A Risk Profile Predicting Psychological Distress in Vietnamese Amerasian Youth ROBERT S. McKELVEY, M.D., ALICE R. MAO, M.D.,



Abstract. The relationship between risk factors and psychological distress was examined in 161 Vietnamese Amerasian youth. Background factors such as a history of missing school, frequent hospitalizations, and previous refugee camp experience distinguished those with higher levels of anxiety and depression. This study provides support for attempts to link specific risk factors with increased levels of psychological distress in immigrant populations. Confirmation of the predictive power of these risk factors awaits completion of a longitudinal study following the Ameriasians as they resettle in the United States. J. Am. Acad. Child Adolesc. Psychiatry, 1992, 31, 5:911-915. Key Words: psychological distress, risk factors, longitudinal study, immigration.

With the passage of the Amerasian Homecoming Act in December 1987, Vietnamese Amerasian youth and their families have been immigrating to the United States in increasing numbers (Brendan, 1990). Living remnants of the United States' longest and most divisive war, they have immense symbolic meaning as "America's children" left behind in a foreign land. The Act was to allow for the departure of all Amerasians from Vietnam by March of 1990. For political reasons, this goal has not been realized and an estimated 33,000 Amerasians and their relatives still remain in Vietnam awaiting placement in the United States (Brendan , 1990). Mental health professionals have long been interested in the relationship between immigrat ion and emotional disturbance (Murphy, 1977; Westermeyer et al., 1983). Interest has been particularly strong during periods of large migratory activity, such as subsequent to World War II, and, more recently, in the wake of America 's disengagement from Vietnam. The sudden arrival of large numbers of Southeast Asian refugees in the United States after 1975 has sharpened concern over our ability to predict which immigrants and refugees are at particular risk for developing mental disorder (Boman and Edwards, 1984; Lin et aI., 1979; Masuda et aI., 1980; Rumbaut, 1985; Westermeyer et al., 1983). These studies have largely assessed risk retrospectively: refugees already settled in their country of destination are asked about factors in their past lives and backgrounds in their homelands that might influence the development of mental health problems. To our knowledge, no study has assessed risk factors prospectively beginning with data collection from refugees while they are still in their homelands (Williams, 1987). The Amerasian Homecoming Act provides a unique opportunity to study an immigrant population from a predetermined departure point in their homeland, through a planned immigration route, to preidentifed resettlement sites in the United States. After initial processing at the Amerasian Accepted July 31, 1991. From the Department of Psychiatry, Baylor College of Medicine, Houston, Texas. Reprint requests to Dr. McKelvey, 4815 Dickson, Houston, TX 77007. 0890-8567 /92/3105-0911$03.00/0© 1992 by the American Academy of Child and Adolescent Psychiatry. J. Am. Acad. Child Adolesc. Psychiatry, 31 :5, September 1992

Transit Center (ATC) in Ho Chi Minh City, Vietnam, Vietnamese Amerasians are transported to the Philippine Refugee Processing Center (P R P C ) . At the PRPC, the Vietnamese Amerasians receive English lessons and vocational skills training and study American culture for 6 months. They are subsequently sent to one of approxim ately 87 cluster sites located in 30 states (Gilzow and Ranard, 1990). Selection of a cluster site is generally randomly determined, unless the Vietnamese Amerasian youth has relatives in the United States. In such cases, efforts are made to place them close to family members. Once in cluster sites, the Amerasians are supported for 3 months by various nonprofit voluntary agencies under contract with the U.S. Department of State and then are essentially on their own. In the United States, they are at risk for the same social stresses that other Indochinese immigrant populat ions have faced, including " loss of role identity and self esteem, social isolation caused by language barriers, and local prejud ice" (Kinzie et aI., 1982). Little is known about the prevalence of mental health symptoms and psychopathology among Amerasians either in Vietnam or after resettlement in the United States. Newspaper and magazine articles have suggested a higher than expected prevalence of mental health problems compared with non-Amerasian refugee peers or U.S. adolescents. The reasons given for this range from Amerasians' ostracization by Vietnamese society for their mixed racial background and lack of fathers in a strongly racist and patrilineal culture, to their multiple educational and financial disadvantages compared to non-Amerasian Vietnamese, to their lack of a strong familial and cultural support system either in Vietnam or the United States. The few formal studies of Vietnamese Amerasian mental health status have supported the popular perception of them as a group at risk for the development of psychopathology. Nicassio et aI. in 1986 studied a small group of Amerasians (N = 24) in one community (Nicassio et aI., 1986). Using the Personality Inventory for Children , they concluded that " Amerasian youth showed greater psychological deviance than one would expect in a nonclinical American sample ." A 1985 study by the U.S. Catholic Conference developed a demographic profile of all Amerasians settled by them in fiscal years 1983 and 1984 (U.S. Catholic Conference, 1985). Ten percent of the Amerasians were seen as having 911


"serious adjustment problems" (manifested in running away, withdrawal, depression). Two major risk factors were identified: not being with one's biological mother (unaccompanied or "free" cases) and having a history of no formal schooling. Felsman et al. (1989) have conducted the most extensive study to date of Amerasian youth. Self-administered questionnaires were used to determine the level of mental health symptomatology in a group of 259 Amerasians awaiting U.S. placement at the PRPC, Bataan, Philippines. The instruments used include: the General Health Questionnaire, the Hopkins Symptom Checklist-25 (HSCL-25), the Vietnamese Depression Scale (VDS), and the Center for Epidemiologic Studies Depression Scale (Felsman et al., 1989; Mollica et aI., 1987). In addition, a questionnaire, the Personal Information Form (PIF), was used to determine family background, formal schooling, previous employment, and family members accompanying each Amerasian (Felsman et aI., 1989). Overall, Vietnamese Amerasians were found to have a high level of mental health symptomatology differentiating them significantly from Vietnamese unaccompanied minors on the VDS and from adolescents on the HSCL-25, depressive subscale. In addition, Vietnamese Amerasians were thought to be at high risk of school failure because of their low level of formal schooling and their relatively poor performance on oral language and reading skills tests. The following risk factors in Vietnamese Amerasians were found by Felsman et al. to be "significantly associated with psychological distress and/or to be face valid for predicting school failure": female, Afro-American, low scores on oral and reading tests, less than 9 years of school in Vietnam, not raised by mother, not accompanied by mother, not accompanied by siblings, history of illness and/ or hospitalization, and history of missing school. The concept of risk factors has been widely used by medical epidemiologists to understand why certain individuals are more susceptible to a given disease than others (Lilienfeld and Lilienfeld, 1980). Psychiatric researchers have expanded the investigation of risk factors beyond somatic illness in an effort to understand the relationship between various features in an individual's background and environment, and psychiatric illnesses such as attention deficit hyperactivity disorder and drug abuse (Costello, 1989; Newcomb et aI., 1986). The risk factor concept is particularly useful in understanding susceptibility to psychiatric illnesses for which specific causes of disorder are not known. In most psychiatric conditions, single risk factors have little predictive power. Only when risk factors are cumulative is an individual at significant risk of developing the disorder. The present article reports on the initial results of risk profile development based on material gathered from subjects while still in Vietnam. The risk profile is examined in relation to indices of anxiety and depression from the HSCL25. Method One hundred and sixty-one subjects were randomly selected from a group of Vietnamese Amerasians awaiting U.S. placement at the ATC in Ho Chi Minh City, Vietnam. 912

Demographic data describing the sample are shown in Table 1. These subjects were administered the HSCL-25 and a version of Felsman et al.'s PIF, modified to reflect administration in Vietnam rather than the Philippines. The HSCL25 is a 25-item checklist measuring symptoms of both anxiety and depression and yielding a total score as well as anxiety and depression subscores. The HSCL-25 was used by Felsman et al. to determine subjects' level of psychological distress and has also been used by other investigators studying Vietnamese and other Indochinese immigrant populations. The PIF is a 35-item questionnaire developed by Felsman et al. to elicit demographic, health, and mental health data from Vietnamese-Amerasians. Additional procedures were administered but will not be reported here. These procedures were the General Health Questionnaire, Vietnamese Depression Scale, and the Diagnostic Interview Schedule. Two other questionnaires developed by the authors (R.M., A.M.) were used: an Expectations Questionnaire and a History of Sexual Abuse Questionnaire. Data Analysis

Several statistical procedures were used to analyze the data. All analyses were done using SPSS-PC version 3.2. Data that examined the relationship between scores on the HSCL-25 and items on the PIF were analyzed using two procedures. Univariate analyses that examined the relationships between individual risk factors and HSCL-25 scores were done using eta coefficients. This procedure is appropriate when the dependent measure is on an interval scale and the independent variable is either on an ordinal or nominal scale (Norusis, 1988). Because some of the items on the PIF were nominal and some were ordinal, this statistic was

TABLE 1. Demographic Features of the Sample

Age: mean (range) Females Males Total Sex (%) Males Females

20.3 20.5 20.4

(17-28) (15-28) (15-28)

65 35

School (%) None 1-4 years 5-8 years 9-12 years > 12 years

28 32 32 12 1

Home (%) Ho Chi Minh City Other city Small town New economic zone

15 18 55 11

Religion (%) Buddhist Catholic Protestant Other None

26 18 17 2 36

J. Am. Acad. Child Adolesc. Psychiatry, 31:5, September 1992


Risk Factors Predicting Increased Levels of Anxiety and Depression on the HSCL-25


Risk Factor Prior camp experience History of hospitalizations History of missing school No school Feeling negative or indifferent toward American father Hostile relationship with step/foster father Very low family income Conduct disorder Did not always live with mother

0.28** 0.25** 0.24** 0.22**

160 158



0.19* 0.19* 0.18* 0.13*

150 160 158 157



Note: HSCL-25 = Hopkins Symptom Checklist -25. *p ::; 0.05, **p ::; om.

chosen because it allows some comparison of the strength of risk factors of both types. Also, eta does not assume a linear relationship between dependent and independent measures. The squared value of the eta coefficient represents the proportion of the total variability in the dependent measure accounted for by the independent measure (Guilford and Fruchter, 1973). Because not all subjects provided complete data, sample size for univariate analyses varied and is reported with the results of each analysis. The following analyses were done, using 136 subjects who provided complete data on the risk factors used in the analyses and the HSCL-25. Analyses that examined the relationship between the number of factors on which an individual was at risk and scores on the HSCL-25 were done using analysis of variance. Because the number of risk factors was a quantitative variable, this involved an analysis for trend. It was expected that the relationship between the number of risk factors and HSCL25 scores would show a linear trend, with increases in the number of risk factors associated with progressively higher scores on the HSCL-25. Additional analyses examined the relationship between symptomatic status on the HSCL-25 (i.e., scores above 1.75) and risk status. Because relatively few of the subjects in the study met this criteria, risk status was collapsed into two categories: those with zero, one, or two risk factors (low risk), and those with three, four, or five risk factors (high risk). Chi-squared analyses were used to test the hypothesis that risk status and symptomatic status were independent. Because the number of risk factors and symptomatic status can be considered ordinal variables, Kendall's tau was used to examine the strength of this relationship. This statis-

tic examines the rank order of two scores (in this case number of risk factors and symptomatic status) and indexes the degree to which these two scores are ranked in the same order (Willemsen, 1974). Results

The 35 items on the PIF were analyzed to determine which ones were related to HSCL-25 total score, using eta coefficients to index the relationship between each item and J. Am. Acad. Child Adolesc. Psychiatry, 31:5,September 1992

the HSCL-25 score. Of these 35, nine were significantly related to HSCL-25 total score on the univariate level. Table 2 presents the nine variables and eta coefficients for each measure as well as the number of subjects who provided this information. The nine risk factors were as follows: whether the Amerasians had been in another camp, history of hospitalizations, history of missing school, type of school attended, negative or indifferent feelings toward their American father, hostile feelings toward their step/foster father, very low family income, a history of conduct disorder, and whether their mother lived with them. Of these nine risk factors, only a history of hospitalizations and a history of missing school were also found to be risk factors by Felsman and his colleagues. Although all of these were related to HSCL-25 scores, each risk factor individually accounted for relatively little variance in HSCL-25 scores. Previous camp experience, for example, accounted for approximately 8% of the variance in HSCL-25 scores. For further analyses, these nine risk factors were coded into a dichotomous variable, with those determined to be at risk assigned a value of one and those not at risk a value of zero. Determination of cut points for determining risk was based on both conceptual and empirical factors. For example, for feelings regarding one's American father, responses indicating "indifference" or "negative regard" were coded as at risk, while responses indicating "mixed feelings" and "positive regard" were not. Here the attempt was to separate positive or partially positive feeling from nonpositive feelings. For each variable, risk was assigned as follows. For a history of hospitalizations and missing school, those who indicated that they had been hospitalized or missed school were considered at risk. Responses of "never," "once," or "two or three times" were not. For length of time in another camp, those who answered "not at all" were coded zero, all others as one. For type of school attended, those who attended no school were classified as at risk, whereas those who attended public or private school were not. Feelings toward one's American father were coded as indifference or negative regard as at risk, whereas positive regard or mixed feelings were not at risk. For the relationship with step/foster father, those who described their relationship as "hostile" were considered at risk, all other responses were not. For family income, responses of "very low" were considered at risk, all others were not at risk. For conduct disorders, reports of problems with truancy, living away from home, stealing, or fighting were counted as at risk, but reports of no problems were not. Those who had not lived with their mothers were considered at risk, whereas those who had were not.

For each subject, the number of risk factors on which he or she met the criteria was summed. As would be expected, most subjects had relatively few risk factors. A total of 136 subjects had data on all 'nine risk measures and were used for analyses. The other 25 subjects had data on at least one risk factor missing and were not included. Seventy-five percent of the subjects had zero, one, or two risk factors (36, 39, and 27 subjects, respectively). Only 34 subjects (25%) had three or more risk factors (21, 10, and 3 subjects had 913


3. Means and Standard Deviations for HSCL-25 Total Depression and Anxiety Subscales

Number of Risk Factors Zero One Two Three Four Five




1.17 1.32 1.29 1.34 1.49 1.84

(0.15) (0.25) (0.18) (0.20) (0.26) (0.45)

Depression X SD

1.18 1.32 1.32 1.38 1.59 1.89

(0.17) (0.29) (0.20) (0.22) (0.26) (0.60)

Anxiety SD


1.16 1.31 1.23 1.27 1.33 1.77

(0.16) (0.25) (0.21) (0.25) (0.31) (0.23)

three, four and five risk factors, respectively). No subject had more than five risk factors. The correlation between the number of risk factors and HSCL-25 total score was 0.42. The correlation between the depression subscale and the number of risk factors was 0.45, somewhat higher than the correlation between the anxiety scale and the number of risk factors 0.27. An analysis of variance using the number of risk factors as the independent measure and HSCL-25 total score as the dependent measure was conducted. Because the number of risk factors was a quantitative variable, an analysis for trend was conducted. Results showed that the omnibus F was significant (F S•130 = 8.4, p < 0.001). Trend analysis showed a significant linear trend (Fl,l3o = 2.2, NS). Separate analyses were done for the depression and anxiety subscales. Because the two subscales are not orthogonal (and indeed are highly correlated), alpha was set at 0.01. Omnibus F-ratios for both subscales were significant at the 0.001 level (for depression, F S•130 = 5.3, p < 0.001; for anxiety, FS,130 = 8.4, p < 0.001). Analyses for trend showed a significant linear trend for both scales (for depression, F 1,130 = 34.5, p < 0.001; for anxiety, Fl,13o= 11.2, P < 0.01). The quadratic trend was not significant for either subscale. These results indicated that a linear function adequately described the data. That is, increases in the number of risk factors were associated with increases in HSCL-25 scores. The lack of significance for the quadratic trend indicated that there was not a point at which the relationship between risk and HSCL-25 scores showed a drop. Table 3 lists the means and standard deviations for the total score and the anxiety and depression subscales of the HSCL-25 for each number of risk factors. The analyses discussed thus far have all examined the relationship between scores on the HSCL-25 and the number of risk factors. As noted earlier, this was done because relatively few subjects were symptomatic at the time of evaluation. Further analyses looked at the relationship between symptomatic status and number of risk factors. A chi-square test to determine if number of risk factors and symptomatic status were independent was conducted also. Results of the chi-square analyses (all using Yate's correction) showed that symptomatic status and risk status were not independent for the total score (X21 = 4.2, p < 0.05), or for the anxiety subscales (X21 = 8.4, p < 0.05), or the depression subscale (X21 = 6.07, p < 0.05). The correlation between number of risk factors and symptomatic status (using Kendall's tau) were 0.21, 0.19, and 914

0,23 for the total, depression, and anxiety subscales, respectively (p S; 0.01 for all three). Although these correlations were statistically significant, they were modest and indicated that risk status accounted for only a small proportion of the variance in symptomatic status.

Discussion The ability to predict, before departure, who will experience difficulties in mental health adjustment after immigration is an important aspect of successful immigrant and refugee placement. The results of this study confirm the results of Felsman et al. (1989) that in a sample of Vietnamese Amerasian youth risk factors predicting current psychological distress can be identified. Individual risk factors in this study had relatively low predictive power. In addition, they differed little in their ability to predict psychological distress, making rank ordering of risk factors not meaningful. It was only as risk factors became cumulative that they were associated with clinically significant symptom levels (Table 3). In this sample, only subjects with a total of five risk factors had symptoms in excess of the clinical cut-off for the HSCL- 25. This fact is of importance for clinicians working with the same or similar populations. Particularly in asymptomatic subjects special attention, and possible preventive intervention, should be reserved for those subjects with five or more risk factors. Isolated risk factors should not be cause for undue concern. As can also be seen from Table 3, depression was more sensitive to increasing numbers of risk factors than either anxiety or the total score of anxiety and depression sub-scales. It is surprising that so few subjects in the study (N = 3) scored above the clinical cut-off. It may be assumed that some subjects minimized psychiatric symptoms in Vietnam. There are several possible reasons for this. They may have feared that "sicker" subjects might not be accepted by the U.S. They may have experienced the "time bound" focus of refugee thought on the present; excluding consideration of past and future until they feel secure (Beiser, 1987). The method of data collection may have impeded truthful responses. Because so many subjects were functionally illiterate, questionnaires had to be administered in groups, with interpreters reading questions and receiving responses orally in front of other group members. Finally, subjects may have actually felt better than usual because they were in a "time of hope," gathered together with others just like themselves, full of expectations for a future outside Vietnam, and not yet having had to match their expectations with reality. It is not yet known whether the risk factors identified in this study will predict future, as well as concurrent, psychological distress. Nor is the relationship known between symptoms of anxiety and depression in the subjects and the diagnosis of mental illness. It is hoped that the first question may be answered by further evaluations of the sample in the Philippines and the U. S., and the second by correlating symptoms with results of the Diagnostic Interview Schedule, which was administered to one-fourth of the subjects at all three sites. With 15 million refugees in the world today, the United J. Am. Acad. Child Adolesc. Psychiatry, 31,'5, September 1992


States' concern for its flood of new arrivals can only be expected to continue. The ability to understand, predict difficulties, and provide early and effective support to these populations will enable resettlement workers and mental health professionals to more successfully cope with the adaptation and adjustment of new Americans.

References Beiser, M. (1987), Changing time perspective and mental health among southeast Asian refugees. Cult. Med. Psychiatry, 11:437-

464. Boman, B. & Edwards, M. (1984), The Indochinese refugee: an overview. Aust. N. Z. J. Psychiatry, 18:40-52. Brendan, M. K (ed.) (1990), Amerasian Update, (Number 24). Washington, DC: Interaction and Lutheran Immigration and Refugee Service. Costello, E. J. (1989), Developments in child psychiatric epidemiology. J. Am. Acad. Child Adolesc. Psychiatry, 28:836-841. Felsman, J. K, Johnson, M. C; Leong, F. T. L. & Felsman, I. C. (1989), Vietnamese Amerasians: practical implications of current research. Washington, DC: Department of Health and Human Services. Gilzow, D. F. & Ranard, D. A. (1990), The Amerasians: a 1990 update: in America. Perspectives on Refugee Resettlement, 9: 1-11. Guilford, J. P. & Fruchter, B. (1973), Fundamental Statistics in Psychology and Education, 5th ed. New York: McGraw Hill. Kinzie, J. D., Manson, S. M., Vinh, D. T., Tolan, N. T., Anh, B. & Pho, T. N. (1982), Development and validation of a Vietnameselanguage depression rating scale. Am. J. Psychiatry, 139:12761281. Lilienfeld, A. M. & Lilienfe1d, P. E. (1980), Foundations of Epidemi-

J. Am. Acad. Child Adolesc. Psychiatry, 31:5, September 1992

ology, 2nd ed. New York: Oxford University Press. Lin, K M., Tazuma, L. & Masuda, M. (1979), Adaptational problems of Vietnamese refugees I. Arch. Gen. Psychiatry, 36:955-961. Masuda, M., Lin, K M. & Tazuma, L. (1980), Adaptational problems of Vietnamese refugees II. Arch. Gen. Psychiatry, 37:447-450. Mollica, R. F., Wyshak, G., de Marneffe, D., Khuon, F. & Lavelle, J. (1987), Indochinese versions of the Hopkins Symptom Checklist25: a screening instrument for the psychiatric care of refugees. Am. J. Psychiatry, 144:497-500. Murphy, H. B. M. (1977), Migration, culture and mental health. Psychol. Med., 7:677-684. Newcomb, M. D., Maddahian, E. & Bentler, P. M. (1986), Risk factors for drug use among adolescents: concurrent and longitudinal analyses. Am. J. Public Health, 6:525-531. Nicassio, P. M., LaBarbera, J. D., Coburn, P. & Finley, R. (1986), The psychosocial adjustment of the Amerasian refugees: findings from the Personality Inventory for Children. J. Nerv. Ment. Dis., 174:541-544. Norusis, M. J. (1988), SPSS/PCT. V2.0 Base Manual. Chicago: SPSS Inc. Rumbaut, R. G. (1985), Mental health and the refugee experience: a comparative study of southeast Asian refugees. In: Southeast Asian Mental Health: Treatment, Prevention, Services, Training and Research, ed. T. C. Owan. Washington, DC: NIMH. United States Catholic Conference. (1985), In our father's land: Vietnamese Amerasians in the United States. USCe. Westermeyer, J., Vang, T. F. & Neider, 1. (1983), Migration and mental health among Hmong refugees. J. Nerv. Ment. Dis., 171:9296. Willemsen, E. W. (1974), Understanding Statistical Reasoning, San Francisco: W. H. Freeman and Company. Williams, C. L. (1987), An Annoted Bibliography on Refugee Mental Health. Washington, DC: U.S. Government Printing Office.


A risk profile predicting psychological distress in Vietnamese Amerasian youth.

The relationship between risk factors and psychological distress was examined in 161 Vietnamese Amerasian youth. Background factors such as a history ...
5MB Sizes 0 Downloads 0 Views