Validation of the Multiple Language Versions of the Hopkins Symptom Checklist-37 for Refugee Adolescents

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INTRODUCTION

During the last 20 years, there has been a substantial influx of immigrants and refugees to Europe (Eurostat, 2002). This has led to many more schools in Dutch and Belgian metropolitan areas providing education for children and adolescents who do not speak the language of the host country fluently. The transition from one country to another implies changes and difficulties such as the loss of social networks, changes in work status as well as encountering discrimination that can be very distressing (Vinokurov, Trickett, & Birman, 2002).

The traditional higher-order latent structure of internalizing (overcontrolling) and externalizing (undercontrolling) problems have for many years been a useful framework for emotional distress and maladaptive behaviors of children and adolescents (e.g., Achenbach & Edelbrock, 1978; Southam-Gerow & Kendall, 2002). In recent years, Krueger and colleagues (2001) confirmed the usefulness of this dichotomy in explaining the covariance among adult mental health and personality disorders. Moreover, Miller and colleagues (2003) have put forward an internalizing/externalizing model to explain the reactions of traumatic stress among adult combat veterans. The internalizing/ externalizing model seems to provide an adequate framework in which traumatic stress reactions and/or (comorbid) psychopathology can be understood.

The literature on the mental health of refugee adolescents depicts a high prevalence of psychosocial symptoms reported by refugee adolescents (Felsman, Leong, Johnson, & Felsman, 1990; Sack et al., 1993; Sourander, 1998; Smith, Perrin, Yule, Hacam, & Stuvland, 2002). The most frequently reported symptoms are somatic complaints, anxiety, depression, and (post)traumatic stress reactions. Unaccompanied refugee minors (URM) run an especially high risk for developing psychopathology due to separation from primary caregivers, exposure to sequential stressful events, limited educational opportunities, and conditions in asylum centers during a very vulnerable developmental period (Felsman et al., 1990; Sourander, 1998). High comorbidity has been documented between reactions to traumatic stress and other disorders such as depression (Sack et al., 1993) and anxiety (Warshaw et al., 1993). Significant adults in the lives of adolescents (i.e., caregivers, teachers) often report a lower prevalence of internalizing problems than do the adolescents themselves since they have difficulty determining the extent to which the adolescents suffer from psychological distress.

On the other hand, perceiving the disturbing nature of externalizing problems is not difficult. Adolescents with conduct problems have been found to be referred much sooner and more often to professional mental healthcare services than adolescents with internalizing problems (Wu et al., 1999). The literature on conduct problems of refugee adolescents is very limited. Allwood, Bell-Dolan, & Husain (2002) found a strong association between witnessing of organized violence and exhibiting aggressive behavior. Jensen and Shaw (1993) suggest that adolescents who have witnessed or taken part in a war are more likely to show delinquent or anti-social behavior. This opinion is, however, not supported in four studies which evaluated the delinquent and aggressive behaviors of refugee adolescents (Raboteg-Saric, Zuzul, & Kerestes, 1994; Mollica et al., 1997; Rousseau, Drapeau, & Corin, 1998; Sourander, 1998). Different authors (i.e., Pynoos & Nader, 1993) report that adolescents may temporarily show increased risk behavior following the witnessing/experiencing of a traumatic event. Moreover, several studies have found high levels of comorbidity between externalizing behavior and experiencing traumatic stress reactions among American adolescents (Deykin & Buka, 1997; Wozniak et al., 1999).

The "pathway" to professional mental healthcare for refugee adolescents has more barriers than for native adolescents in host countries (e.g., Howard & Hodes, 2000). There is sufficient evidence in the literature suggesting that young people in general who are in need of psychological support or treatment do not receive it (i.e., U.S. Department of Health and Human Services, 1999; Cuffe, Waller, Cuccaro, Pumareiga, & Garrison, 1995) or only when the symptoms have progressed and are perceived by significant adults in their lives (e.g., Wu et al., 1999). The psychological suffering of Unaccompanied Refugee Minors (URM) can go completely unnoticed due to the absence of parents or permanent caregivers, language difficulties, and living in minimally adult-supervised residential settings. Mental healthcare professionals in host countries are often hindered in acquiring accurate information concerning the mental health status of refugee adolescents due, in part, to language difficulties, lack of medical/psychological background information and reliable and valid translated diagnostic instruments.

Approaching refugee youth with long psychological questionnaires/interviews can be overwhelming (Barenbaum, Ruchkin, & Schwab-Stone, 2004). Brief, translated psychological instruments that measure reactions associated with traumatic stress could be of great assistance to mental healthcare professionals in the process of screening, diagnosing, and monitoring the mental health status of this specific population. An increasing number of studies have been conducted with refugee culturally homogeneous samples (Papageorgiu et al., 2000; Thabet & Vostanis, 1999) or samples from two different countries of origin (Rousseau & Drapeau, 1998). Smith and colleagues (2003) have validated the Revised-Impact of Events Scale with older children from Bosnia. However, the same instrument yielded less reliable results with older children and adolescents from Rwanda (Dyregrov, Gupya, Gjestad, & Mukanoheli, 2000) which clearly illustrates that a measure that has been validated for one immigrant or refugee population does not implicitly infer that it is valid and reliable for all refugee and immigrant populations.

Furthermore, a limited number of reliable and valid diagnostic instruments have established norms for immigrant/refugee adolescents to measure psychosocial distress and maladaptive behaviors. The Youth Self Report (Achenbach, 1991) and Strengths and Difficulties questionnaire (Goodman, 1997) have been used with refugee adolescents from certain countries to measures emotional and behavior problems (Fazel & Stein, 2002; Mollica et al., 1997). However, as far as it is known by the authors, these checklists as well as others used with refugee children (i.e., Smith et al., 2002) have not been validated for culturally diverse adolescent populations following the five dimensions of equivalence for cross-cultural validation of an instrument proposed by Flaherty et al. (1988).

Aims of the Study

Modifications were made to one of the well-known instruments that has been used with refugees/non-western populations of adults over the last 15 years, the Hopkins-Symptom Checklist-25 (Lie, 2002; Mollica et al., 1987) to make it accessible to immigrant/refugee adolescents from a variety of cultures. The objective of this study was to provide preliminary information concerning the psychometric properties of the modified version of the HSCL-25 (Winokur, Winokur, Rickels, & Cox, 1984) the HSCL-37 for adolescents. Twelve externalizing items have been added to the 25 original items related to internalizing problems in order to measure externalizing problematic behavior in adolescents which may be trauma-related.

MATERIALS AND METHODS

Context of the Validation Study

In the years preceding 2001, there was a dramatic increase in the number of URM living in the Netherlands, peaking at 15,000 in 2001. Because there was (and still is) a lack of research on the mental health and service utilization of URM, a national and longitudinal research project "Unaccompanied Refugee Minors and Dutch Mental Health Care Services" was started among unaccompanied refugee minors living in The Netherlands and their guardians, teachers, and professional mental healthcare providers. A secondary aim of the project was to validate and standardize screening instruments for this specific population group. It was also possible to administer the HSCL-37A in an independent research project conducted by the Department of Orthopedagogics, Ghent University, Belgium that examined whether being unaccompanied is a risk factor for refugee children …