J Immigrant Minority Health DOI 10.1007/s10903-014-0143-3
ORIGINAL PAPER
Differences in Psychopathology Between Immigrant and Native Adolescents Admitted to a Psychiatric Inpatient Unit Ana Bla´zquez • Josefina Castro-Fornieles Inmaculada Baeza • Astrid Morer • Esteban Martı´nez • Luisa La´zaro
•
Ó Springer Science+Business Media New York 2014
Abstract It has been postulated that immigrant children are at increased risk of mental health problems. This study examined differences in psychopathology between immigrant and non-immigrant adolescents admitted for the first time to a child and adolescent inpatient psychiatry unit. Participants were 234 adolescents (191 non-immigrants and 43 immigrants). There were significant differences between the two groups in relation to certain stressors: parental separation, family breakdown, being under state custody, physical and/or psychological maltreatment and sexual abuse. Differences between the main diagnoses of the two groups were found in relation to schizophrenia and anorexia nervosa. There are differences between immigrants and natives in terms of diagnosis, and these differences are influenced by ethnicity and stressors. Future studies should seek to identify protective factors in order to prevent mental health disorders in the immigrant population.
A. Bla´zquez (&) J. Castro-Fornieles I. Baeza A. Morer E. Martı´nez L. La´zaro Department of Child and Adolescent Psychiatry and Psychology, Institute of Neurosciences, Hospital Clı´nic Universitari, C/Villarroel n8170, 08036 Barcelona, Spain e-mail: [email protected] J. Castro-Fornieles I. Baeza A. Morer L. La´zaro IDIBAPS (Institut d’Investigacions Biome`diques August Pi i Sunyer), Barcelona, Spain J. Castro-Fornieles I. Baeza A. Morer L. La´zaro Department of Psychiatry and Clinical Psychobiology, University of Barcelona, Barcelona, Spain J. Castro-Fornieles L. La´zaro CIBERSAM, Barcelona, Spain
Keywords Adolescents Immigration Acculturation Mental health Risk factors
Background Over the last decade, the immigrant population of Catalonia (an autonomous community in north-eastern Spain) has increased dramatically. Figures for January 2014 show that approximately 15 % of the Catalonian population could be considered as immigrants from a wide range of countries including Morocco, Romania and Ecuador [1]. Latin Americans represent the single largest immigrant group in Spain (36 %) [2], with 50 % of them being women [1, 3]. Approximately 30 % of immigrants come from European countries and 25 % from Africa [2]. Latin American families do not typically immigrate as one unit, it being common for the mother to come first to Spain, leaving her children behind in the country of origin. In most cases children re-join their mother after a number of years, and this reunification during adolescence could increase conflicts with parents, especially as some children may resent being left behind [4]. Several studies have suggested that immigrant children are at increased risk of mental health problems [4–6], and three main reasons have been put forward to explain this: firstly, the stress caused by migration (due to loss of friends, family, etc.); secondly, the stress caused by adaptation to a society in which they are in a minority position and where they are sometimes the victims of racism or discrimination; and thirdly, the acculturation process, whereby immigrants have to adapt to a new cultural environment [3, 6, 7]. The purpose of acculturation is to adapt to the dominant culture, and this may mean that immigrants lose their original cultural identity. These
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adjustments to new beliefs, routines or social roles can cause acculturative stress [7]. The most common nosological categories associated with immigrant children are psychotic disorders, depression, post-traumatic stress disorder and conduct disorders [8–11]. Pre-emigration experiences, the stress caused by migration, social adversity and the acculturation process seem to predispose immigrants to developing a psychotic disorder [9, 12, 13]. It has also been hypothesized that people with a genetic or environmental predisposition to psychosis are more likely to emigrate to a foreign country [14]. In a meta-analysis of migration and schizophrenia in adults Cantor-Graae and Selten [15] found that the risk of developing a schizophrenic disorder was 2.9 times higher in immigrants than in non-immigrants. This risk can also differ markedly according to ethnic origin, and studies carried out with adults in European countries have found, for example, an increased risk of schizophrenia among immigrants from Surinam or Morocco [1]. Depressive and anxiety disorders are also frequent in immigrants, and the risk of developing the former varies according to ethnic group [3]. In Latin American adolescents depressive and anxiety disorders have been associated with pre-emigration stressors such as poverty, sexual abuse, maltreatment or substance abuse, acculturation and dissatisfaction with the decision to migrate [8, 10, 16]. Conversely, previous studies have found that school connectedness was the strongest protective factor, with family connectedness and religious attendance/religiosity having a roughly equivalent protective association [8, 17, 18]. Other studies have also demonstrated that ethnic culture competence promotes psychological adaptation within own ethnic socio-cultural settings whereas host culture competence facilitates adaptation within the mainstream society [19, 20]. After adjusting for socio-demographic factors and social support, differences in depressive symptoms between Latin American adolescents and Spanish natives disappear [16]. The literature also reports a predisposition to suicidal behaviour among adolescent Latin American immigrants [9, 10], although the risk of completed suicide is lower than in other ethnic groups [21]. Expectations related to family obligations appear to play an important role in suicidal behaviour [22], and high levels of acculturative stress have been shown to be correlated positively with suicidal behaviour [8]. However, the findings for conduct disorders (oppositional defiant disorder and conduct disorder) are contradictory. A review of research with adolescents concluded that differences in the diagnosis of behavioural disorders depend highly on the informant and on the measure used [6]. The aim of the present study was to analyse retrospectively the differences in certain stressors and diagnoses between immigrants and natives admitted for the first time
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to an adolescent psychiatric inpatient unit in Spain, as well as to identify potential stressors that may influence the mental health of immigrants.
Methods Participants and Data Collection For this retrospective study the charts of all patients admitted between October 2009 and March 2011 to the inpatient unit of the Department of Child and Adolescent Psychiatry and Psychology of the Hospital Clinic, Barcelona were reviewed. Only those patients who were admitted for the first time were selected. The immigrant group was defined as: children or adolescents born in a foreign country, who moved to Spain for the purpose of permanent residence and who migrated at the same time as their parents or who re-joined them some years later. Children born in other countries and adopted by Spanish families were excluded in order to identify which pre-emigration stressors might be associated with the psychiatric disorders presented by immigrants. All procedures were approved by the hospital’s Ethics Committee. Measures For both immigrant and native adolescents the following socio-demographic data were collected: sex, age, country of origin and parental socio-economic status (SES), the latter being estimated by means of the Hollingshead Redlich scale [23]. A series of potential stressors was also analyzed: pre-emigration stressors such as physical and/or psychological maltreatment and sexual abuse and migration and post-migration stressors such as parental separation, family breakdown, being in state custody and the number of months separated from mother. With respect to diagnoses, inpatients were assigned a final DSM-IV-TR diagnosis on discharge, generated by comprehensive assessments carried out by the attending psychiatrist. Main and comorbid diagnoses were established according to DSM-IV-TR criteria [24]. Statistical Analysis All data were analysed using SPSS 15.0 for Windows. The Kolmogorov–Smirnov test was used to assess the normality of variables, while the percentages of discrete variables were compared by means of the Chi-squared or Fisher’s exact test. The Student’s t test was used to compare means of continuous variables between immigrants and natives. Variables that were significant in the bivariate analysis
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were subsequently entered into a logistic regression analysis to identify factors that were independently associated with main diagnoses. The aim was to determine which stressors or demographic characteristics might best predict the different diagnoses. Statistical significance was set at p \ 0.05. The minimum sample size was calculated previously (for the main comparisons) in order to ensure that the analysis had sufficient statistical power. Therefore, considering a desired statistical power level of 0.8 and a probability level of 0.05, the N was 43.
Table 1 Differences between the two groups in relation to potential stressors Immigrants (N = 43) N%
Nonimmigrants (N = 191) N%
v2
pa
Pre-emigration stressors Physical and/or psychological maltreatment Sexual abuse
8 (18.6)
5 (3.6)
6.96
0.021
5 (11.6)
3 (1.6)
22.73
0.000
Migration and post-migration stressors
Results
Differences in Stressors Between the Two Groups Table 1 lists the potential stressors which were analysed. There were significant differences between the two groups in relation to parental separation, family breakdown, being under state custody, physical and/or psychological maltreatment and sexual abuse.
29 (67.4)
72 (37.7)
12.69
0.001
Family breakdown
15 (34.9)
17 (8.9)
20.07
0.000
6 (13.9)
8 (4.2)
5.95
0.026
Being in state custody
Descriptive Characteristics of the Sample The initial sample included 244 adolescents who had been admitted for the first time. After excluding children born in other countries and adopted by Spanish families (N = 10) the final sample comprised 234 patients (43 immigrants and 191 natives). Of the 43 immigrants, 19 were males (44.2 %) and 24 females (55.8 %), while the natives were 82 males (42.9 %) and 109 females (57.1 %). The mean age of immigrants and non-immigrants was, respectively, 14.86 years (SD = 1.66) and 14.33 years (SD = 2.19). There were no significant differences between the groups in terms of sex or age. Most of the immigrants came from Central or South America (67.4 %), with the countries of origin being Ecuador (18.6 %), Peru and Brazil (11.1 % each), Uruguay, Colombia and the Dominican Republic (7.0 % each), and Argentina and Cuba (2.3 % each). The other immigrants came from European countries (16.3 %: Poland, 4.7 %; Romania, 4.7 %; Bosnia, Germany and France, 2.3 % each), from Africa (Morocco, 11.6 %) and from Asia (Bangladesh, 4.7 %). The mean number of months in Spain was 68.91 (SD = 36.51). There was a significant difference between the parental SES of natives (mostly middle; mean score = 36.18, SD = 17.01) and immigrants (mostly low-middle; mean score = 45.84, SD = 20.64) (t = 3.23, p \ 0.001).
Parental separation
v2 Chi-square a
Fisher’s exact test
considered as the main one. The most prevalent diagnoses in immigrants were psychotic disorders (including schizophrenia, schizoaffective disorder and unspecified psychotic disorder) and affective disorders (including bipolar disorder and major depressive disorder). In non-immigrants the most prevalent diagnoses were eating disorders (mainly anorexia nervosa), affective disorders and conduct disorders (oppositional defiant disorder and conduct disorder). There were significant differences between immigrants and non-immigrants in relation to schizophrenia and anorexia nervosa. As regards comorbid diagnoses the most prevalent diagnosis in immigrants was cannabis misuse, while for natives the most prevalent were cannabis misuse, attention deficit hyperactivity disorder and conduct disorders. Significant differences were found between immigrants and natives in relation to adjustment disorder and post-traumatic stress disorder, which were more prevalent among immigrants. The sample of immigrants was then divided into four groups (Latin Americans, Europeans, Africans and Asians). In Latin Americans the main diagnoses were psychotic disorders (27.6 %), major depressive disorder (20.7 %) and bipolar disorder (17.3 %). Psychotic disorders were the main diagnosis in Europeans and Africans (28.5 and 40 %, respectively), whereas in Asians the main diagnoses were psychotic and anxiety disorders (50 % each). Differences in Demographic Characteristics and Stressors According to Different Diagnoses
Main and Comorbid Diagnoses Table 2 shows the main and comorbid diagnoses at discharge. The diagnosis which led to admission was
Table 3 shows the comparison of demographic factors and stressors with respect to different diagnoses in the sample as a whole (immigrants plus natives). In the bivariate
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J Immigrant Minority Health Table 2 Main and comorbid diagnoses
Adjustment disorder
Immigrants, N % (N = 43)
Non-immigrants, N % (N = 191)
Main diagnosis
Main diagnosis
Comorbid
Main diagnosis
Comorbid
pa
Comorbid diagnoses pa
4 (9.3)
2 (11.1)
12 (6.3)
0
0.504
0.033
7 (16.3) 5 (11.6)
0 0
25 (13.1) 10 (5.2)
1 (1.2) 0
0.624 0.161
1.000 – 0.033
Affective disorders Major depressive disorder Bipolar disorder Anxiety disorders Post-traumatic stress disorder
2 (4.7)
2 (11.1)
1 (0.5)
0
0.088
Obsessive–compulsive disorder
2 (4.7)
1 (5.6)
65 (3.1)
1 (1.2)
0.642
0.229
Generalized anxiety disorder
1 (2.3)
2 (11.1)
9 (4.7)
4 (4.7)
0.694
0.304
Attention deficit hyperactivity disorder
1 (2.3)
2 (11.1)
12 (6.3)
23 (27.4)
0.472
0.271
Cannabis misuse
0
8 (44.4)
10 (5.2)
27 (32.4)
0.215
0.480
Conduct disorders Oppositional defiant disorder
2 (4.7)
0
19 (9.9)
11 (13.1)
0.223
0.382
Conduct disorder
1 (2.3)
1 (5.6)
9 (4.8)
7 (8.3)
0.694
1.000
0
0
0
2 (2.3)
–
1.000
Conversion disorder Eating disorders Anorexia nervosa
4 (9.3)
0
50 (26.2)
4 (4.7)
0.016
0.596
Bulimia nervosa
1 (2.3)
0
3 (1.5)
0
0.559
–
0
0
3 (1.6)
3 (3.5)
1.000
1.000
Pervasive developmental disorder Psychotic disorders Unspecified psychotic disorder
7 (16.3)
0
16 (7.5)
0
0.512
–
Schizophrenia
4 (9.3)
0
2 (1.0)
0
0.011
–
Schizoaffective disorder
0.088
2 (4.7)
0
1 (0.5)
0
Tic disorder
0
0
1 (0.5)
1 (1.2)
1.000
1.000
No Axis I diagnosis
0
0
2 (1.0)
0
1.000
–
Total
43
18
191
84
234
102
a
Fisher’s exact test
analysis, patients with a psychotic disorder tended to be male immigrants with a significantly lower mean SES score. Patients with an eating disorder were predominantly female non-immigrants with a stable nuclear family and a significantly higher mean SES scores. Anxiety disorders were associated with immigrants and victims of sexual abuse. Family breakdown was related to attention deficit hyperactivity disorder, while parental separation was linked to conduct disorders. Logistic regression analyses were then conducted with the statistically significant variables (for each diagnosis) from the bivariate analysis (see Table 4). Being a victim of sexual abuse was the best predictor of post-traumatic stress disorder and generalized anxiety disorder, predicting 94.9 % of anxiety disorders. Family breakdown predicted 94.4 % of attention deficit hyperactivity disorder cases. As regards eating disorders, female gender and no parental separation predicted 75.6 % of cases. Male gender and being an immigrant predicted 87.2 % of psychotic disorder cases.
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Immigrant Diagnoses and their Relationship with Stressors The relationship between diagnoses and stressors was analysed in the immigrant group. In the bivariate analysis statistically significant associations were found for sexual abuse and anxiety disorders (especially post-traumatic stress disorder: v2 = 9.26, p = 0.016), as well as for family breakdown and adjustment disorder (v2 = 8.26, p = 0.016). Due to the small sample no regression analysis was performed.
Discussion This study found statistically significant differences in the diagnoses given to immigrant and non-immigrant adolescents admitted for the first time to a psychiatric inpatient unit. In immigrants psychotic disorders (mainly schizophrenia) and affective disorders (bipolar disorder and
61.5/38.5 61.5/38.5 53.3/46.7 45.2/58.8 5.2/94.8 31.3/68.7 75.0/25.0
Anxiety disorders (post-traumatic stress disorder ? generalized anxiety disorder) N = 13
Attention deficit hyperactivity disorder N = 13 Bipolar disorder N = 15
Conduct disorders N = 31
Eating disorders N = 58
Major depressive disorder N = 32
Psychotic disorders N = 32
3.1/96.9 12.5/78.5
Eating disorders N = 58
Major depressive disorder N = 32
Psychotic disorders N = 32
b
Student’s t test
Fisher’s exact test
6.5/93.5 0/100
Conduct disorders N = 31
15.4/84.6 0/100
Attention deficit hyperactivity disorder N = 13
7.7/92.3
Anxiety disorders (post-traumatic stress disorder ? generalized anxiety disorder) N = 13
Bipolar disorder N = 15
12.5/87.5
Yes/no (%)
Adjustment disorder N = 16
a
15.33
2.14
45.36
0.58
1.89 0.67
1.89
0.01
v
2
2.79
0.54
4.91
0.14
1.02
2.16
0.72
1.29
v2
Being under state custody
43.8/56.2
Adjustment disorder N = 16
Male/female (%)
Sex
0.107
0.699
0.024
1.000
0.608
0.178
0.561
0.246
pa
0.000
0.179
0.000
0.847
0.249 0.432
0.249
1.000
p
a
0.87
0.58
2.45
0.03
-2.27
0.06
1.40 -1.38
t
0.015
0.971
0.024
0.954
0.162 0.169
0.981
0.560
p
b
59.4/40.6
53.1/46.9
22.4/77.6
61.3/18.09
23.1/76.9 46.7/53.3
46.2/53.8
50.0/50.0
Yes/no (%)
9.4/90.6
3.1/96.9
0/100
3.2/96.8
6.7/93.3
7.7/92.3
30.8/69.2
6.3/93.8
Yes/no (%)
0.21
0.12
3.44
0.96
1.02
0.39
0.72
0.16
v2
1.000
1.0000
0.071
1.000
0.608
0.442
0.100
0.515
pa
3.97
1.50
13.53
0.06
2.26 0.80
0.50
0.33
v
2
Parental separation
Physical and/or psychological maltreatment
45.16/18.49
38.06/19.38
33.31/14.91
38.13/18.09
44.77/21.22 31.73/18.06
42.23/.19.14
40.50/15.73
Mean/SD
SES
Table 3 Differences in demographic characteristics and stressors according to different diagnoses (immigrants plus natives)
21.9/78
25.0/75.0
0/100
16.1/83.9
38.5/61.5 6.7/93.3
7.7/92.3
25.0/75.0
Yes/no (%)
3.1/96.9
9.4/90.6
0/100
0/100
6.7/93.3
0/100
30.8/69.2
6.3/93.8
Yes/no (%)
2.36
1.81
3.81
1.76
0.19
0.68
20.88
0.09
v2
12.11
4.03
12.22
0.18
7.16 0.67
0.42
1.87
v2
Family breakdown
Sexual abuse
0.055
0.252
0.000
0.954
0.159 0.793
1.000
0.608
p
a
0.143
0.178
0.070
0.368
0.525
1.000
0.022
0.549
pa
0.166
0.550
0.000
0.587
0.020 0.700
1.000
0.246
pa
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J Immigrant Minority Health Table 4 Variables predicting diagnoses Post-traumatic stress disorder ? generalized anxiety disorder N = 13
Attention deficit hyperactivity disorder N = 13
Conduct disorders N = 31
Eating disorders N = 58
Odds ratio (95 % CI)
p
Odds ratio (95 % CI)
p
Odds ratio (95 % CI)
p
Odds ratio (95 % CI)
p
Odds ratio (95 % CI)
p
Sex
–
–
–
–
–
–
0.41 (0.01–0.14)
0.000
5.14 (2.12–12.49)
0.000
Immigration
0.37 (0.56–2.49)
0.309
–
–
–
–
0.67 (0.21–2.17)
0.502
3.86 (1.59–9.32)
0.003
SES
–
–
–
–
–
–
1.01 (0.98–1.03)
0.588
0.98 (0.96–1.01)
0.144
Parental separation
–
–
–
–
2.35 (1.08–5.07)
0.032
0.43 (0.19–0.95)
0.036
–
–
Family breakdown
–
–
4.49 (1.37–14.73)
0.013
–
–
0.00
0.998
–
–
Being under state custody
–
–
–
–
–
–
–
–
–
–
Sexual abuse
24.48 (3.84–156.02)
0.000
–
–
–
–
–
–
–
–
Psychotic disorders N = 32
Bold values represent Fisher’s exact test
major depressive disorder) were the most prevalent diagnoses, while in natives the most common diagnosis was eating disorders (mainly anorexia nervosa). These results are consistent with the published literature, except as regards post-traumatic stress disorder being another prevalent diagnosis in immigrants [8–11]. Post-traumatic stress disorder is frequent in community sample studies of immigrants and in studies conducted in outpatient samples. Our study was performed at an inpatient unit, so subjects frequently presented other main diagnoses such as major depressive disorder, bipolar disorder and schizophrenia. So the prevalence of post-traumatic stress disorder is not generalizable to studies performed in outpatients. Migration has been recognized as a risk factor for psychoses (especially schizophrenia) among first- and second-generation immigrants [13, 25]. However, despite the various explanations proposed by adult studies the basis for this relationship remains unclear [15, 25, 26]. One reason given relates to selective migration, i.e. individuals with a genetic predisposition toward schizophrenia are more likely to emigrate [14, 25]. Another important point is that the risk of developing a psychotic disorder seems to vary according to ethnic origin, with some studies suggesting that Moroccans and black Caribbeans have an increased risk for schizophrenia [11, 25, 27]. The present study found no differences in relation to ethnicity, and this was probably due to the small sample size. Research has also shown that pre-migration stressors such as social adversity, as well as the subsequent acculturation process, seem to be involved in the development of
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psychotic symptoms [9, 12, 13]. Indeed, ongoing social adversity (poverty, discrimination, etc.) seems to play an important role in psychotic disorders among both first- and second-generation immigrants [25, 26]. One review about the impact of migration on the development of adolescent schizophrenia concluded that the incidence of schizophrenia was higher compared to that among natives [28]. The explanations given for this increased risk are the same as in the adult population [9, 12, 13, 28]. An interesting finding in the present study was that the frequency of schizophrenia was higher among male than among female adolescents in both the immigrant and non-immigrant groups. This result was consistent with previous studies which have shown that men tend to manifest schizophrenia for the first time at an earlier age than women [29, 30]. Genetic and hormonal dispositions may be the cause of this difference in the age at onset [31, 32]. Equally behavioural gender differences may play a role: men fare particularly poorly at young age and significantly better later in life, whereas women fare considerably better until menopause, but worse afterwards [31]. We also observed a relationship between lower SES and psychosis. However, although immigrants’ SES was lower than that of natives, this difference disappeared when comparing SES in relation to psychotic disorders, with psychotic patients in both groups having a low-middle SES. Previous studies have reported a possible relationship between low SES and psychotic disorders [25, 28]. In natives the most prevalent diagnosis was eating disorders (mainly anorexia nervosa). The prevalence of anorexia nervosa in Spain is around 0.3–0.4 % [33], while the
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percentage of adolescents at risk of developing an eating disorder is around 11 % [34]. The high incidence of anorexia nervosa in our sample could be explained by the influence of cultural models. In Europe the current standard of beauty has imposed the concept of a social ideal self, which refers to the act of comparing one’s actual self to what one imagines others expect one to be [35]. By contrast, a study of Latin American adults in the USA reported the prevalence of anorexia nervosa to be around 0.12 % [36]. The lower rate of anorexia nervosa among Latin Americans may be due to cultural differences in the representation of eating disorder symptoms, such that they are more likely to binge than to restrict [35]. As in the case of schizophrenia, sex differences were found for both groups in relation to eating disorders, with anorexia nervosa being more prevalent in females. This is consistent with previous findings [33, 37]. Although the literature has reported an increased risk of major depressive disorder among immigrants the present study found no significant differences in this regard. One explanation for this is that our study involved hospitalized patients, who probably represent the most severe cases, less influenced by environmental factors. Another possible explanation is the ethnic mix of the study sample. Previous research with Africans and black Caribbeans have found no evidence of an increased risk for major depressive disorder following migration [38], whereas studies in South and Central Americans have found, in females, a vulnerability to develop anxiety or depression due to the acculturation process and pre-emigration stressors [8, 10, 16]. With respect to stressors, a higher percentage of family breakdown, of being under state custody and of parental separation were observed among immigrants. By contrast, a previous study carried out in Greece found no differences between immigrants and non-immigrants as regards parental separation [39]. A possible explanation for this is that most of the Greek sample came from East European countries, whereas most of our adolescents came from South and Central America, and typically the mother had emigrated first, leaving her family behind in the country of origin [4]. What often happens in this process is that the mother loses touch with her partner and it is only her children who re-join her in Spain. This reunification may itself be a stressor because the children have to leave their family and friends in order to be with someone with whom they have had almost no contact [4, 7]. On the other hand, leaving children alone in the country of origin can make them more vulnerable to maltreatment [40]. A further point to consider is that when children arrive in Spain they often cannot be supervised full-time by the mother as she is alone in Spain, and invariably she shares a flat with other immigrants. These two situations constitute a risk for family breakdown and could lead not only to the child being taken into state custody but also to the development of adjustment disorder.
The present study also found an increased risk of sexual abuse among immigrants, which may be due to an enforced lack of maternal supervision. Whatever the reason, victims of sexual abuse are more vulnerable to post-traumatic stress disorder, adjustment disorder, major depressive disorder and suicidal behaviour [40–45]. Therefore, sexual abuse and family breakdown may be stressors that contribute to the development of a psychiatric disorder. The present study has two main limitations: firstly, the retrospective design, which means that the variables were not assessed specifically for the purpose of the study, and secondly, the variability of the countries of origin, which affects the homogeneity of the sample. Conversely, the study has a number of strengths, notably the overall sample size, which included all the adolescents admitted to a psychiatric unit, and the fact that very few published studies have examined psychiatric diagnoses in relation to immigrant adolescents. Conclusions There are differences between immigrant and native adolescents as regards the diagnosis they receive. The most prevalent diagnosis among our sample of immigrants was psychotic disorders, while in non-immigrants it was anorexia nervosa. These diagnostic differences are influenced by ethnicity and stressors. Future studies should seek to identify protective factors in order to prevent mental health disorders in the immigrant population. New Contribution to Literature This is the first study done in Spain with immigrant adolescents (mainly from Central and South America). The study shows differences between the two groups in diagnoses, being anorexia nervosa the most prevalent diagnose in natives, while psychosis was more prevalent in immigrants. This study also shows differences between the two groups in maltreatment, sexual abuse and parental separation. It is important to identify protective factors and develop programs in order to prevent psychopathology in migrant children. References 1. Perfils demogra`fics dels collectius me´s nombrosos a Catalunya. Xifres provisionals gener 2014. Departament de benestar social i familia. Generalitat de Catalunya 1–42. http://www20.gencat.cat/ docs/dasc/03Ambits%20tematics/05Immigracio/02Dadesimmi graciocatalunya/01perfilsdemografics/Documents/PERFIL_Pai sos.pdf. Accessed 03 July 2014. 2. Instituto de Estadı´stica de Catalun˜a. La Inmigracio´n ahora y aquı´. Catalun˜a 2008. Datos Estadı´sticos. 2009; 1–23. Generalitat de Catalun˜a. Available in http://www.idescat.cat/cat/idescat/publica cions/cataleg/pdfdocs/immigracio08es.pdf. Accessed 03 July 2014.
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J Immigrant Minority Health 3. Revollo HW, Qureshi A, Collazos F, et al. Acculturative stress as a risk factor of depression and anxiety in the Latin American immigrant population. Int Rev Psychiatry. 2011;23(1):84–92. 4. Garcia C, Lindgren S. ‘‘Life grows between the rocks’’: latino adolescents’ and parents’ perspectives on mental health stressors. Res Nurs Health. 2009;32(2):148–62. 5. Torres Stone RA, Meyler D. Identifying potential risk and protective factors among non-metropolitan Latino youth: cultural implications for substance use research. J Immigr Minor Health. 2007;9:95–107. 6. Stevens GW, Vollebergh WA. Mental health in migrant children. J Child Psychol Psychiatry. 2008;49(3):276–94. 7. Caplan S. Latinos, acculturation, and acculturative stress: a dimensional concept analysis. Policy Polit Nurs Pract. 2007;8(2):93–106. 8. Yearwood EL, Crawford S, Kelly M, Moreno N. Immigrant youth at risk for disorders of mood: recognizing complex dynamics. Arch Psychiatr Nurs. 2007;21(3):162–71. 9. Lindert J, Schouler-Ocak M, Heinz A, et al. Mental health, health care utilisation of migrants in Europe. Eur Psychiatry. 2008;23(Suppl 1):S14–20. 10. Potochnick SR, Perreira KM. Depression and anxiety among firstgeneration immigrant Latino youth: key correlates and implications for future research. J Nerv Ment Dis. 2010;198(7): 470–7. 11. Dealberto MJ. Ethnic origin and increased risk for schizophrenia in immigrants to countries of recent and longstanding immigration. Acta Psychiatr Scand. 2010;121(5):325–39. 12. Hjern A, Wicks S, Dalman C. Social adversity contributes to high morbidity in psychoses in immigrants—a national cohort study in two generations of Swedish residents. Psychol Med. 2004;34(6): 1025–33. 13. Selten JP, Cantor-Graae E, Kahn RS. Migration and schizophrenia. Curr Opin Psychiatry. 2007;20:111–5. 14. Pedersen CB, Mortensen PB, Cantor-Graae E. Do risk factors for schizophrenia predispose to emigration? Schizophr Res. 2011;127:229–34. 15. Cantor-Graae E, Selten JP. Schizophrenia and migration: a metaanalysis and review. Am J Psychiatry. 2005;162(1):12–24. 16. Mikolajczyk RT, Bredehorst M, Khelaifat N, et al. Correlates of depressive symptoms among Latino and non-Latino white adolescents: findings from the 2003 California Health Interview Survey. BMC Public Health. 2007;21(7):21. 17. Blum RW, Ireland M. Reducing risk, increasing protective factors: findings from the caribbean youth health survey. J Adolesc Health. 2004;35(6):493–500. 18. Ohene S, Ireland M, Blume RW. The clustering of risk behaviors among Caribbean youth. Matern Child Health J. 2005;9(1): 91–100. 19. Birman D, Trickett EJ. Acculturation andadaptation of Soviet Jewish refugee adolescents: predictors of adjustment across life domains. Am J Community Psychol. 2002;30:585–605. 20. Oppedal B, Roysamb E, Heyerdahl S. Ethnic group, acculturation, and psychiatric problems in young immigrants. J Child Psychol Psychiatry. 2005;46(6):646–60. 21. Zayas LH, Pilat AM. Suicidal behavior in Latinas: explanatory cultural factors and implications for intervention. Suicide Life Threat Behav. 2008;38(3):334–42. 22. Goldston DB, Molock SD, Whitbeck LB, et al. Cultural considerations in adolescent suicide prevention and psychosocial treatment. Am Psychol. 2008;63(1):14–31. 23. Hollingshead AB, Redlich FC. Social class and mental illness. New York: Wiley; 1958. 24. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th edn, DSM-IV). Washington DC: Author; 1994.
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25. Bourque F, van der Ven E, Malla A. A meta-analysis of the risk for psychotic disorders among first- and second-generation immigrants. Psychol Med. 2009;41:897–910. 26. Morgan C, Charalambides M, Hutchinson G, Murray RM. Migration, ethnicity, and psychosis: toward a sociodevelopmental model. Schizophr Bull. 2010;36(4):655–64. 27. Veling W, Selten JP, Susser E, et al. Discrimination and the incidence of psychotic disorders among ethnic minorities in The Netherlands. Int J Epidemiol. 2007;36:761–8. 28. Ampadu E. The impact of immigration on the development of adolescent schizophrenia. J Child Adolesc Psychiatr Nurs. 2011;24(3):161–7. 29. Faraone SV, Chen WJ, Goldstein JM, Tsuang MT. Gender differences in age at onset of schizophrenia. Br J Psychiatry. 1994;164(5):625–9. 30. Castle D, Sham P, Murray R. Differences in distribution of ages of onset in males and females with schizophrenia. Schizophr Res. 1998;33:179–83. 31. Ha¨fner H. Gender differences in schizophrenia. Pychoneuroendocrinology. 2003;28(Suppl. 2):17–54. 32. Grossman LS, Harrow M, Rosen C, Faull R, Strauss GP. Sex differences in schizophrenia and other psychotic disorders: a 20-year longitudinal study of psychosis and recovery. Compr Pscychiatry. 2008;49(6):523–9. 33. Lopez-de-Andres A, Carrasco-Garrido P, Herna´ndez-Barrera V, et al. Hospitalization trends in Spanish children and adolescents with eating disorders (1998–2007). Appetite. 2010;55(1):147–51. 34. Pamies-Aubalat L, Marcos YQ, Castan˜o MB. Study of risk of eating disorders in a representative sample of adolescents. Med Clin (Barc). 2011;136(4):139–43. 35. Gunnard K, Krug I, Jime´nez-Murcia S, Penelo E, Granero R, Treasure J, et al. Relevance of social and self-standards in eating disorders. Eur Eat Disord Rev. 2012;20(4):271–8. 36. Alegria M, Woo M, Cao Z, Torres M, et al. Prevalence and correlates of eating disorders in Latinos in the United States. Int J Eat Disord. 2007;40(Suppl):S15–21. 37. Pratt BM, Woolfenden SR. Interventions for preventing eating disorders in children and adolescents. Cochrane Database Syst Rev. 2002;2:CD002891. 38. Swinnen SG, Selten JP. Mood disorders and migration: metaanalysis. Br J Psychiatry. 2007;190:6–10. 39. Anagnostopoulos DC, Vlassopoulou M, Rotsika V, et al. Psychopathology and mental health service utilization by immigrants’ children and their families. Transcult Psychiatry. 2004;41(4):465–86. 40. Woods SJ. Intimate partner violence and post-traumatic stress disorder symptoms in women: what we know and need to know. J Interpers Violence. 2005;20(4):394–402. 41. Clear PJ, Vincent JP, Harris GE. Ethnic differences in symptom presentation of sexually abused girls. J Child Sex Abus. 2006;15(3):79–98. 42. Hulme PA. Childhood sexual abuse, HPA axis regulation, and mental health: an integrative review. West J Nurs Res. 2010;9(8):1–29. 43. Kelly UA. Symptoms of PTSD and major depression in Latinas who have experienced intimate partner violence. Issues Ment Health Nurs. 2010;31(2):119–27. 44. Bowman K, Rew L, Murphey C. Childhood maltreatment among community dwelling adult Latinas. Issues Ment Health Nurs. 2009;30:443–50. 45. Newcomb MD, Munoz DT, Carmona JV. Child sexual abuse consequences in community samples of Latino and European American adolescents. Child Abus Negl. 2009;33(8):533–44.
ORIGINAL PAPER
Differences in Psychopathology Between Immigrant and Native Adolescents Admitted to a Psychiatric Inpatient Unit Ana Bla´zquez • Josefina Castro-Fornieles Inmaculada Baeza • Astrid Morer • Esteban Martı´nez • Luisa La´zaro
•
Ó Springer Science+Business Media New York 2014
Abstract It has been postulated that immigrant children are at increased risk of mental health problems. This study examined differences in psychopathology between immigrant and non-immigrant adolescents admitted for the first time to a child and adolescent inpatient psychiatry unit. Participants were 234 adolescents (191 non-immigrants and 43 immigrants). There were significant differences between the two groups in relation to certain stressors: parental separation, family breakdown, being under state custody, physical and/or psychological maltreatment and sexual abuse. Differences between the main diagnoses of the two groups were found in relation to schizophrenia and anorexia nervosa. There are differences between immigrants and natives in terms of diagnosis, and these differences are influenced by ethnicity and stressors. Future studies should seek to identify protective factors in order to prevent mental health disorders in the immigrant population.
A. Bla´zquez (&) J. Castro-Fornieles I. Baeza A. Morer E. Martı´nez L. La´zaro Department of Child and Adolescent Psychiatry and Psychology, Institute of Neurosciences, Hospital Clı´nic Universitari, C/Villarroel n8170, 08036 Barcelona, Spain e-mail: [email protected] J. Castro-Fornieles I. Baeza A. Morer L. La´zaro IDIBAPS (Institut d’Investigacions Biome`diques August Pi i Sunyer), Barcelona, Spain J. Castro-Fornieles I. Baeza A. Morer L. La´zaro Department of Psychiatry and Clinical Psychobiology, University of Barcelona, Barcelona, Spain J. Castro-Fornieles L. La´zaro CIBERSAM, Barcelona, Spain
Keywords Adolescents Immigration Acculturation Mental health Risk factors
Background Over the last decade, the immigrant population of Catalonia (an autonomous community in north-eastern Spain) has increased dramatically. Figures for January 2014 show that approximately 15 % of the Catalonian population could be considered as immigrants from a wide range of countries including Morocco, Romania and Ecuador [1]. Latin Americans represent the single largest immigrant group in Spain (36 %) [2], with 50 % of them being women [1, 3]. Approximately 30 % of immigrants come from European countries and 25 % from Africa [2]. Latin American families do not typically immigrate as one unit, it being common for the mother to come first to Spain, leaving her children behind in the country of origin. In most cases children re-join their mother after a number of years, and this reunification during adolescence could increase conflicts with parents, especially as some children may resent being left behind [4]. Several studies have suggested that immigrant children are at increased risk of mental health problems [4–6], and three main reasons have been put forward to explain this: firstly, the stress caused by migration (due to loss of friends, family, etc.); secondly, the stress caused by adaptation to a society in which they are in a minority position and where they are sometimes the victims of racism or discrimination; and thirdly, the acculturation process, whereby immigrants have to adapt to a new cultural environment [3, 6, 7]. The purpose of acculturation is to adapt to the dominant culture, and this may mean that immigrants lose their original cultural identity. These
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adjustments to new beliefs, routines or social roles can cause acculturative stress [7]. The most common nosological categories associated with immigrant children are psychotic disorders, depression, post-traumatic stress disorder and conduct disorders [8–11]. Pre-emigration experiences, the stress caused by migration, social adversity and the acculturation process seem to predispose immigrants to developing a psychotic disorder [9, 12, 13]. It has also been hypothesized that people with a genetic or environmental predisposition to psychosis are more likely to emigrate to a foreign country [14]. In a meta-analysis of migration and schizophrenia in adults Cantor-Graae and Selten [15] found that the risk of developing a schizophrenic disorder was 2.9 times higher in immigrants than in non-immigrants. This risk can also differ markedly according to ethnic origin, and studies carried out with adults in European countries have found, for example, an increased risk of schizophrenia among immigrants from Surinam or Morocco [1]. Depressive and anxiety disorders are also frequent in immigrants, and the risk of developing the former varies according to ethnic group [3]. In Latin American adolescents depressive and anxiety disorders have been associated with pre-emigration stressors such as poverty, sexual abuse, maltreatment or substance abuse, acculturation and dissatisfaction with the decision to migrate [8, 10, 16]. Conversely, previous studies have found that school connectedness was the strongest protective factor, with family connectedness and religious attendance/religiosity having a roughly equivalent protective association [8, 17, 18]. Other studies have also demonstrated that ethnic culture competence promotes psychological adaptation within own ethnic socio-cultural settings whereas host culture competence facilitates adaptation within the mainstream society [19, 20]. After adjusting for socio-demographic factors and social support, differences in depressive symptoms between Latin American adolescents and Spanish natives disappear [16]. The literature also reports a predisposition to suicidal behaviour among adolescent Latin American immigrants [9, 10], although the risk of completed suicide is lower than in other ethnic groups [21]. Expectations related to family obligations appear to play an important role in suicidal behaviour [22], and high levels of acculturative stress have been shown to be correlated positively with suicidal behaviour [8]. However, the findings for conduct disorders (oppositional defiant disorder and conduct disorder) are contradictory. A review of research with adolescents concluded that differences in the diagnosis of behavioural disorders depend highly on the informant and on the measure used [6]. The aim of the present study was to analyse retrospectively the differences in certain stressors and diagnoses between immigrants and natives admitted for the first time
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to an adolescent psychiatric inpatient unit in Spain, as well as to identify potential stressors that may influence the mental health of immigrants.
Methods Participants and Data Collection For this retrospective study the charts of all patients admitted between October 2009 and March 2011 to the inpatient unit of the Department of Child and Adolescent Psychiatry and Psychology of the Hospital Clinic, Barcelona were reviewed. Only those patients who were admitted for the first time were selected. The immigrant group was defined as: children or adolescents born in a foreign country, who moved to Spain for the purpose of permanent residence and who migrated at the same time as their parents or who re-joined them some years later. Children born in other countries and adopted by Spanish families were excluded in order to identify which pre-emigration stressors might be associated with the psychiatric disorders presented by immigrants. All procedures were approved by the hospital’s Ethics Committee. Measures For both immigrant and native adolescents the following socio-demographic data were collected: sex, age, country of origin and parental socio-economic status (SES), the latter being estimated by means of the Hollingshead Redlich scale [23]. A series of potential stressors was also analyzed: pre-emigration stressors such as physical and/or psychological maltreatment and sexual abuse and migration and post-migration stressors such as parental separation, family breakdown, being in state custody and the number of months separated from mother. With respect to diagnoses, inpatients were assigned a final DSM-IV-TR diagnosis on discharge, generated by comprehensive assessments carried out by the attending psychiatrist. Main and comorbid diagnoses were established according to DSM-IV-TR criteria [24]. Statistical Analysis All data were analysed using SPSS 15.0 for Windows. The Kolmogorov–Smirnov test was used to assess the normality of variables, while the percentages of discrete variables were compared by means of the Chi-squared or Fisher’s exact test. The Student’s t test was used to compare means of continuous variables between immigrants and natives. Variables that were significant in the bivariate analysis
J Immigrant Minority Health
were subsequently entered into a logistic regression analysis to identify factors that were independently associated with main diagnoses. The aim was to determine which stressors or demographic characteristics might best predict the different diagnoses. Statistical significance was set at p \ 0.05. The minimum sample size was calculated previously (for the main comparisons) in order to ensure that the analysis had sufficient statistical power. Therefore, considering a desired statistical power level of 0.8 and a probability level of 0.05, the N was 43.
Table 1 Differences between the two groups in relation to potential stressors Immigrants (N = 43) N%
Nonimmigrants (N = 191) N%
v2
pa
Pre-emigration stressors Physical and/or psychological maltreatment Sexual abuse
8 (18.6)
5 (3.6)
6.96
0.021
5 (11.6)
3 (1.6)
22.73
0.000
Migration and post-migration stressors
Results
Differences in Stressors Between the Two Groups Table 1 lists the potential stressors which were analysed. There were significant differences between the two groups in relation to parental separation, family breakdown, being under state custody, physical and/or psychological maltreatment and sexual abuse.
29 (67.4)
72 (37.7)
12.69
0.001
Family breakdown
15 (34.9)
17 (8.9)
20.07
0.000
6 (13.9)
8 (4.2)
5.95
0.026
Being in state custody
Descriptive Characteristics of the Sample The initial sample included 244 adolescents who had been admitted for the first time. After excluding children born in other countries and adopted by Spanish families (N = 10) the final sample comprised 234 patients (43 immigrants and 191 natives). Of the 43 immigrants, 19 were males (44.2 %) and 24 females (55.8 %), while the natives were 82 males (42.9 %) and 109 females (57.1 %). The mean age of immigrants and non-immigrants was, respectively, 14.86 years (SD = 1.66) and 14.33 years (SD = 2.19). There were no significant differences between the groups in terms of sex or age. Most of the immigrants came from Central or South America (67.4 %), with the countries of origin being Ecuador (18.6 %), Peru and Brazil (11.1 % each), Uruguay, Colombia and the Dominican Republic (7.0 % each), and Argentina and Cuba (2.3 % each). The other immigrants came from European countries (16.3 %: Poland, 4.7 %; Romania, 4.7 %; Bosnia, Germany and France, 2.3 % each), from Africa (Morocco, 11.6 %) and from Asia (Bangladesh, 4.7 %). The mean number of months in Spain was 68.91 (SD = 36.51). There was a significant difference between the parental SES of natives (mostly middle; mean score = 36.18, SD = 17.01) and immigrants (mostly low-middle; mean score = 45.84, SD = 20.64) (t = 3.23, p \ 0.001).
Parental separation
v2 Chi-square a
Fisher’s exact test
considered as the main one. The most prevalent diagnoses in immigrants were psychotic disorders (including schizophrenia, schizoaffective disorder and unspecified psychotic disorder) and affective disorders (including bipolar disorder and major depressive disorder). In non-immigrants the most prevalent diagnoses were eating disorders (mainly anorexia nervosa), affective disorders and conduct disorders (oppositional defiant disorder and conduct disorder). There were significant differences between immigrants and non-immigrants in relation to schizophrenia and anorexia nervosa. As regards comorbid diagnoses the most prevalent diagnosis in immigrants was cannabis misuse, while for natives the most prevalent were cannabis misuse, attention deficit hyperactivity disorder and conduct disorders. Significant differences were found between immigrants and natives in relation to adjustment disorder and post-traumatic stress disorder, which were more prevalent among immigrants. The sample of immigrants was then divided into four groups (Latin Americans, Europeans, Africans and Asians). In Latin Americans the main diagnoses were psychotic disorders (27.6 %), major depressive disorder (20.7 %) and bipolar disorder (17.3 %). Psychotic disorders were the main diagnosis in Europeans and Africans (28.5 and 40 %, respectively), whereas in Asians the main diagnoses were psychotic and anxiety disorders (50 % each). Differences in Demographic Characteristics and Stressors According to Different Diagnoses
Main and Comorbid Diagnoses Table 2 shows the main and comorbid diagnoses at discharge. The diagnosis which led to admission was
Table 3 shows the comparison of demographic factors and stressors with respect to different diagnoses in the sample as a whole (immigrants plus natives). In the bivariate
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J Immigrant Minority Health Table 2 Main and comorbid diagnoses
Adjustment disorder
Immigrants, N % (N = 43)
Non-immigrants, N % (N = 191)
Main diagnosis
Main diagnosis
Comorbid
Main diagnosis
Comorbid
pa
Comorbid diagnoses pa
4 (9.3)
2 (11.1)
12 (6.3)
0
0.504
0.033
7 (16.3) 5 (11.6)
0 0
25 (13.1) 10 (5.2)
1 (1.2) 0
0.624 0.161
1.000 – 0.033
Affective disorders Major depressive disorder Bipolar disorder Anxiety disorders Post-traumatic stress disorder
2 (4.7)
2 (11.1)
1 (0.5)
0
0.088
Obsessive–compulsive disorder
2 (4.7)
1 (5.6)
65 (3.1)
1 (1.2)
0.642
0.229
Generalized anxiety disorder
1 (2.3)
2 (11.1)
9 (4.7)
4 (4.7)
0.694
0.304
Attention deficit hyperactivity disorder
1 (2.3)
2 (11.1)
12 (6.3)
23 (27.4)
0.472
0.271
Cannabis misuse
0
8 (44.4)
10 (5.2)
27 (32.4)
0.215
0.480
Conduct disorders Oppositional defiant disorder
2 (4.7)
0
19 (9.9)
11 (13.1)
0.223
0.382
Conduct disorder
1 (2.3)
1 (5.6)
9 (4.8)
7 (8.3)
0.694
1.000
0
0
0
2 (2.3)
–
1.000
Conversion disorder Eating disorders Anorexia nervosa
4 (9.3)
0
50 (26.2)
4 (4.7)
0.016
0.596
Bulimia nervosa
1 (2.3)
0
3 (1.5)
0
0.559
–
0
0
3 (1.6)
3 (3.5)
1.000
1.000
Pervasive developmental disorder Psychotic disorders Unspecified psychotic disorder
7 (16.3)
0
16 (7.5)
0
0.512
–
Schizophrenia
4 (9.3)
0
2 (1.0)
0
0.011
–
Schizoaffective disorder
0.088
2 (4.7)
0
1 (0.5)
0
Tic disorder
0
0
1 (0.5)
1 (1.2)
1.000
1.000
No Axis I diagnosis
0
0
2 (1.0)
0
1.000
–
Total
43
18
191
84
234
102
a
Fisher’s exact test
analysis, patients with a psychotic disorder tended to be male immigrants with a significantly lower mean SES score. Patients with an eating disorder were predominantly female non-immigrants with a stable nuclear family and a significantly higher mean SES scores. Anxiety disorders were associated with immigrants and victims of sexual abuse. Family breakdown was related to attention deficit hyperactivity disorder, while parental separation was linked to conduct disorders. Logistic regression analyses were then conducted with the statistically significant variables (for each diagnosis) from the bivariate analysis (see Table 4). Being a victim of sexual abuse was the best predictor of post-traumatic stress disorder and generalized anxiety disorder, predicting 94.9 % of anxiety disorders. Family breakdown predicted 94.4 % of attention deficit hyperactivity disorder cases. As regards eating disorders, female gender and no parental separation predicted 75.6 % of cases. Male gender and being an immigrant predicted 87.2 % of psychotic disorder cases.
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Immigrant Diagnoses and their Relationship with Stressors The relationship between diagnoses and stressors was analysed in the immigrant group. In the bivariate analysis statistically significant associations were found for sexual abuse and anxiety disorders (especially post-traumatic stress disorder: v2 = 9.26, p = 0.016), as well as for family breakdown and adjustment disorder (v2 = 8.26, p = 0.016). Due to the small sample no regression analysis was performed.
Discussion This study found statistically significant differences in the diagnoses given to immigrant and non-immigrant adolescents admitted for the first time to a psychiatric inpatient unit. In immigrants psychotic disorders (mainly schizophrenia) and affective disorders (bipolar disorder and
61.5/38.5 61.5/38.5 53.3/46.7 45.2/58.8 5.2/94.8 31.3/68.7 75.0/25.0
Anxiety disorders (post-traumatic stress disorder ? generalized anxiety disorder) N = 13
Attention deficit hyperactivity disorder N = 13 Bipolar disorder N = 15
Conduct disorders N = 31
Eating disorders N = 58
Major depressive disorder N = 32
Psychotic disorders N = 32
3.1/96.9 12.5/78.5
Eating disorders N = 58
Major depressive disorder N = 32
Psychotic disorders N = 32
b
Student’s t test
Fisher’s exact test
6.5/93.5 0/100
Conduct disorders N = 31
15.4/84.6 0/100
Attention deficit hyperactivity disorder N = 13
7.7/92.3
Anxiety disorders (post-traumatic stress disorder ? generalized anxiety disorder) N = 13
Bipolar disorder N = 15
12.5/87.5
Yes/no (%)
Adjustment disorder N = 16
a
15.33
2.14
45.36
0.58
1.89 0.67
1.89
0.01
v
2
2.79
0.54
4.91
0.14
1.02
2.16
0.72
1.29
v2
Being under state custody
43.8/56.2
Adjustment disorder N = 16
Male/female (%)
Sex
0.107
0.699
0.024
1.000
0.608
0.178
0.561
0.246
pa
0.000
0.179
0.000
0.847
0.249 0.432
0.249
1.000
p
a
0.87
0.58
2.45
0.03
-2.27
0.06
1.40 -1.38
t
0.015
0.971
0.024
0.954
0.162 0.169
0.981
0.560
p
b
59.4/40.6
53.1/46.9
22.4/77.6
61.3/18.09
23.1/76.9 46.7/53.3
46.2/53.8
50.0/50.0
Yes/no (%)
9.4/90.6
3.1/96.9
0/100
3.2/96.8
6.7/93.3
7.7/92.3
30.8/69.2
6.3/93.8
Yes/no (%)
0.21
0.12
3.44
0.96
1.02
0.39
0.72
0.16
v2
1.000
1.0000
0.071
1.000
0.608
0.442
0.100
0.515
pa
3.97
1.50
13.53
0.06
2.26 0.80
0.50
0.33
v
2
Parental separation
Physical and/or psychological maltreatment
45.16/18.49
38.06/19.38
33.31/14.91
38.13/18.09
44.77/21.22 31.73/18.06
42.23/.19.14
40.50/15.73
Mean/SD
SES
Table 3 Differences in demographic characteristics and stressors according to different diagnoses (immigrants plus natives)
21.9/78
25.0/75.0
0/100
16.1/83.9
38.5/61.5 6.7/93.3
7.7/92.3
25.0/75.0
Yes/no (%)
3.1/96.9
9.4/90.6
0/100
0/100
6.7/93.3
0/100
30.8/69.2
6.3/93.8
Yes/no (%)
2.36
1.81
3.81
1.76
0.19
0.68
20.88
0.09
v2
12.11
4.03
12.22
0.18
7.16 0.67
0.42
1.87
v2
Family breakdown
Sexual abuse
0.055
0.252
0.000
0.954
0.159 0.793
1.000
0.608
p
a
0.143
0.178
0.070
0.368
0.525
1.000
0.022
0.549
pa
0.166
0.550
0.000
0.587
0.020 0.700
1.000
0.246
pa
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J Immigrant Minority Health Table 4 Variables predicting diagnoses Post-traumatic stress disorder ? generalized anxiety disorder N = 13
Attention deficit hyperactivity disorder N = 13
Conduct disorders N = 31
Eating disorders N = 58
Odds ratio (95 % CI)
p
Odds ratio (95 % CI)
p
Odds ratio (95 % CI)
p
Odds ratio (95 % CI)
p
Odds ratio (95 % CI)
p
Sex
–
–
–
–
–
–
0.41 (0.01–0.14)
0.000
5.14 (2.12–12.49)
0.000
Immigration
0.37 (0.56–2.49)
0.309
–
–
–
–
0.67 (0.21–2.17)
0.502
3.86 (1.59–9.32)
0.003
SES
–
–
–
–
–
–
1.01 (0.98–1.03)
0.588
0.98 (0.96–1.01)
0.144
Parental separation
–
–
–
–
2.35 (1.08–5.07)
0.032
0.43 (0.19–0.95)
0.036
–
–
Family breakdown
–
–
4.49 (1.37–14.73)
0.013
–
–
0.00
0.998
–
–
Being under state custody
–
–
–
–
–
–
–
–
–
–
Sexual abuse
24.48 (3.84–156.02)
0.000
–
–
–
–
–
–
–
–
Psychotic disorders N = 32
Bold values represent Fisher’s exact test
major depressive disorder) were the most prevalent diagnoses, while in natives the most common diagnosis was eating disorders (mainly anorexia nervosa). These results are consistent with the published literature, except as regards post-traumatic stress disorder being another prevalent diagnosis in immigrants [8–11]. Post-traumatic stress disorder is frequent in community sample studies of immigrants and in studies conducted in outpatient samples. Our study was performed at an inpatient unit, so subjects frequently presented other main diagnoses such as major depressive disorder, bipolar disorder and schizophrenia. So the prevalence of post-traumatic stress disorder is not generalizable to studies performed in outpatients. Migration has been recognized as a risk factor for psychoses (especially schizophrenia) among first- and second-generation immigrants [13, 25]. However, despite the various explanations proposed by adult studies the basis for this relationship remains unclear [15, 25, 26]. One reason given relates to selective migration, i.e. individuals with a genetic predisposition toward schizophrenia are more likely to emigrate [14, 25]. Another important point is that the risk of developing a psychotic disorder seems to vary according to ethnic origin, with some studies suggesting that Moroccans and black Caribbeans have an increased risk for schizophrenia [11, 25, 27]. The present study found no differences in relation to ethnicity, and this was probably due to the small sample size. Research has also shown that pre-migration stressors such as social adversity, as well as the subsequent acculturation process, seem to be involved in the development of
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psychotic symptoms [9, 12, 13]. Indeed, ongoing social adversity (poverty, discrimination, etc.) seems to play an important role in psychotic disorders among both first- and second-generation immigrants [25, 26]. One review about the impact of migration on the development of adolescent schizophrenia concluded that the incidence of schizophrenia was higher compared to that among natives [28]. The explanations given for this increased risk are the same as in the adult population [9, 12, 13, 28]. An interesting finding in the present study was that the frequency of schizophrenia was higher among male than among female adolescents in both the immigrant and non-immigrant groups. This result was consistent with previous studies which have shown that men tend to manifest schizophrenia for the first time at an earlier age than women [29, 30]. Genetic and hormonal dispositions may be the cause of this difference in the age at onset [31, 32]. Equally behavioural gender differences may play a role: men fare particularly poorly at young age and significantly better later in life, whereas women fare considerably better until menopause, but worse afterwards [31]. We also observed a relationship between lower SES and psychosis. However, although immigrants’ SES was lower than that of natives, this difference disappeared when comparing SES in relation to psychotic disorders, with psychotic patients in both groups having a low-middle SES. Previous studies have reported a possible relationship between low SES and psychotic disorders [25, 28]. In natives the most prevalent diagnosis was eating disorders (mainly anorexia nervosa). The prevalence of anorexia nervosa in Spain is around 0.3–0.4 % [33], while the
J Immigrant Minority Health
percentage of adolescents at risk of developing an eating disorder is around 11 % [34]. The high incidence of anorexia nervosa in our sample could be explained by the influence of cultural models. In Europe the current standard of beauty has imposed the concept of a social ideal self, which refers to the act of comparing one’s actual self to what one imagines others expect one to be [35]. By contrast, a study of Latin American adults in the USA reported the prevalence of anorexia nervosa to be around 0.12 % [36]. The lower rate of anorexia nervosa among Latin Americans may be due to cultural differences in the representation of eating disorder symptoms, such that they are more likely to binge than to restrict [35]. As in the case of schizophrenia, sex differences were found for both groups in relation to eating disorders, with anorexia nervosa being more prevalent in females. This is consistent with previous findings [33, 37]. Although the literature has reported an increased risk of major depressive disorder among immigrants the present study found no significant differences in this regard. One explanation for this is that our study involved hospitalized patients, who probably represent the most severe cases, less influenced by environmental factors. Another possible explanation is the ethnic mix of the study sample. Previous research with Africans and black Caribbeans have found no evidence of an increased risk for major depressive disorder following migration [38], whereas studies in South and Central Americans have found, in females, a vulnerability to develop anxiety or depression due to the acculturation process and pre-emigration stressors [8, 10, 16]. With respect to stressors, a higher percentage of family breakdown, of being under state custody and of parental separation were observed among immigrants. By contrast, a previous study carried out in Greece found no differences between immigrants and non-immigrants as regards parental separation [39]. A possible explanation for this is that most of the Greek sample came from East European countries, whereas most of our adolescents came from South and Central America, and typically the mother had emigrated first, leaving her family behind in the country of origin [4]. What often happens in this process is that the mother loses touch with her partner and it is only her children who re-join her in Spain. This reunification may itself be a stressor because the children have to leave their family and friends in order to be with someone with whom they have had almost no contact [4, 7]. On the other hand, leaving children alone in the country of origin can make them more vulnerable to maltreatment [40]. A further point to consider is that when children arrive in Spain they often cannot be supervised full-time by the mother as she is alone in Spain, and invariably she shares a flat with other immigrants. These two situations constitute a risk for family breakdown and could lead not only to the child being taken into state custody but also to the development of adjustment disorder.
The present study also found an increased risk of sexual abuse among immigrants, which may be due to an enforced lack of maternal supervision. Whatever the reason, victims of sexual abuse are more vulnerable to post-traumatic stress disorder, adjustment disorder, major depressive disorder and suicidal behaviour [40–45]. Therefore, sexual abuse and family breakdown may be stressors that contribute to the development of a psychiatric disorder. The present study has two main limitations: firstly, the retrospective design, which means that the variables were not assessed specifically for the purpose of the study, and secondly, the variability of the countries of origin, which affects the homogeneity of the sample. Conversely, the study has a number of strengths, notably the overall sample size, which included all the adolescents admitted to a psychiatric unit, and the fact that very few published studies have examined psychiatric diagnoses in relation to immigrant adolescents. Conclusions There are differences between immigrant and native adolescents as regards the diagnosis they receive. The most prevalent diagnosis among our sample of immigrants was psychotic disorders, while in non-immigrants it was anorexia nervosa. These diagnostic differences are influenced by ethnicity and stressors. Future studies should seek to identify protective factors in order to prevent mental health disorders in the immigrant population. New Contribution to Literature This is the first study done in Spain with immigrant adolescents (mainly from Central and South America). The study shows differences between the two groups in diagnoses, being anorexia nervosa the most prevalent diagnose in natives, while psychosis was more prevalent in immigrants. This study also shows differences between the two groups in maltreatment, sexual abuse and parental separation. It is important to identify protective factors and develop programs in order to prevent psychopathology in migrant children. References 1. Perfils demogra`fics dels collectius me´s nombrosos a Catalunya. Xifres provisionals gener 2014. Departament de benestar social i familia. Generalitat de Catalunya 1–42. http://www20.gencat.cat/ docs/dasc/03Ambits%20tematics/05Immigracio/02Dadesimmi graciocatalunya/01perfilsdemografics/Documents/PERFIL_Pai sos.pdf. Accessed 03 July 2014. 2. Instituto de Estadı´stica de Catalun˜a. La Inmigracio´n ahora y aquı´. Catalun˜a 2008. Datos Estadı´sticos. 2009; 1–23. Generalitat de Catalun˜a. Available in http://www.idescat.cat/cat/idescat/publica cions/cataleg/pdfdocs/immigracio08es.pdf. Accessed 03 July 2014.
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