the development ofdepressive symptoms in a sample of 375 adoles­cents aged 15 years. Similar trends were evidentin the study by Garrison et al.,24 who also foundthat gender interacted with race (black v whiteAmericans), with black girls scoring the higheston the Center for Epidemiologic Studies Depres­sion Scale and white boys the lowest. Allgood­Merten et al. 25 also reported higher scores for

THE MIGRATION-MORBIDITY HYPOTHESIS

girls with this scale, but noted that the effect ofgender could be eliminated by taking into ac­count gender differences in self-esteem andbody image dissatisfaction. Similar findings werereported by Roberts26 in a study including aculturally mixed sample (Anglo, African, Mexi­can, and other Hispanic-Americans) using theCenter for Epidemiologic Studies DepressionScale. In addition, this study reported higherscores for girls in social anxiety and self­consciousness, but no differences between boysand girls on antisocial behavior and State-TraitAnxiety measures.

Fichter et al. 14 reported higher scores in girlscompared with boys using the 28-item version ofthe General Health Questionnaire, a patternevident in all three of their samples (Greeks inMunich, Greeks in Greece, and Turks in Tur­key). Using the emotional distress section of theCornell Medical Index in a sample of Vietnam­ese adolescents, Charron and Ness16 found thatone of the strongest predictors of distress wasfemale gender. In a large community sample,McGee et al.27 reported a higher prevalence ofDSM-IlI disorders in girls than in boys. Girlshad a higher prevalence in all but three of thedisorders reported (total of 12), and conductdisorder (aggressive type) was unique to boys.Johnson and Kaplan28 reported higher rates ofaggressive behavior in boys compared with girls,whereas Horwitz and White29 noted that genderrole orientation may be a significant moderatorvariable in the expression of distress, with girlstending to internalize distress and boys tendingto express distress outwardly and primarilythrough disorders of conduct. Some support forthis comes from the study by Weinstein et al.,30who found higher scores on the Youth Self­Report Checklist in girls compared with boysfor depression and internalizing. However, theyalso found some surprising results: female ado·lescents with DSM diagnoses of attention deficitdisorder and conduct disorder scored higherthan males on externalizing, pointing to a com­plex interaction between gender and type ofdisorder. Using the Child Behavior Checklist ina sample of successive clinic referrals, Lambertet al.31 found an interaction between genderand so-called "overcontrolled" and "under­controlled" problem behaviors (a dimensionthat appears to be related to the "internalizing" /

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"externalizing" construct). Examples of theformer include fearfulness, sleeping problems,and somaticizing, whereas undercontrolled be­haviors include fighting, stealing, and disobedi­ence. Overcontrolled behaviors were reportedmore often in girls, and undercontrolled behav·iors in boys, although the effect sizes of thesetrends were relatively small.

In the present study, it was expected thatsupport for the migration-morbidity hypothesiswould be evident in differences in mean scoreson psychopathology measures among four immi­grant-status groups~native-born adolescentswith native-born parents, second-generationadolescents, immigrant adolescents, and Viet­namese refugee adolescents. It was expectedthat immigrant and refugee groups would scorehigher on psychopathology than nonimmigrantand second-generation groups and that refu­gees would score higher than immigrants giventhe experiences of premigration traumatization.Gender differences are also explored in thepresent study. It was expected that girls wouldscore higher than boys on general measures ofpsychopathology and that this would be particu­larly the case in some of the subscales, such asdepression, somatic concerns, and socialanxi­ety, in line with the literature reviewed above.Measures of psychopathology include indices ofanxiety, depression, and interpersonal difficul­ties. The focus on these indices is based on theexpectation that such pathologies would beamong the more common problems found in acommunity sample. In addition to the develop­ment of specific scales, a general index ofpsychopathology is used to compare the immi­grant-status groups. The study also developsmeasures of self-concept based on Monge'sbipolar self-descriptors32,33 as a second set ofindices of psychological morbidity and to inves­tigate the concurrent validity of the psychopa­thology measures.

METHOD

Subjects

The subjects for the present analyses were drawn from asample of 631 adolescents with a mean age (±SD) of 17.2 ±0.99 years. Sampling procedures are reported elsewhere.34,35

Briefly, subjects were volunteers sampled from 20 differenteducational institutions in Melbourne and Albury/Wodonga(a provincial town). Sampling in Melbourne was guided byAustralian Census statistics informing researchers where

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schools with large immigrant populations may be located.Questionnaires were administered in class settings. Thecountry of birth of parents and adolescents were variablesused to isolate five sUbsamples from this pool. Theseincluded Australian-born adolescents with Australian-bornparents ([A] n = 253); Australian-born adolescents withparents who were born in non-English-speaking countriesother than Vietnam (the second-generation group [S],n = 171); overseas-born adolescents who were children ofoverseas-born parents from non-English-speaking coun­tries other than Vietnam, defining the immigrant group ([I]n= 101); and Vietnam-born adolescents with Vietnam­born parents, defining the refugee group ([R] n = 91).Group I subjects were born in 39 different countries,representing a culturally heterogeneous group. The fifthsubsample consisted of immigrant offspring of immigrantparents born in English-speaking countries. Since thissubsample consisted of only 15 adolescents, they wereeXcluded from further consideration in the present analyses.Preliminary analyses revealed the R group to be signifi"cantly older than the remaining groups [F(2,626) = 7.69,P < .000] as indicated by post-hoc Scheffe contrasts. How­ever, their mean age was 17.7 years, which, althoughstatistically significant, is a very small difference in age.Although the total sample was biased with respect to gender(414 females and 217 males), this bias was evident across allgroups as shown by the lack of statistical difference in thegender distributions using the chi"square statistic.

Development and Validation ofthe Measures

Measures of psychopathology and self-concept scales arethose discussed in our previous report.35 Briefly, the originalpsychopathology instrument was devised to screen forclinical problems in 17 different phenomenological domainsusing 51 items. These domains and items were derivedclinically and from older instruments35 and included scalesof anxiety, compulsions, obsessions, ruminations, depres­sion, activation state, somatic symptoms, conversions, disso­ciations, phobic symptoms, cognitive inefficiency, contritionbeliefs, passivity and voices, anger-hostility, social anxiety,and grandiosity. To generate items to measure anxiety,depression, and interpersonal difficulties, the 51-item instru­ment was inspected and items were selected from a numberof clinical scales including anxiety, depression, ruminations,somatic symptoms, phobic symptoms, social anxiety, andpersecution beliefs. Responses to psychopathology itemswere on a three-point scale (never, sometimes, often).Self-concept items were semantic differential scales withbipolar descriptors derived from the studies of Monge.32

Responses to the self-concept items were made on afive-point scale that carried descriptors at every point (e.g.,very happy, slightly happy, in between, slightly sad, verysad). Ratings of self-concept were based on the question"How are you in general?", whereas symptom reports wereassessed for the period of "the past 3 months includingtoday." The final compositions of psychopathology andself-concept scales, based on factor-analytic explorations,are presented in Tables land2, respectively.

Items measuring psychopathology were submitted toprincipal-components analysis with orthogonal rotation ofthe factors to aid interpretation. Three factors were ex-

KliMIDIS ET AL

Table 1. Varimax-Flotated Principal-Components Analysis

Solution for Psychopathology Items

Factor Labels and Abbreviated Factor Factor FactorItems 1 2 3 h'

Social anxietyFelt shy and embarrased

when Iwas with others .72 .11 -.06 .54Been concerned about

what other people thinkof me .68 .13 .15 .50

Been feeling that othersjUdge me badly .65 .19 .28 .54

Been feeling that others arewatching or talking aboutme .59 .21 .18 .54

Felt afraid or panicky inplaces where there aremany people .57 .09 .17 .42

Felt unattached or uncon-nected to people andthings .54 .28 .29 .45

Anxiety stateNoticed parts of my body

feel tense or tight .18 .69 .15 .53Had a number of aches and

pains without reason -.02 .69 .23 .53Had headaches or pressure

in the head .13 .67 .07 .46Felt tense, unsettled, or

restless .36 .57 .16 .48Noticed my heart racing or

pounding hard .33 .54 .08 .41Felt nervousness or shaki-

ness inside .39 .51 .13 .44Depressive state

Felt cursed or doomed for-ever .14 -.03 .72 .55

Had thoughts about deathor ending my life .14 .19 .63 .45

Been feeling that the futureis hopeless .08 .32 .62 .49

Worried that somethingbad will happen in thefuture .13 .36 .59 .50

Felt like Icommitted the• most wicked, unforgiv-able sin .10 .01 .58 .35

Worried that something inmy life is lett unfinishedor unsettled .32 .21 .55 .44

Percent variance 31.2 8.4 7.2Cronbach's", coefficient .765 .763 .746

tracted on the basis of eigenvalues greater than one. Thethree factors together accounted for 46.8% of the variancein items.. The solution is shown in Table 1. Cronbach's Ci

coefficients are also shown in Table 1 and are high given thesmall number of items (six) in each scale, suggesting that thescales are reasonably uniform in what they measure. The

THE MIGRATION-MORBIDITY HYPOTHESIS

Table 2. Varimax-Rotated Principal-Components AnalysisSolution for Self-Concept Items

Factor Labels and Bipolar Items Factor 1 Factor 2 Factor 3 h'

Low confidencetRelaxed-nervous" .71 .03 .17 .54Secure-insecure* .67 .04 .34 .57Confident"unsure* .67 .24 .19 .55

Steady-shaky" .64 .21 .24 .51Superior-inferior" .59 .35 -.09 .48

Low self-worth:!:Nice-awful -.04 .68 .13 .49

Valuable-worthless .23 .68 .25 .58Loved-hated .03 .62 .36 .51Popular-unpopular .35 .57 .03 .48Productive-unproductive .27 .53 .16 .38Hopeful-hopeless* .40 .48 .25 .45

Low satisfaction§Peaceful-unsettled .00 .22 .70 .54Satisfied-dissatisfied .22 .18 .69 .56Stable-unstable .33 .20 .61 .52

Happy-sad* .40 .15 .60 .54

Percent variance 35.3 8.7 7.1Cronbach's (J[ coefficient .760 .751 .713

*Reverse-scored items for the purpose of analysis; theseitems are shown in reversed form in Table 2.

tHigh score indicates low confidence.:!:High score indicates low self-worth.§High score indicates low satisfaction.

first factor represents the construct of social anxiety, withitems such as shyness, fear of negative evaluation, andself-consciousness loading highly. The factor was labeledsocial anxiety. The second factor was labeled anxiety state,given loadings of items such as subjective tension and thesomatic manifestations of an anxiety state such as rapidheart rate, headaches, and tension in parts of the body. Thethird factor, labeled depressive state, includes such items assuicidal ideation, hopelessness, feelings of gloom, andworry. Nevertheless, the structure represented in the psycho­pathology items was relatively weak. The ct coefficient of allitems shown in Table 1 treated as a scale was found to be.866. This indicates a fairly uniform scale, with the subscalesrepresented in Table I being strongly intercorrelated. In­deed, oblique rotation of the factors indicated that correla­tions between the factors ranged from .32 to 040. A generalindex based on the sum of all items, to be used in furtheranalyses below, was termed general psychopathology.

Similar analysis was performed with the bipolar items ofthe self-concept scale. To aid interpretation and internal­reliability analysis, several items (Table 2) were reverse­scored so that positive self-evaluations were to the left andnegative to the right. Three factors were extracted based oneigenvalues being greater than one. The varimax-rotatedsolution is shown in Table 2. The three factors togetheraccounted for 51.1 % of the variance in the items. Factor Iwas labeled low confidence to reflect the right-most pole(i.e., high-score pole). The factor discriminates betweenthose considering themselves confident, superior, secure,relaxed, and steady from those considering themselves

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unsure, insecure, inferior, nervous, and shaky. The secondfactor contains at the one pole descriptors such as nice,valuable, loved, hopeful, productive, and popular and iscontrasted at the right-most pole by descriptors of awful,worthless, hated, unpopular, unproductive, and hopeless.The label given to this factor was low self-worth to denotethe self-evaluative aspect of this dimension at its right-mostpole. The final factor was labeled low satisfaction, althoughthe term "instability" fits just as well. The left-most poleincludes descriptors such as peaceful, satisfied, stable, andhappy, and the right-most pole includes descriptors such asunsettled, dissatisfied, unstable, and sad. Table 2 alsoindicates high internal reliabilities among items in theself-concept scales, ranging from o.n to 0.76. Internalconsistency of all items together was high, with an ct

coefficient of .869, indicating, as was the case with thepsychopathology items, that the structure represented inTable 2 is weak, and that it is reasonable to sum items into asingle index reflecting a bipolar construct of positive andnegative self-concept. This index, to be used in furtheranalyses below, was named negative self-concept since highscores would reflect the right pole of the measure.

To explore the construct validity of the scales (throughthe concurrent validity method), correlations between thetwo sets of measures were calculated. It was expected thatadolescents experiencing higher levels of psychopathologywould also have more negative self-conceptions. As indi­cated in Table 3, the correlation between general psychopa­thology and negative self-concept was .479, which is moder­ately high. In particular, low confidence and low satisfactionself-concept subscales were correlated moderately withpsychopathology (Table 3). Moreover, the strongest correla­tion of social anxiety was with low confidence, as was that ofanxiety state. The strongest correlation with depressivestate was with low satisfaction.

RESULTS

Analyses of variance comparing genders andgroups were conducted for both psychopathol­ogy and self-concept measures. For compari­sons involving the three dimensions from eachof the psychopathology and self-concept mea­sures, estimated regression factor scores wereused from the orthogonally rotated solutions. Inaddition to these analyses, the effects of genderand groups were sought in the two general

Table 3. Correlations Between Pathology and Self-ConceptMeasures

Low Low Low NegativeConfidence Self·Worth Satisfaction Self·Concept

Social anxiety .335t .104t .118t .344tAnxiety state .259t -.035 .142t .224tDepressive state .101 * .071 .299t .262tGeneral psych-

pathology .409t .081* .311t .479t

*p < .05.tP < .01.

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indices general psychopathology and negativeself-concept, which were shown above to havehigh internal consistency.

Table 4 summarizes the findings of thesecomparisons and gives a breakdown of the meanscores according to gender and groups. Asindicated in Table 4, none of the comparisonsshowed a significant effect of groups in relationto the three psychopathology indices or thegeneral psychopathology index. Girls did notdiffer from boys on social anxiety and depressivestate factors. However, girls were found to scoresignificantly higher than boys on the anxietystate dimension. None of the two-way interac­tions between gender and groups were signifi·cant.

With respect to the self-concept measures, ascan be seen in Table 4, girls scored significantlyhigher than boys on low confidence. In addition,a main effect of groups was found to be signifi­cant. The interaction between gender and groupswas not significant on this measure. Exploringthe main effect of groups with post-hoc Scheffecontrasts failed to find any two groups signifi­cantly different from each other, suggesting thatthe effect is small and unreliable. As Table 4indicates, groups were also significantly differ­ent with respect to scores on the low self-worthfactor. Further post-hoc explorations indicatedthat the refugee group (R) scored significantlyhigher than all other groups on this factor. Themain effect for gender and the interaction

KLiMIDIS ET AL

between gender and groups were not significantfor the low self-worth measure.

Similar comparisons for the general measurenegative self-concept indicated significant maineffects for gender and groups (Table 4). Theinteraction between groups and gender was notsignificant. Higher negative self-concept scoresare evident for females compared with males.Post-hoc Scheffe contrasts exploring the maineffect of groups showed significantly higherscores for the refugee group compared with allAustralian-born adolescents (Le., A and Sgroups), and immigrant adolescents (group I)scored significantly higher than the group whowere Australian-born of Australian-born par­ents (group A).

Table 5 presents results of analyses con­ducted at the level of each item from thepsychopathology and self-concept scales. Clearly,the effect of immigrant-status group was notsignificant at the item-level analysis, with twoexceptions. For the first exception, "panicky inpublic places," post-hoc comparisons indicatedhigher scores for the refugee group comparedwith the two native-born groups, whereas forthe second exception, "committed sin," second­generation adolescents scored significantlyhigher than group A. The overall uniformity ofthe negative results, contrary to expectationsfrom the migration-morbidity hypothesis, is moreimpressive than the few exceptions, only one ofwhich can be regarded as being consistent with

Table 4. Means and F Statistics for Group and Gender Contrasts

Boys Girls F Value

A S R A S R Gender Group

Pathology

Social anxiety -.106 -.077 -.102 -.467 .085 -.008 .089 -.029 NS NS

Anxiety state -.435 -.455 -.447 -.538 .270 .278 .294 .031 74.8:1: NS

Depressive state -.060 .174 .277 .048 -.125 .102 .006 -.043 NS NS

General psychopathology 10.49 11.21 10.13 11.35 13.73 14.24 14.32 12.68 29.2:1: NS

Self-concept

Low confidence -.549 -.437 -.168 .030 .119 .176 .314 .287 47.9:1: 3.4*

Low self-worth .005 -.242 -.231 .564 -.195 -.148 .165 .690 NS 17.3:1:

Low satisfaction .006 -.070 .023 .313 -.001 -.067 .127 -.204 NS NS

Negative self-concept 23.01 22.07 23.60 30.00 25.52 25.88 28.89 29.39 35.4:1: 5.8t

Abbreviations: A. Australian-born adolescents with Australian-born parents (n = 253); S. Australian-born adolescents with parents

who were born in non-English-speaking countries other than Vietnam, the second-generation group!n =171); I, overseas-born

adolescents who were children of overseas-born parents from non~English-speakjngcountries other than Vietnam, the immigrant

group (n =101); R,Vietnam-born adolescents with Vietnam-born parents, the refugee group!n = 91).*p < .05.

tP < .01.

:l:P < .001.

Gender Group

table 5. F Statistics for Group and Gender Contrastsfor Each Item

THE MIGRATION-MORBIDITY HYPOTHESIS

Pathology items

Social anxietyFelt shy and embarrassed when I was

with othersBeen concerned about what other

people think of meBeen feeling that others judge me badlyBeen feeling that others are watching or

talking about me

Felt afraid or panicky in places wherethere are many people

Felt unattached or unconnected to

people andthings

Anxiety stateNoticed parts of my bodyfeel tense or

tight

Had a number of aches and painswithout reason

Had headaches or pressure in the headFelt tense, unsettled, or restlessNoticed my heart racing or pounding

hardFelt nervousness or shakiness inside

Depressive stateFelt cursed or doomed foreverHad thoughts about death or ending my

lifeBeen feeling that the future is hopeless

Worried that something bad will happenin the future

Felt like I committed the most wicked,

unforgivable sinWorried that something in my life is left

unfinished or unsettled

Self-concept itemsLow confidence

Relaxed-nervousSecure-insecureConfident-unsure

Steady-shakySuperior-inferior

Low self-worthNice-awful

Valuable-worthlessLoved-hatedPopular-unpopular

Productive-unproductiveHopeful-hopeless

Low satisfactionPeaceful-unsettledSatisfied-dissatisfied

Stable-unstableHappy-sad

'p < .05.

tP < .05.:l=P < .01.§P < .001.

7.1:1: NS

9.6:1: NSNS NS

NS NS

8.1:1: 9.7:1:

3.8' NS

17.3§ NS

27.3§ NS62.0§ NS28.44§ NS

20.4§ NS35.0§ NS

NS NS

NS NS

10.0:1: NS

6.6t NS

NS 5.5:1=

NS NS

19.7§ 3.3t20.3§ NS29.3§ NS

NS 13.6§

29.5§ NS

NS 8.3§

NS 12.3§9.6§ 7.5§

13.6§ 9.7§

12.2§ 13.0§

NS 8.8§

NS NS

NS NS12.6§ NS

NS 2.8t

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the hypothesis. Only one interaction term waSfound to be significant at the item-level analysisfor the item "unattached or unconnected topeople and things around me" [F(3, 608) = 3.27,P < .05], and inspection of the group means(not shown here) suggested that the differinggroup was the immigrant boys (I), with scoreslower on this item than the remaining groups,particularly compared with the female samples.

The item-level analysis (Table 5) showswideranging gender differences, adding to theinformation gathered through the analysis offactor scores. Girls scored significantly higherthan boys on all items constituting the anxietystate scale. Four of the six items in the socialanxiety scale were found to discriminate be­tween boys and girls, with girls having highermean scores on all social anxiety items. Twoitems from the depressive state scale discrimi­nated between boys and girls, with girls againhaving higher mean item scores. Both of theseitems represent anxious ruminations about thefuture, and both items have partial loadings onthe anxiety state factor (Table 2). It may be saidthat the general trend of the findings is that thegirls in the sample experienced higher levels ofanxiety state and social anxiety than boys.

In relation to the effect of immigrant statuson self-concept item scores, the item~level analy­sis generally parallels the findings from thefactor~score analysis. That is, group differenceswere mainly evident for the low self-worth scaleitems. Of the three exceptions (Table 5), resultspertaining to the items "relaxed-nervous" and"happy-sad" were not reliable, since post-hocScheffe comparisons failed to find significantdifferences among the groups. Post-hoc con­trasts for the item "steady-shaky" indicated thatthe refugee group scored significantly higherthan all other groups. With the items from thelow self-worth scale, consistent with the factor­score analysis, the refugee group was found toscore higher than remaining groups on all items.Significantly elevated scores for this group com­pared with all remaining groups were foundfor the items "nice-awful" and "popular­unpopular." The refugee group scored signifi­cantly higher than the two native-born sampleson the remaining items. In addition, the immi­grant group scored higher than the two native­born groups on the item "valuable-worthless,"

400

and they scored higher than the second­generation group on the item "productive­unproductive." Only one interaction term provedsignificant, that relating to the item "stable­unstable" [F(3, 608) = 3.83, P < .05], and fur·ther inspection of the group means (not shownhere) suggested that refugee boys scored higher(more unstable) than the remaining groups onthis item. Overall, it cannot be said from theseminor differences in scores between groups thatimmigrant adolescents have a higher negativeself-evaluation. On the other hand, refugeeadolescents appear to have more negative self­constructions, particularly in the domain ofself-worth.

Gender differences on self-concept items re­flected those found with analysis of the factorscores from the low confidence dimension. Allbut one item (Table 5) from this scale discrimi­nated between the genders, with girls describingthemselves, compared with boys, as less relaxed,secure, confident, and superior. In addition,several items from the remaining scales werefound to discriminate between genders (Table5). Girls described themselves as more lovedbut less popular, productive, and stable thanboys. In general, gender differences in theself-concept measures are consistent with thosefound with the psychopathology scales wherethere were higher scores for girls compared withboys on anxiety state and social anxiety items.

DISCUSSION

The results of the present study fail to sup­port the migration-morbidity hypothesis. Noconsistent effect of immigrant status could bedemonstrated on the four measures ofpsychopa­thology-social anxiety, anxiety state, depres­sive state, and the overall index of generalpsychopathology. Item-level analyses confirmedthis picture, suggesting that the negative find­ings were not due to dilution of differencesresulting from having discriminating and nondis­criminating items contributing to the more gen­eral scores (i.e., factor and sum-of-items scores).The results are consistent with other studiesthat have used appropriate comparative method­ology, 10-14 but are inconsistent with studies usinggeneral indices (such as health, social, or wel­fare contact statistics) and studies lacking appro­priate control samples.2,6,7 The present study,

KLIMIDIS ET AL

together with that of Fichter et al.,14 providesstrong evidence against the migration-morbidityhypothesis. An advantage of the present studylies in the sampling of a wide variety of immi­grant and second-generation adolescents interms of ethnic origin, thus randomizing anyspecific symptom-report biases that may exist inparticular cultural groups. Although cultureand immigrant status is confounded with re­spect to the refugee group, no symptom-leveldifferences were found between this group andother samples.

As in studies with adult samples examiningthe same issue,36-38 it is important that furtherstudy in the area of morbidity risk be framed asa multifactorial question that considers a widevariety of factors, including premigration, migra­tion, and postmigration resettlement factors. AsFabrega39 notes, in drawing together the find­ings of studies with adult samples, "The strictepidemiological approach which aims to showwhether psychiatric disorder is or is not mademore likely in specific instances of migrationand/or acculturation appears rather simplisticwhen one considers the complexity of issuesbrought into play when individuals of a particu­lar background move to or live in an environ­ment that contains individuals and groups follow­ing cultural patterns that are different" (p. 324).We consider Fabrega's comment to be of rel­evance to the study of adolescent samples. It isprobable that a multifactorial approach accom­modating the variation suggested by Fabrega39

and others36-38 will demonstrate that there arerisk factors common to all adolescents, regard­less of immigrant status or ethnicity (for ex·ample, the effects of gender on symptom re­port), and that there are some specific factorsapplying to only some groups,such as exposureto traumatic incidents among refugee adoles­cents. Further analyses of results from oursample will explore sociodemographic and per­sonal-history variables that may elucidate differ­ential risk of psychological morbidity, indepen­dent of immigrant status.

In addition to failing to find differences in theprevalence of psychopathology, only one of theself-concept measures, low self-worth, discrimi­nated between immigrant-status groups reli­ably. Vietnamese refugee adolescents scoredhigher on this scale than both native-born

THE MIGRATION-MORBIDITY HYPOTHESIS

groups, but did not differ from other immigrantadolescents. Immigrant children differed onlyfrom the native-born group with native-bornparents and did not differ from the second­generation group on this measure. Low self­worth includes self-descriptors of awful, worth­less, hated, unpopular, unproductive, andhopeless. Nevertheless, no immigrant-status dif­ferences could be found on the other twoself-concept measures, i.e., low confidence andlow satisfaction, which were most strongly re­lated to the three scales of psychopathology(i.e., social anxiety, anxiety state, and depressivestate). Item-level analyses confirmed these find·ings in showing generally a uniform differencebetween refugee adolescents and the remainingsamples on the low self-worth scales. It ispossible that the items comprising the lowself-worth factor measure a relatively commonoutcome of Vietnamese youth living in Austra­lia. It is possible that this group's cultural andracial distinctiveness has led to experiences ofprejudice and discrimination that have pro­moted self-reflections of lower popularity, lowerperceptions of being loved, worthlessness, andhopelessness, and higher self-ratings of awful.For example, preliminary analyses in our sampleof refugees have indicated a small but signifi­cant correlation (in the order of .25) between ameasure of experienced discrimination and lowself-worth factor scores. Scores from the remain­ing two factors were not related to discrimina­tion experiences.

Alternatively, there may be cultural differ­ences in self-concept structure that underlie thereported differences found between the refugeesample and the remaining adolescent samples.There is a general agreement that self-concep­tions are influenced by sociocultural variables40

such as collectivism and individualism. Ethno­graphic and clinical accounts suggest that tradi­tional Vietnamese culture is collectivist in orien­tation,41,42 contrasting with the individualistorientation of, in particular, our Australiansample. Other cultural dimensions have alsobeen discovered empirically.43 However, we arenot aware of any studies that explore directlythe relationship between semantic differentialmeasures of self-concept like the ones we haveused and such cultural dimensions. It is interest­ing, too, that self-concept differences in the

401

refugee adolescents compared with the remain­ing groups were not reflected in differences inthe psychopathology items. The reason for thisis unclear. It is possible that although lowself-worth scores were higher in the refugees,these were not sufficiently high to reach expres­sion in actual psychopathological signs andsymptoms. It is also possible that the high socialstigma attached to mental disorder and itssymptoms in Vietnamese culture 44 may havesuppressed report of items that are more obvi·ous measures of disorder, as are the psychopa·thology items compared with the self-conceptitems. There is a need for further research onthe influence of social desirability on self·reported psychiatric complaints in Vietnameseyouth.

Gender differences were apparent in self­reported psychopathology, with higher scoresfor girls. The higher rate of self-reported psycho­pathology in girls is consistent with studies usingself-report indices such as the General HealthQuestionnaire14 and the mental health sectionof the Cornell Medical Index16 and with thosestudies applying standard diagnostic interviewprocedures.27 Consistent with the study by Rob­erts,26 which found girls to be more self­conscious and to have higher levels of socialanxiety than boys, the present results indicateddifferences between boys and girls on the major­ity of the social anxiety scale items. Only anonsignificant trend was found at the level offactor-score analysis that indicated higher scoresfor girls on the social anxiety measure, suggest­ing a dilution of the score due to nondiscriminat­ing items. In contrast to the report by Roberts,26which found no gender differences on the State­Trait Anxiety scale, the present study foundhigher scores on the anxiety state factor forgirls, which contained many somatic symptoms.In the present study, large-effect size differ­ences between genders on all individual itemsfrom the anxiety state scale were evident. Thereason for the difference in findings betweenthe two studies is unclear, particularly given thesimilarity in the content of the anxiety measuresused in the two studies.

The expected difference between boys andgirls in depression was not found in the presentstudy. Several studies24.26 with adolescentsamples found higher scores for girls on the

402

Center for Epidemiologic Studies DepressionScale, and a higher diagnosed prevalence ofdepression was reported for girls by McGee etai.27 using interview procedures. It is not clearwhy the present sample did not show this trend.It is possible that differing item content in theassessment procedures may be responsible forthe different results. Further analysis of theitems from the depression scale in the presentstudy did show higher scores on two items forgirls compared with boys-"feeling that thefuture is hopeless" and "worried that somethingbad will happen in the future"-but there wereno differences in the key item "I have hadthoughts about death or ending my life," nor onitems reflecting contrition beliefs. The latterhad relatively low base rates, which might ex­plain the lack of gender difference on thesevariables. Endorsement rates based on thesample percentage endorsing the item as occur­ring "often" (in the past 3 months) for the twocontrition beliefs were 5.7% (for "felt like Icommitted the most wicked, unforgivable sin")and 4.0% (for "felt like I am cursed or doomedforever") of the sample. This compares to15.8% and 21.4% rates in the two items wheregender differences were found. Although thevalidity of contrition-belief items in depressionhas been established with clinical popula­tions,45.46 it may be said that their relevance asscreening items for depression in communitysamples such .as the present may be limited.This is supported by the fact that such beliefshave been considered within the domain ofdelusions in previous studies and to be particu­larly linked to cases with psychotic depres­sion.45,46 The combined effect of low endorse­ment frequency on some items and genuine lackof difference in gender endorsement in others islikely to have led to a lack of difference ingender comparisons in the overall score fromthe depressive state dimensions in the presentstudy. In addition, the two depression itemswhere girls did score significantly higher thanboys both loaded partially on the anxiety statefactor, and the gender differences found inthese items may simply reflect differences in theexperience of anxiety symptoms (rather thandepression) for the period of assessment.

The present study found a number of signifi­cant differences between genders on the self-

KLiMIDIS ET AL

concept measures. Analyses of factor scoresindicated that girls scored higher than boys onthe low confidence dimension, which includeddescriptors of tension (e.g., relaxed v nervous)along with character descriptors (e.g., secure vinsecure). The gender differences in this dimen·sion are consistent with the gender differencesfound in relation to anxiety state and socialanxiety measures. In addition, compared withboys, girls tended to rate themselves as moreunpopular, unproductive, hopeless, and un­stable. Monge33 reported gender differences insemantic differential scales similar to those ofthe present study using a sample of over 4,300subjects varying in age from 9 to 89 years.Inspecting the common items between the pre­sent study and Monge's study indicated thatfemales in that study were more likely thanmales to describe themselves as inferior, worth­less, unsure, and shaky (comprising in partMonge's Leadership factor) and were morelikely than males to describe themselves asunstable, nervous, and dissatisfied (comprisingin part Monge's Adjustment factor). Althoughthe present factor structure differs from Monge's(as might be expected, given that the presentstudy included different scale items), there isconsiderable similarity in the findings with re­spect to gender differences on the commonself-concept items in the two studies.

In conclusion, the present study dealt withthe question of whether immigrant and refugeeadolescents are at higher risk for psychologicalmorbidity than native-born controls (includingsecond-generation controls). This was termedthe migration-morbidity hypothesis. The resultssupported rejection of this hypothesis. Only oneset of measures (reflecting low self-worth)showed reliable differences, with only the refu­gee group scoring differently compared with theremaining groups. Further investigations of riskof psychological morbidity in immigrant adoles­cents need to be conducted within a multifacto­rial framework that can identify common andspecific risk factors in different ethnic minoritysamples of adolescents. This will form the sub·ject of a future report from our group.

ACKNOWLEDGMENT

The authors gratefully acknowledge the assistance of D.Lloyd, N. Ranieri, and Dr. C. Batten in the development ofthis investigation.

THE MIGRAtiON-MORBIDITY HYPOTHESIS

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