Depression in Hispanic adults who immigrated as youth: results from the National Latino and Asian American study.
This perceived stress requires a coping response that allows the individual to tolerate the stress. How each individual copes with the stress varies (Thoits, 1995). Undesirable stress has been linked with mental distress and mental illness (Rahe, 1968; Vinokur & Selzer, 1975), and there is abundant literature establishing the risks associated with developing depression (Cuijpers, de Graaf, & van Dorsselaer, 2004). However, the specific relationship between the immigration process and subsequent experiencing of mental illness, such as the symptoms of depression, has not been examined in detail.
Numerous factors influence an immigrant's risk of developing a mental illness. Risk factors of depression and anxiety in Hispanic immigrants include low socioeconomic status, linguistic barriers (Morales, Lara, Kington, Valdez, & Escarce, 2002), discrimination and acculturation (Hovey & Magana, 2002), and even gender (Portes & Rumbaut, 2001). Sociocultural characteristics that are specific to distinct immigrant populations, such as the different rates of adaptation for children and parents noted above, may also contribute to the development of mental illness (Berry, Kim, Minde, & Mok, 1987; Yearwood, Crawford, Kelly, & Moreno, 2007).
This article reports the findings of a study that was intended to describe the relationship between cultural adaptation and mental illness among Hispanic immigrants, with special attention given to those migrating at a young age. This study utilized acculturation as an indicator of cultural adaptation as it focused on changes resulting from immigration into a different cultural context. Specifically, this study addressed the effects of acculturation, dissonant acculturation, acculturative stress, ethnic social identity, family cohesion, and subjective social status on the number of depressive symptoms experienced. This study's aim was to describe how these variables relate to one another and to examine the effect of acculturation on the mental health of Hispanic immigrants who migrated during their youth.
The process of immigration can be viewed as both an individual and a family journey. This process is influenced by a desire to adapt, widely known as acculturation. For children brought into a new country, the family is an essential element for a successful transition (Bacallo & Smokowski, 2007). The cohesiveness of families undertaking immigration and acculturation is essential given the multiple pressures faced by immigrant youth. These pressures include ethnic identity formation, social status, and discrimination. When this process does not go smoothly, individuals may experience mental health problems, including depression. This study examined the relation of these constructs in a sample of Hispanic adults who migrated during their youth.
Acculturation can be defined as continuous firsthand contact between differing cultures, resulting in changes in the cultural patterns in one or both groups (Redfield, Linton, & Herskovits, 1936). Much of the research on acculturation has focused on changes in the immigrant minority resulting from this contact. Gordon's (1964) cultural assimilation theory proposed that acculturation was the first among many processes that an immigrant must undertake in order to adapt. Subsequent theorists have stated that acculturation is a process of psychological and social adaptation resulting from sustained interaction with a new culture (Berry, 2006; Bourhis, Moise, Perreault, & Senecal, 1997).
The experience of younger immigrants differs dramatically from that of their parents. Whereas the immigrant parents come into the host country with an established identity and a set of cultural values, young immigrants are challenged with establishing an identity and a set of values and beliefs while being situated in between two cultural systems. Successful cultural adaptation requires that the immigrant navigate the cultural system of the host country and that of the native country. Whereas younger immigrants bring a set of cultural beliefs from their native country, these beliefs have typically not yet solidified into a structured value system (Phinney, Horenczyk, Leibkind, & Vedder 2001). Because young immigrants are still learning their values, beliefs, and culture, the transition into a different country is about negotiating the two cultural systems that are each imposing themselves on them. Differing cultural systems can impress contradictory expectations upon second generation immigrants (Foner, 1997). Continuous firsthand contact is unique among second generation immigrants, simultaneously occurring during the development process and affecting identity and personal beliefs.
Acculturative stress has been conceptualized as the stress experienced by individuals during the acculturation process, generally arising from difficulties during intercultural exchanges (Berry, 2006; Berry et al., 1987). Acculturative stress experienced by Mexican Americans and by Mexican immigrants is linked with difficulties with depression, anxiety, substance use, and social functioning (Finch, Kolody, & Vega, 2000; Hovey, 2000a, 2000b; Hovey & Magana, 2002). Whereas researchers such as Smart and Smart (1995) have shown that acculturative stress can span an individual's entire lifetime, varying in prevalence and intensity, few studies have included acculturative stress in models developed to predict psychological and social functioning (Archuleta, 2010). Further, individuals who are less acculturated have higher levels of acculturative stress (Caetano, Ramisetty-Mikler, Caetano-Vadeth, & Harris, 2007; Miranda & Matheny, 2000). Family supports often aid in buffering the negative effect of acculturative stress by allowing individuals to engage with existing cultural resources (Berry, 2003; Finch & Vega, 2003).
Children of immigrants tend to acculturate at a faster rate than do their parents (Szapocznik & Truss, 1978). This phenomenon, known as dissonant acculturation, suggests that children acquire the language of their new environment as their first language; adopt the values and norms, beliefs, and attitudes of the host society more readily; and develop cross-cultural relationships more easily than their parents (Portes & Rumbaut, 2001). This leads to a difference in attitudes and beliefs between parent and child that is known as the acculturation gap. Implicit in the acculturation gap distress model is the belief that the acculturation gap is inherently stressful. This stress affects both the parent and the child because of differences in acculturation rates. As a consequence of this gap, parents may restrict the child's continued acculturation, inciting further rejection of the parental culture by the child (Santisteban et al., 1996; Szapocznik, Santisteban, Kurtines, Ferez-Vidai, & Hervis, 1984).
Ethnic Social Identity
The adaptation of immigrants to a new culture involves the acceptance of norms, values, and belief systems that are alien. Confronted with these alien ideas, individuals are often forced to question their own identity. Social Identity Theory posits that individuals achieve and maintain group membership based on having characteristics similar to those of other group members (Tajfel & Turner, 1979). In turn, this contributes to a process of identification through membership with the group. Membership with such groups plays an important part in an individual's developing a sense of personal identity.
Cultural identity has been conceptualized as "the part of social identity that reflects the individual's self-perception and self-definition as a member of a cultural group" (Tartakovsky, 2009, p. 655). Cultural identity can be a complex issue for individuals who come from ethnically blended families. Those who have immigrated may associate with multiple cultures and nationalities (Phinney, 1990; Schwartz, Montgomery, & Briones, 2006). A strong sense of ethnic identity has been found to be a positive predictor of adjustment in adolescent immigrants (Fuligni, Witkow, & Garcia, 2005). Nesdale, Rooney, and Smith (1997) demonstrated that a strong sense of ethnic identity could predict coping resources for recent migrants. However, the complexity of ethnicity and ethnic identity cannot be understated.
Family cohesion is defined as "shared affection, support, and helpfulness among family members" (Barber & Buehler, 1996, p. 433) or a feeling of closeness among the members of a family. Movement from a familiar cultural environment into a new, unfamiliar one affects the entire family. In a series of studies using samples of Latino immigrant families, Marsiglia and his team found that higher levels of family cohesion are associated with lower rates of rule-breaking behavior and lower levels of adaptation-related internal strife and conflict within the family (Marsiglia, Parsai, & Kulis, 2009). Additionally, they found both high and low levels of family cohesion to be predictive of adolescent alcohol use compared to medium levels of family cohesion in immigrant Latino families. These results indicated that medium levels of cohesion are protective, but excess cohesion is as harmful as too little cohesion. These findings are consistent with studies of family dynamics that suggest that too much or too little cohesion may result in what are termed disengaged families or enmeshed families (Miranda, Estrada, & Firpo-Jimenez, 2000).
Subjective Social Status
Although there is general agreement about objective measures of social status, this agreement does not exist for subjective social status (Demakakos, Nazroo, Breeze, & Marmot, 2008). Subjective social status is a measure of what someone believes to be his or her social status relative to others (Adler, Epel, Castellazzo, & Ickovics, 2000). The impact of subjective social status upon stress and mental health outcomes has been repeatedly demonstrated (Kessler, 1979). A study among Asian immigrants found that subjective social status affected the mental health of those migrating after adulthood, whereas there was no effect for those migrating during their youth (Leu, Yen, Gansky, & Walton, 2008). There are myriad conflicting views on the importance and reliability of subjective social status. There is very limited research on subjective social status and Hispanic immigrants. One study indicated that subjective social status has no effect on the health of low-income Mexicans when objective measures are included (Franzini & Fernandez-Esquer, 2006). This paucity of findings on subjective social status may suggest that Hispanic immigrants, due to their status relative to the native majority, may succumb to worsening mental health outcomes.
Discrimination denotes the experiences or expectations of unfair treatment, often attributed to race or ethnicity (Rumbaut, 2005). Individuals who experience discrimination are expected to react negatively to it. This reaction commonly manifests itself through the development of mental health problems (Araujo & Borrell, 2006). It is common for immigrants as under-socialized groups to experience acts of discrimination. As mental health problems present themselves in culturally bound ways, rates of discrimination and responses to discrimination are important considerations in understanding experiences of immigration and acculturation. Discrimination has a profound negative impact on the psychological well-being of immigrants (Liebkind & Jasinskaja-Lahti, 2000) as well as being associated with an increase in depressive symptoms (Noh, Kaspar, & Wickrama, 2007). The mental health effects of discrimination are less for those adopting an identity reflective of the native majority than for those with a strong ethnic identity (Rumbaut, 2005; Yip, Gee, & Takeuchi, 2008).
Several contextual variables have been demonstrated to have an effect on both cultural adaptation and depression. In samples of all ethnic groups as well as in Hispanic-only samples, females are more likely to suffer from depression than are males (Golding & Karno, 1988; Hiott, Grzywacz, Arcury, & Quandt, 2006; Nolen-Hoeksema, 2001; Portes & Rumbaut, 2001; Weissman & Klerman, 1977). Gender role expectations also differ between immigrants and natives (Dion & Dion, 2001). These differences in gender expectations may affect the acculturation of young immigrants as they seek to adapt to two different cultural systems.
Some maintain that more years of education increase the likelihood of one's successful assimilation into the mainstream (Portes & Rumbaut, 2001). Akhtar-Danesh and Landeen (2007) demonstrated that those with higher education are less likely to suffer from depression, thus increasing their overall functioning. Those from lower socioeconomic backgrounds have consistently been shown to be more likely to suffer from depression and other mental health problems than individuals from groups with higher socioeconomic status (Kessler, 1982; Murphy et al., 1991; Zimmerman & Katon, 2005).
Depression is the most common mental illness and is described as more than just sadness; it includes prolonged periods of weight loss or gain, insomnia, and feelings of worthlessness among other symptoms (American Psychological Association, 2013). Although Hispanic immigrants are less likely to suffer from a mental illness than their U.S.-born Hispanic counterparts, longer residence in the United States increases the lifetime prevalence of mental illness (Alegria et al., 2007). This trend is similar for the prevalence of major depressive episode (MDE) among immigrant and nonimmigrant Hispanics. The prevalence of MDE among Hispanic immigrants is lower than for U.S.-born Hispanics (Alegria et al., 2008). This has led researchers to suggest that an acculturation effect leads to increased stress and higher risk of mental illness (Ortega, Rosenheck, Alegria, & Desai, 2000).
Previous research has emphasized the immigrant's psychological functioning in society. For example, among Latino immigrants, perceived stress and social sup port are predictive of psychological health (Dunn & O'Brien, 2009). The psychological health variable in the study reported by Dunn and O'Brien measured a broad array of psychological symptoms, focusing on psychological health instead of diagnoses. Many of the psychosocial and environmental conditions immigrant families must endure as a consequence of immigration result in the development of diagnosable mental illness. Stressful life events such as emigration (Golding & Burnam, 1990; Hammen, 2005), the lack of intact support systems (Kim & McKenry, 1998; Vega, Kodoly, Valle, & Weir, 1991), and poor living conditions (Aroian & Norris, 2002; Pachter, Auinger, Palmer, & Weitzman, 2006) have all been linked to higher odds of experiencing depression. Thus, two approaches exist for assessing mental well-being in immigrant groups. One approach emphasizes psychological functioning and the other focuses on risk factors related to diagnosable mental illnesses.
Counting or summing depressive symptoms has been used to screen for clinical depression in various populations (Pignone et al., 2002). Tools such as the Center for Epidemiologic Studies' Depression Scale (CES-D) are designed to assess for depressive symptoms in the general population (Radloff, 1977). Although diagnoses place all of those who meet the criteria for that label (including the least and most severe cases) in the same category, examination of symptoms provides a more nuanced look at the psychological phenomenon (Persons, 1986).
The use of a diagnosis, such as depression, also has advantages when examining mental health. Depression has a uniform criterion established by the Diagnostic and Statistical Manual of Mental Disorders IV-TR (4th ed., text rev., American Psychiatric Association, 2000). This means that individuals diagnosed with depression have met the criteria for the condition, separating them from those who do not have the condition. Diagnostic criteria allow mental health professionals to diagnose and treat mental illness with the goal of alleviating the condition.
The effect of acculturation on depression is an ongoing area of research. Although Hispanic immigrants suffer from depression less often than U.S.-born Hispanics, residing in the United States appears to be a risk factor for developing depression (Alegria et al., 2007). The current study examined the effect of acculturation, along with many of the other variables known to change after immigration, such as ethnic social identity and subjective social status, on depression. Because immigration into the United States is not slowing, it is essential to develop a more thorough understanding of the risks attributable to acculturation. This study attempted to address those risks, with specific attention given to young immigrants who were brought here by their adult parents.
A secondary analysis of data from the National Latino and Asian American Study (NLAAS) was conducted. The NLASS is a cross-sectional study providing information on mental illness and service use among Latinos and Asian Americans that was collected between May 2002 and November 2003. It provides a nationally representative sample of Latinos and Asian Americans in the United States (Alegria & Takeuchi, 2007). For a more complete discussion of the NLAAS sample, see Alegria & Takeuchi, 2007.
Current Study Sample
The current study focused on Latinos born outside the United States who migrated to the United States by age seventeen. All study participants (N = 581) were adults over the age of eighteen at the time of data collection, and the mean age of the sample was 35.67 years. For the purposes of this study, the term immigrant included those residing in Puerto Rico who relocated to the United States.
Information on the origin, measurement technique, and purpose of each instrument used in the study is presented below. Table 1 provides the Cronbach's alpha level for each scale in the study sample.
Acculturation, This construct was assessed using two three-item subscales designed to measure language proficiency. The Spanish language version of the language proficiency scale used in the NLAAS was derived from the Cultural Identity Scale for Latino Adolescents (Felix-Ortiz, Newcomb, & Meyers, 1994). The English language version was developed specifically for the NLAAS. Higher scores represent higher linguistic proficiency and lower scores represent lower proficiency (Alegria & Takeuchi, 2007). For this study, the English language proficiency and Spanish language proficiency measures were recoded and combined into a single measure of acculturation. Negative scores represent a greater proficiency in Spanish, whereas positive scores represent a greater proficiency in English. A zero score represents equal proficiency in both languages. Questions asked respondents how well they spoke, read, and wrote in English and in Spanish. Response categories included poor, fair, good, and excellent.
Acculturative Stress. An eight-item scale was used to measure acculturative stress. The scale was taken from the Mexican-American Prevalence and Services Survey (Vega et al., 1998) and measured the stress of cultural change. Questions asked respondents about the stresses of adapting and about difficulties with the English language. The scale was measured with yes (1) and no (0) responses, with lower scores indicating lower stress.
Dissonant Acculturation. A five-item scale was used to measure dissonant acculturation. The scale addressed "cultural and intergenerational conflict that arises between respondents and their families" (Alegria et al., 2004, p, 2 78). These items were drawn from the Hispanic Stress Inventory (Cervantes, Padilla, & Salgado de Snyder, 1991). Likert-style response categories included hardly ever or never (1), sometimes (2), and often (3). Higher scores indicated greater dissonant acculturation.
Ethnic Social Identity. Three items were used to measure ethnic social identity. Participants were asked how close they felt to those of the same ethnicity, how close their ideas and feelings were to those of the same ethnicity, and how much time they liked to spend with those of the same ethnicity. Responses were scored using a four-point Likert scale with higher numbers representing more favorable in-group comparisons.
Family Cohesion. Measurement of family cohesion was obtained through summation of a ten-item scale developed by Olson (1986). Respondents were asked to indicate how much they agreed with a variety of statements about their family. Responses ranged from strongly agree to strongly disagree on a four-point scale. Higher scores indicated a higher level of family cohesion.
Subjective Social Status. Two items were used to measure subjective social status. Participants were asked to think of a ladder with ten rungs. At the top of the ladder are those who are the best off, and at the bottom are those who are the worst off. For one item participants were asked on which rung they would be compared to others in their community. For the second item participants were asked on which rung they would be compared to others in the United States. Responses ranged from 0 to 10 for each item. Higher numbers indicated a higher subjective social status.
Discrimination. Nine items were used to measure discrimination. Taken from the Detroit Area Study (Williams, Vu, Jackson, & Anderson, 1997), these items asked respondents to indicate how often they experienced being treated with less respect than other people, having people act scared of them, and/or being insulted. The scale used a six-point Likert scale with scores ranging from almost every day to never. Higher scores indicated a higher incidence of discrimination.
Psychosocial Context. As shown in Table 2, variables used to capture psychosocial context included the participant's gender, educational level (three categories: 0 = 0-11 years; 1 = 12 years; 2 = >12 years), years spent in the United States (four categories: <5 years; 5-10 years; 11-20 years; 20+ years), poverty ratio, gender (male = 0), age in years, and ethnic origin (Cuban, Puerto Rican, Mexican, or other Hispanic). The poverty ratio was the ratio between the participant's reported income and the 2001 Census poverty threshold. Age at immigration was used for descriptive purposes (two categories: less than 12 years old and 13 to 17 years old).
Depression. Although the primary outcome of this study was depressive symptoms, the calculated twelve-month prevalence of major depressive episode was also examined. This provided researchers the opportunity to examine the psychosocial functioning and clinical implications of the variables considered in the study.
Depressive Symptoms. A thirty-four-item checklist of depressive symptoms was used to assess participants for symptoms of depression. The checklist is part of a modified version of the World Mental Health Initiative Composite International Diagnostic Interview (CIDI) developed by Kessler and Ustun (2004). The CIDI is designed to assess participants for mental illnesses as outlined by the World Health Organization's International Classification of Disease (ICD) criteria and the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). Participants were asked a series of questions, each reflecting a specific symptom or set of symptoms indicative of depression. Responses, including yes (1) and no (0), were summed to provide a total symptom count.
Major Depressive Episode--Twelve-Month Prevalence. In order to assess the clinical significance of the variables in the resulting model on a diagnosis of depression in the sample, a binomial logistic regression was also conducted. The NLAAS data set provides computed prevalence rates for major DSM-IV-TR diagnoses. Specifically, this study focused on the twelve-month prevalence rate of major depressive episode in assessing the clinical significance of the selected variables. Participants completing the CIDI either endorsed the diagnosis (1) or did not endorse the diagnosis (0).
To address the two different outcomes in this study, two different analyses were conducted. A recursive regression analysis was used with the depressive symptom count. A binomial logistic regression was used in the analysis of the major depressive episode variable.
Recursive regression was used to test the effects of cultural adaptation on depressive symptoms among immigrants who immigrated during their youth. Recursive regression allows for the decomposition of effects into direct and indirect components in lieu of computation of direct and indirect effects from the coefficients of a structural equation. The successive computation of equations employing ordinary least squares regression allows the researcher to determine direct and indirect effects while providing a path diagram that represents the statistical findings (Alwin & Hauser, 1975; Strang, 2009). Recursive regression, as an analytic tool for conducting path analysis, has the ability to incorporate the variables in the psychosocial context, allowing for greater control of extraneous demographic information. It also is not hindered by the number of hypothesized paths as compared to the number of variables. The end product of a recursive regression analysis is a statistical model that does not force paths that aren't significant. Instead, paths that do not fit will fall away as a statistical model develops that can be compared with the conceptual model (Alwin & Hauser, 1975; Strang, 2009).
In order to assess the clinical significance of the variables in the proposed model on depression, a binomial logistic regression was also conducted. The NLAAS data set provides computed prevalence rates for major DSM-IV-TR diagnoses. Specifically, this study focused on the twelve-month prevalence rate of major depressive episode in assessing the clinical significance of the selected variables. Independent variables from the recursive regression analysis were used as independent variables to predict the twelve-month prevalence of major depressive episode.
Table 3 shows the results of differences in predictor and outcome variables by age at immigration as calculated by chi square and t-test. Variables found to be significantly different between younger migrants (those migrating by age twelve) and older migrants (those migrating between ages thirteen and seventeen) include acculturation, acculturative stress, perceived social status, and discrimination.
The effect of all exogenous and endogenous variables in the model was calculated beginning with the primary dependent variable (depressive symptoms). This procedure was repeated in turn for each endogenous variable in the model; those endogenous variables that were most closely linked to the primary dependent variable underwent calculation first and those farthest away were calculated last. Calculation of direct and indirect effects required that these elements be put into the model successively instead of simultaneously. Psychosocial context variables, family cohesion, and acculturation, which is an exogenous variable, contributed to model specificity at every level. Table 4 displays the results of the recursive regression analyses. Figure 1 depicts the final path analysis including the significant and nonsignificant paths with standardized coefficients for each path.
Binomial Logistic Regression
Table 5 provides an overview of the findings. Subjective social status ([beta] = -.123, p < .01) and gender ([beta]= 1.085, p < .01) were significantly related to a diagnosis of major depressive episode in the past twelve months.
Chi-square testing was conducted on the two significant variables in order to confirm within-group differences. The median value of subjective social status (M = 13) was used to divide the variable into two groups for testing. Results confirm that those with a lower subjective social status endorse a diagnosis of major depressive episode more frequently than those with a higher subjective social status ([chi square] = 10.81, p < .001). Similarly, females report a higher frequency of major depressive episode than males ([chi square] = 7.38, p < .001).
The findings from this study provide a model of the cultural adaptation process on depressive symptoms while examining the effects of family cohesion and contextual factors such as age and gender in a sample of Hispanic individuals who immigrated to the United States prior to their eighteenth birthday. This process begins with acculturation and continues with changes in subjective social status, discrimination experiences, and changes in ethnic social identity and acculturative stress that can lead to dissonant acculturation and ultimately depressive symptoms. Two themes emerged from this study: the importance of family and the risk associated with stress in the adaptation process.
Importance of Family
Our study suggests that dissonant acculturation can influence the development of depressive symptoms in Hispanic immigrants. Given this sample's age at immigration, it is likely that many of the participants acculturated at a much faster pace than did their parents. The consequences of this faster acculturation may have included increased amounts of conflict with parents or other adult family members, specifically regarding issues pertaining to cultural values and the adaptation of beliefs. The results of this family conflict are reflected as increased symptoms of depression.
The potential harm caused by dissonant acculturation was offset by high levels of family cohesion. This is not to say that dissonant acculturation did not exist in families with high family cohesion. Rather, high family cohesion was associated with low levels of dissonant acculturation. Still, family cohesion and dissonant acculturation were not predictors of a diagnosis of major depressive episode in the past twelve months. This discrepancy is at least partly attributable to the model, which attributes endogenous and exogenous characteristics to independent variables, whereas the binomial logistic regression simply assumes that all independent variables occur simultaneously. More research is needed to describe why this particular difference exists. It is possible that dissonant acculturation may account for a particular set of symptoms of depression but may not account for the entire spectrum of symptoms, thus limiting its utility in applying a diagnosis.
Risk Associated with Stress in the Adaptation Process
Acculturative stress had a direct impact on both dissonant acculturation and depressive symptoms. Previous studies demonstrated that one outcome from the stress response is the development of symptoms of depression (Hovey & King, 1996). The current study confirms those findings in Hispanic immigrants who migrate at a young age. Although acculturative stress predicted discrimination, the association between these two constructs may partly explain acculturative stress as well. It is likely that the relationship between acculturative stress and discrimination is more complex, possibly covarying.
Results of the logistic regression indicated that only gender and subjective social status were predictive of major depressive episodes. Consistent with previous studies (Nolen-Hoeksema, 2001; Weissman & Klerman, 1977), females were more likely to suffer from depression than were males. This finding was reinforced by the finding of the recursive regression analysis that females experienced more symptoms of depression than did men.
The final model was unable to predict a diagnosis of major depressive episode (12-month prevalence), a complex psychiatric condition that is patently different from the symptom count. In order to assign a diagnosis of major depressive episode, some specific symptoms must be present for a minimum period of time, other conditions (such as bereavement or medical causes) must be ruled out, and clinically significant impairment must be observed (American Psychiatric Association, 2000). Thus, although the model appears to have some usefulness in detecting the more straightforward psychological phenomena, further refinement is needed to predict more complex psychiatric conditions such as depression.
Best Practices with Young Hispanic Immigrants
Myriad studies now exist that call for culturally competent practice models to integrate knowledge of acculturation into treatment of Hispanic clients (cf. Cardona et al., 2009; Lara, Gamboa, Kahramanian, Morales, & Bautista, 2005). Clinical consideration should be given to the issue of acculturation in this population. Mental health workers need to demonstrate an awareness and sensitivity to possible issues of cultural stress and how these issues may manifest as symptoms of depression when working with Hispanic youth. Although heterogeneous differences among ethnic Hispanic groups make recommending a single treatment protocol for depression difficult, prior study has indicated that Hispanic clients may prefer counseling or counseling and medication over treatment with medication alone (Lewis-Fernandez, Das, Alfonso, Weissman, & Olfson,, 2005). This issue may be attributable to the immigration process itself (Kirmayer et al., 2011). The results of the current study support the notion of therapeutic modalities as a preferred method of treatment to help young Hispanic immigrants negotiate potential risk for depression. Specifically, acculturative stress, dissonant acculturation, and family cohesion were all shown to be significant predictors in the recursive model, and they are all environmental influences not easily managed by medication alone. Rather, a combination approach may be most useful to help young immigrants balance new and differing cultural stresses with the expectations placed upon them by family members who grew up outside the United States.
The authors note several limitations of this study. First, the data used for this study were originally collected for the NLAAS; thus, it is difficult to evaluate their accuracy. Second, the data used for this study were cross-sectional. Therefore, no assumption about causality may be made from the results. Linguistic proficiency was used as a proxy for acculturation, relying on the Sapir-Whorf hypothesis (Kay & Kempton, 1984). Although this is common, it provides only a global assessment of the participants' level of acculturation and is not a nuanced measure. Because questions were asked about experiences during childhood, there is the potential for participants to engage in impression management by attempting to influence study personnel's perceptions. Finally, this study modeled the effect of cultural adaptation on depressive symptoms, which are not a measure of depression. Although the depressive symptoms identified in the CIDI measure represent the psychological symptoms associated with depression and they are cumulative, a formal diagnosis of depression requires more information than a count of symptoms.
The results of this study indicate that families play an important part in the cultural adaptation process in immigrant Hispanic youth. Dissonant acculturation or parent-child value differences that arise from acculturation contribute to the number of depressive symptoms reported by the child. Simultaneously, family cohesion may reduce the effects of dissonant acculturation; this study's results suggest that increasing family cohesion may reduce dissonant acculturation. To that end, family-based programs to increase cohesion and reduce dissonant acculturation are needed. Other family-based programs with family cohesion components have been shown to reduce problem behaviors in Hispanic adolescents (Coatsworth, Pantin, & Szapocznik, 2002) and to reduce and prevent drug abuse among Hispanic adolescents (Szapocznik et al., 1989). Therefore, adapting or applying these programs to Hispanic immigrant families with minor children may prove useful. Further study is needed on the interactive effects of dissonant acculturation and family cohesion to provide a clearer picture of family dynamics during the acculturation process.
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Jeremiah W. Jaggers, MSW, PhD, is assistant professor at the Indiana University School of Social Work in Indianapolis. Gordon MacNeil, MSW, PhD, is associate professor at the University of Alabama School of Social Work in Tuscaloosa.
Table 1 Internal Consistency (Cronbach's Alpha) of Measures No. of Scale Alpha N items Acculturation 0.670 563 6 Acculturative stress 0.706 580 9 Dissonant acculturation 0.791 577 4 Ethnic social identity 0.770 576 5 Subjective social status 0.764 568 2 Discrimination 0.893 570 9 Family cohesion 0.933 575 10 Table 2 Sample Characteristics N % Gender Male 270 46.5 Female 311 53.5 Education <12 years 210 36.1 12 years 138 23.8 >12 years 233 40.1 No. of years in the U.S. <5 32 5.5 5-10 40 6.9 11-20 159 27.4 >20 350 60.2 Income to needs ratio At or below 100% 208 35.8 poverty level (2001) Greater than 100% but 78 13.4 not exceeding 200% Greater than 200% 295 50.8 Ethnicity Cuban 131 22.5 Puerto Rican 116 20 Mexican 203 34.9 Other Hispanic 131 22.5 Age at immigration <12 years 365 62.8 13-17 years 216 37.2 Table 3 Descriptive Results of Predictor and Outcome Variables by Age at Immigration Mean (SD) Range Mean (SD) Predictor <12 years 13-17 years old old Acculturation * .295 (3.43) -9-9 -3.59 (2.92) Acculturation stress * 1.66 (1.31) 0-8 2.54 (1.71) Perceived social status * 12.74 (3.22) 2-20 11.89 (3.87) Discrimination * 15.32 (6.02) 4-39 13.75 (5.81) Ethnic social identity 9.92 (1.87) 3-12 9.92 (2.03) Dissonant acculturation 6.59 (2.06) 5-15 6.27 (1.93) Family cohesion 35.65 (5.54) 10-40 36.42 (5.12) Outcome Mean (SD) Range Mean (SD) <12 years old 13-17 years old Depressive 3.79 (2.06) 0-26 3.24 (7.06) symptoms N (%) N (%) <12 years old 13-17 years old Endorsed for 32 (8.8) 23 (10.6) major depressive episode (12 months) * .05 significance. Table 4 Recursive Regression Results Standardized regression coefficient Subjective Acculturative social stress status Acculturation -.301 *** .067 Acculturative stress -.062 Subjective social status Discrimination Ethnic social identity Dissonant acculturation Family cohesion -.042 .098 * Gender -.075 .031 Education -.051 .150 ** Years in U.S. -.077 -.071 Income -.049 .192 *** Age -.104 .117 * Cuban -.035 .002 Puerto Rican -.066 -.056 Other Hispanic -.034 -.052 *** Adjusted [R.sup.2] .174 *** .125 *** Error 0.826 0.875 Standardized regression coefficient Ethnic social Discrimination identity Acculturation .258 *** -.095 * Acculturative stress .280 *** .060 Subjective social status -.030 .053 *** Discrimination .025 *** Ethnic social identity Dissonant acculturation Family cohesion -.170 *** .169 *** Gender -.075 -0.007 Education .115 * 0.035 Years in U.S. -.018 -0.085 *** Income .051 -0.036 Age -.021 0.059 *** Cuban -.149 ** 0.065 *** Puerto Rican .084 0.118 Other Hispanic -.023 -0.135 Adjusted [R.sup.2] .171 *** .067 *** Error 0.829 0.933 *** Standardized regression coefficient Symptoms Dissonant of acculturation depression Acculturation 0.021 0.044 *** Acculturative stress .085 ** .094 * Subjective social status -0.038 *** -0.082 Discrimination .160 *** -0.166 Ethnic social identity -0.003 -0.028 Dissonant acculturation .180 *** Family cohesion -.528 *** -0.035 Gender .071 * .132 ** Education .083 * -0.004 Years in U.S. -0.017 -0.043 Income -0.056 -0.002 Age 0.053 *** 0.102 Cuban 0.031 0.06 *** Puerto Rican -0.028 *** 0.092 *** Other Hispanic 0.02 *** 0.039 *** Adjusted [R.sup.2] .357 *** .068 *** Error 0.643 0.932 *** * < .05; ** < .01; *** < .001. Table 5 Binomial Logistic Regression Results Model summary Cox & Snell [R.sup.2] .084 Nagelkerke [R.sup.2] .185 Hosmer & Lemeshow .387 Goodness of Fit Test B Acculturation -0.043 Acculturation stress .164 Subjective social status -.123 ** Discrimination .033 Ethnic social identity -.065 Dissonant acculturation .104 Family cohesion -.043 Gender 1.085 ** Education (12 yr) ([dagger]) -.035 Education (>12 yr) ([dagger]) .368 Years in U.S. -.249 Income -.078 Age .023 Cuban .801 Puerto Rican .256 Other Hispanic -.117 ([dagger]) < 12 years education. ** < .01 Significance
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|Author:||Jaggers, Jeremiah; MacNeil, Gordon|
|Publication:||Best Practices in Mental Health|
|Date:||Sep 22, 2015|
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