ethnicity and internalizing disorders in youth: A review

Clinical Psychology Review 30 (2010) 338–348

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Clinical Psychology Review

Race/ethnicity and internalizing disorders in youth: A review Emily R. Anderson ⁎, Linda C. Mayes 1 Yale University Child Study Center, 230 South Frontage Rd., New Haven, CT 06520, United States

a r t i c l e

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Article history: Received 15 June 2009 Received in revised form 18 December 2009 Accepted 22 December 2009 Keywords: Internalizing disorders Race Ethnicity

a b s t r a c t This review examines the impact of race/ethnicity and cultural differences in the presentation and prevalence rates of internalizing disorders in youth, as well as a variety of associated factors. There is robust support for higher prevalence rates of depression and anxiety in ethnic minority youth living in the United States. Gender differences are consistent across ethnicity, but symptom presentation, biological factors, and family processes vary somewhat by ethnic group. Environmental factors and acculturation are considered in relation to internalizing disorders in ethnic minority youth. Several problems with the literature are outlined. Several recommendations are made including better operationalization of internalizing disorders in the DSM and key issues that warrant being added to background text in the DSM. A research agenda is outlined to address possible mechanisms by which culture and race/ethnicity impact internalizing symptomatology. © 2010 Elsevier Ltd. All rights reserved.

Contents 1. Depressive disorders: Prevalence rates and longitudinal course 2. Anxiety disorders: Prevalence rates . . . . . . . . . . . . . 3. Evidence for no differences by ethnicity . . . . . . . . . . . 4. Symptom expression . . . . . . . . . . . . . . . . . . . . 5. Biological factors . . . . . . . . . . . . . . . . . . . . . . 6. Family processes and parenting . . . . . . . . . . . . . . . 7. Environmental/social risk factors . . . . . . . . . . . . . . 8. Within ethnicity factors . . . . . . . . . . . . . . . . . . . 9. Cultural identity and acculturation . . . . . . . . . . . . . 10. General problems with the research . . . . . . . . . . . . . 11. Recommendations . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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This purpose of this review is to examine race/ethnicity differences in youth internalizing disorders, including anxiety disorders (panic disorder with/without agoraphobia, generalized anxiety disorder, post-traumatic stress disorder, specific phobia, social phobia, separation anxiety disorder, and obsessive compulsive disorder) and depressive disorders (major depressive disorder and dysthymia). Cultural and race/ethnicity related differences in internalizing disorders are apparent across prevalence rates, comorbidity, longitudinal course, symptom expression, genetic/biological risk factors, family processes/parenting, and environmental/social risk factors. Under⁎ Corresponding author. Tel.: +1 203 737 1538. E-mail addresses: [email protected] (E.R. Anderson), [email protected] (L.C. Mayes). 1 Tel.: +1 203 737 1538. 0272-7358/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.cpr.2009.12.008

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standing the impact of culture and race/ethnicity on internalizing disorders also has relevance for operationalization of these disorders in diagnostic nosologies such as the DSM. The following ethnic groups are examined: European American, African American, Latino American, Asian American, and Native American. Although examination of cross-cultural research is important, this review is limited to research conducted in the United States. Prior to an examination of race/ethnicity differences in youth internalizing disorders, construct definition is necessary. Race is defined by observable physiognomic characteristics such as skin, hair, and eye color, which signify underlying biological factors that are commonly shared by a specific section of the population (Safren et al., 2000). Ethnicity and culture are closely related constructs and include unique traditions, language, and heritage that persist across generations (Safren et al., 2000); these constructs will be used throughout

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this review to describe youth in a categorical manner, consistent with the research reviewed. It is important to note that throughout the literature, there is an inconsistent overlap in usage of the terms race and ethnicity, which likely contributes to some contradictory findings. Numerous studies have documented higher rates of internalizing disorders among Native American, Latino American, Asian American, and African American adolescents compared to European American adolescents (Kennard, Mahtani, Hughes, Patel, & Emslie, 2006). The National Longitudinal Study of Adolescent Health (Add Health) study is one of the most prominent longitudinal, school-based, epidemiological studies of adolescent depression, encompassing a diverse range of adolescents in grades seven through twelve. The sample is representative of schools across the U.S. with respect to region, urbanity, school type, ethnicity, and school size. Students completed questionnaires in school and a subset were subsequently interviewed at home. In this study ethnic minority adolescents were more likely to report higher baseline levels of depression (Brown, Meadows, & Elder, 2007) on the Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1991). An important caveat, however, is that few adolescents reported clinical levels of depression, and thus these findings may not generalize to clinically depressed adolescents. Secondary analyses identified several factors that predicted higher risk for the onset of a depressive episode including African American/ Latino American ethnicity, female gender, and low-income socioeconomic status (SES) (Van Voorhees et al., 2008). Latino Americans reported the highest levels of depressive symptoms of all ethnic groups across three separate waves of data collection, and Asian Americans reported similarly high levels, followed by African Americans (Brown et al., 2007). European American adolescents had the lowest depressive scores over time, whereas depression scores for all other ethnic groups converged, despite initial differences. 1. Depressive disorders: Prevalence rates and longitudinal course European Americans. European American youth have been the comparison group to which ethnic minority youth are compared, based on evidence that supports fewer depressive symptoms/diagnoses in the former group (i.e., Brown et al., 2007; Kennard et al., 2006). In a large community sample, based on a three-stage area probability sampling frame and oversampling for ethnic minority adolescents, European American adolescent boys reported the lowest scores on the Children's Depression Inventory (CDI; Kovacs, 1992) during a homebased interview, compared to African American and Asian American boys (Siegel, Aneshensel, Taub, Cantwell, & Driscoll, 1998). European American girls in grades three to five reported more depressive symptoms on the CDI than European American boys, in a schoolbased survey study (Kistner, David, & White, 2003). In a six-month longitudinal follow-up European American girls were twice as likely to report CDI scores in the clinical range compared to boys (Kistner, DavidFerdon, Lopez, & Dunkel, 2007), and girls scored higher on anhedonia and negative mood; there were no differences over time. Lower academic achievement scores, based on a review of school records, were associated with depressive symptoms for boys and girls (Kistner et al., 2007). Each of these studies controlled for SES; results, however, may not apply to youth with clinically diagnosed depression, given that only self-report measures were utilized. African Americans. African American boys in grades three through five reported more depressive symptoms on the CDI compared to European American boys (Kistner et al., 2003), controlling for SES. No differences emerged between African American and European American girls. In a longitudinal follow-up, African American boys reported more depressive symptoms on all five CDI subscales compared to European American boys and girls, and also compared to African American girls (Kistner et al., 2007). African American boys were twice as likely to have a CDI score in the clinical range compared to African American girls. Depressive symptoms among African

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American boys increased over time, whereas symptoms remained stable or decreased over time for the other three groups. Lower academic achievement scores were associated with increased depressive symptoms for African American boys, which may account in part for these results, given that African American boys had lower academic achievement scores compared to the other three groups. Some evidence supports lower rates of depressive symptoms in African American youth. Using a nationally representative sample of adolescents in grades five through twelve, African American and European American youth self-reported the lowest rates of depressive symptoms on the CDI, compared to Latino American and Asian American youth (Schraedley, Gotlib, & Hayward, 1999). This sample was drawn from the Commonwealth Adolescent Health Study, which assessed depressive symptoms and correlates in a school survey. In the epidemiological Smokey Mountain study, parents participated in a telephone screen and youth subsequently participated in a validated diagnostic interview. African American youth, ages 9–17, had a lower prevalence of depressive disorders compared to European American youth (Angold et al., 2002). It is possible that these results differ from those of Kistner and colleagues because the latter utilized older, nationally representative and epidemiological samples, whereas Kistner and colleagues used a younger, single school-based sample. It also is possible that regional/environmental differences could account for some observed discrepancies. For example in the Add Health study, African American adolescents living within predominantly European American neighborhoods exhibited a notably highrisk for frequent depressive symptoms (Wight, Aneshensel, Botticello, & Sepulveda, 2005). It was suggested that these adolescents may miss the social cohesion and sense of shared history provided by living in predominantly African American neighborhoods. Latino Americans. Latino American youth report the highest depression scores among Asian American, African American, and European American youth in a number of studies, independent of SES (Cespedes & Huey, 2008; McDonald et al., 2005; Siegel et al. 1998; Umana-Taylor & Updegraff, 2007). The risk of depressive symptoms, as measured by the CES-D, was twice as high among Latino American youth compared to European American youth in a secondary analysis of the 2003 California Health Interview Survey data (Mikolajczyk, Bredehorst, Khelaifat, Maier, & Maxwell, 2007), which included telephone interviews with a random sample of adolescents. There were fewer differences in depressive symptoms, however, in the low SES group, which suggests that SES may be related to depression. Furthermore, Latino American adolescent girls exhibited higher CDI scores compared to European American and African American adolescents, as well as Latino American boys, in a sample from two middle schools in the Northeast (McLaughlin, Hilt, & NolenHoeksema, 2007). Notable limitations of this study, however, were that no data were collected on SES and the Latino American group was significantly larger, and thus there was more power to detect differences in this group. Latina American girls endorsed the most depressive symptoms of all girls on the CES-D (Brown et al., 2007) in the Add Health study. With regard to sub-populations of Latino Americans, Latin American youth and Mexican American preadolescents self-reported reported higher levels of depressive symptoms compared to European American youth in school and community samples (Roberts, Roberts, & Chen, 1997; Siegel et al., 1998; Siegel, Yancey, Aneshensel, & Schuler, 1999). Only one study found that Latino American youth, participating in a federally funded community mental health program, were less likely than European American youth to be diagnosed with Major Depressive Disorder or Dysthymia, controlling for SES, age, gender, and functional impairment (Nguyen, Huang, Arganza, & Liao, 2007). Several studies have controlled for SES, however, and dissimilar results have been found, which suggests that factors other than SES may be related to differential prevalence rates. Another possible reason for this discrepant finding is that Nguyen and colleagues

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obtained diagnostic status through a chart review, whereas most other investigations utilized self-report questionnaires. Nguyen and colleagues furthermore included a broader age range (i.e., ages 5–18) than the previously reviewed studies, which may impact results. Asian Americans. There is precious little research supporting higher rates of depressive symptoms in Asian American youth. Asian American adolescents scored lower on the CDI compared to Latino American, European American, and African American adolescents (Siegel et al., 1998) in a large community sample. Additionally, Chen, Roberts, and Aday (1998) found lower rates of depression, as measured by the DSM Scale for Depression (DSD; checklist derived from a diagnostic interview, R. E. Roberts, School of Public Health, University of Texas Health Science Center, Houston), among Chinese American middle school students compared to European Americans. In a school-based longitudinal study of psychopathological symptoms in Hawaiian high school students, there were no differences in depressive symptoms on the CES-D between European American and Filipino American adolescents (Edman et al., 1998), even among extremely high CES-D scores. Failure to find group differences in this study may be related to the lack of a “majority group” in Hawaii, as well as a high rate of cultural interaction. Adolescents may be exposed to a different cultural environment compared to adolescents in the continental U.S., and thus geographic location may impact internalizing symptoms. American Indians. Significantly less research has examined rates of depression in American Indian youth. Using data from a multinational, cross-sectional, school-based survey in grades 6, 8, and 10, the prevalence of depression was highest for American Indian adolescents, followed by Latino American, European American, Asian American, and finally African American adolescents (Saluja et al., 2004). It is important to note, however, that depression was measured by two items from a larger questionnaire, including items on healthrelated behaviors, and thus this finding should be interpreted cautiously. More research is necessary in this population. 2. Anxiety disorders: Prevalence rates Limited epidemiological evidence evaluates possible ethnicity differences in the prevalence of anxiety disorders in youth. Similar to depression research, European American youth typically are the comparison group. European American children self-reported the lowest levels of anxiety and fear compared to other ethnic groups in a recent literature review (McLaughlin et al., 2007). These children, however, had significantly higher incidences of school refusal and their primary anxiety disorders were rated as more severe than those of ethnic minority children. Such discrepancy may reflect differences between results from interviews and behavioral data compared to self-reported symptoms. African Americans. In a treatment-seeking sample, African American youth, ages 5–17, were more likely to have a lifetime diagnosis of PTSD on the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS; Kaufman et al., 1997), compared to European American children, controlling for SES (Last & Perrin, 1993). In another study test anxiety, as measured by self-report, was more prevalent among African American school children compared to European Americans (Beidel, Turner, & Trager, 1994), controlling for SES. More children in the former group were diagnosed with Social Phobia on the Anxiety Disorders Interview Schedule for DSM-IV (ADIS; Silverman & Albano, 1996). Children were recruited from school districts in which they were in the majority group, and thus issues related to group dominance should not have impacted results. Among treatment-seeking youth, African Americans reported more fear on the Fear Survey Schedule for Children-Revised (FSSC-R; Ollendick, 1983), than European Americans (Last & Perrin, 1993), controlling for SES and age. African American school children and preadolescents, ages 7–13, self-reported more worries of war, per-

sonal harm, and family on the Revised Children's Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1978) compared to European American and Latino American youth (Silverman, La Greca, & Wasserstein, 1995). These results should be interpreted cautiously, however, given the small number of Latino American youth in this sample relative to the other two groups. During an individual interview that occurred after group administration of self-report measures, African American youth reported more health worries than European Americans and African American boys endorsed more performance worries than the other groups, which may reflect concerns regarding lower academic performance. Latino Americans. Research substantiates high rates of anxiety disorders in Latino American youth (Ginsburg & Silverman, 1996; Silverman et al., 1995). Among clinic-referred youth, Latino Americans had higher rates of diagnosed Separation Anxiety Disorder and more worry on the RCMAS compared to European Americans (Ginsburg & Silverman, 1996; Pina and Silverman, 2004; SuarezMorales & Bell, 2006; Varela et al., 2004), regardless of gender (McLaughlin et al., 2007). Being a Latina American girl was associated with more comorbid disorders compared to being European American and African American (McLaughlin et al., 2007). In this sample from two middle schools in the Northeast, Latina American middle school girls self-reported higher overall anxiety on the Multidimensional Anxiety Scale for Children (MASC; March, Parker, Sullivan, Stallings, & Connors, 1997) compared to girls in the “Other” ethnic group. Latino American boys and girls self-reported more worry on the Penn State Worry Questionnaire for Children (PSWQ-C; Chorpita, Tracey, Brown, Collica, & Barlow, 1997) than European Americans. The Latino American group, as noted, was significantly larger than the other groups, thus providing more power to detect differences for this group. In another school-based survey study Mexican American adolescents reported higher levels of anxiety than European Americans on a validated broad-based self-report measure (Glover, Pumariega, Holzer, Wise, & Rodriguez, 1999). Higher rates of self-reported anxiety sensitivity, as measured by the Childhood Anxiety Sensitivity Index, (CASI; Silverman, Fleisig, Rabian, & Peterson, 1991) are consistently found in Latino American youth compared to European Americans (Pina & Silverman, 2004; Varela et al., 2004; Weems, Hayward, Killen, & Taylor, 2002). Although anxiety sensitivity is associated with panic disorder, high stability of anxiety sensitivity and increasing symptomatology over time was not as strongly related to panic attacks in Latino American youth as European Americans (Weems et al., 2002) in a longitudinal study of high school students. Thus, it was hypothesized that fear of anxietyrelated physiological and cognitive symptoms may be normative for Latino American youth. Asian Americans. Asian American children exhibited higher selfreported test anxiety and stronger efforts directed at pleasing parents compared to European American children (Pang, 1991), which Pang hypothesized as being related to parental pressure to perform and a need to please. Relative to youth of other ethnicities and compared to students in the continental U.S. (Guerrero et al., 2003), Native Hawaiian adolescents had a two-fold higher risk for OCD, as assessed by the Diagnostic Interview Schedule for Children-IV (DISC-IV; Shaffer et al., 1993), as part of a larger study of psychiatric symptoms in high school students. Native Hawaiian and other Polynesian youth also have an increased risk for the genetic and environmental factors related to streptococcal infections and autoimmune sequelae, which are associated with OCD and may account, in part, for higher risk for the disorder. 3. Evidence for no differences by ethnicity Despite considerable research supporting differences in internalizing symptoms by ethnicity, some studies are equivocal. Several factors may mediate the relationship between ethnicity and depression

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in youth similarly across ethnic groups. Among African American, Latino American, and European American community adolescents, ethnic differences in depression, as measured by the Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996), disappeared when controlling for parent education level (Kennard et al., 2006). Furthermore, among adolescents with high levels of poverty and low perceived support at home and school, European American and Latino Americans evidenced a similar risk of depressive symptoms, using a reduced version of the CES-D (Mikolajczyk et al., 2007). These results suggest that factors related to ethnicity but unaccounted for in previous research may be related to differential depressive symptoms. Several empirical studies failed to find differences in anxiety disorder prevalence by ethnicity in treatment-seeking youth (Ginsburg & Silverman, 1996; Treadwell, Flannery-Schroeder, & Kendall, 1995). African American and European American treatment-seeking children did not differ with regard to age, gender, duration of diagnosed anxiety disorder, or lifetime history of anxiety disorders on the K-SADS (Last & Perrin, 1993). There were no differences in symptomatic presentation or severity of social phobia symptoms on the ADIS between European American and African American children and preadolescents referred for social phobia treatment (Ferrell, Beidel, & Turner, 2004). No ethnic differences in PTSD symptoms emerged between inner-city African American and Latino American children who witnessed a fatal sniper attack (Pynoos et al., 1987). Prevalence of anxiety disorders among clinically-referred youth may be equivocal across ethnic groups, whereas self-reported anxious symptoms may differ by ethnic group. 4. Symptom expression Depressive and anxiety symptom expression among youth may vary by ethnocultural group. Choi and Park (2006) have begun some valuable research in this area. In a cross-sectional, school-based survey study conducted in three middle schools in a large city, African American preadolescents reported more symptoms of diminished pleasure on the DSD compared to European Americans (Choi & Park, 2006). Symptom expression varied, such that African American youth reported increased anger, aggression, and irritability with depression, whereas Asian American youth were more likely to report sad mood. Latino American youth endorsed diminished pleasure, decreased energy, low self-esteem, crying, and difficulties in concentration with depression. Results of this study should be interpreted cautiously, however, given that the sample was limited to students in several middle schools in one city. The most consistent finding of between-group differences is somatic symptom presentation. Among preadolescent schoolchildren, the highest rates of somatic symptoms were reported in Latino American and Asian American youth (Choi & Park, 2006). Latino American youth endorsed constipation or diarrhea in particular and were less likely to endorse nausea or indigestion than other somatic symptoms. In this study, the extent to which somatic symptoms contributed to depressive symptoms, as measured by the DSD, was larger among Latino American youth compared to other youth. Choi and Park (2006) suggested that somatic symptoms may be a culturally acceptable method to express depression for Latino American children. Among boys who subscribe to the cultural construct of machismo, expression of internalizing symptoms may be a weakness; however, expression of somatic symptoms may be more acceptable. Latino American youth, ages 5–17, diagnosed with at least one anxiety disorder on the ADIS and presenting for anxiety treatment self-reported more somatic symptoms on the Physiological Scale of the RCMAS than European Americans with similar diagnoses (Pina & Silverman, 2004). As suggested by Varela, Weems, Berman, Hensley, and Rodriguez de Bernal (2007), is it possible that fear of anxietyrelated phenomena and physiological symptoms is more normative in

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Latino culture. In a school-based survey study by Varela and colleagues, anxiety sensitivity, as measured by the CASI, did not amplify somatic complaints for Latino American adolescents as it did for European American youth. European American and Latino American adolescents were recruited from schools with a majority of students with the same ethnicity, which may have implications with regard to acculturation of Latino Americans. Some differences may occur within Latino American youth. For example, Cuban American treatmentseeking youth rated somatic symptoms the Physiological Scale of the RCMAS as less distressing compared to non-Cuban American Latino youth (Pina & Silverman, 2004). Evidence suggests that Asian American youth also are likely to somaticize psychological problems. It is possible that low rates of depressive illness among Chinese American youth are related to the tendency to somaticize emotional disturbances (Chen et al., 1998). Cultural stigma associated with psychological illness may lead to reports of somatic symptoms, which are socially recognized and accepted (Greenberger & Chen, 1996), in lieu of depressive symptoms. Using data from the Add Health study, however, ethnicity was not associated with differential somatic symptoms for Filipino American, Chinese American, or European American adolescents (Willgerodt & Thompson, 2006). These results should be interpreted cautiously, given that somatic symptoms were assessed without a validated measure. 5. Biological factors There are initial data for individual differences in polymorphism distribution among different ethnic groups. In an examination of the 5HT transporter gene-linked polymorphic region, which has been linked to mood/anxiety disorders, Murakami et al. (1999) found that the distribution of allele frequencies was different between Japanese and European American adults. The frequency of the (l) allele, which is associated with fewer anxiety-related traits, was lower in Japanese adults. Another Japanese study (Katsuragi et al., 1999) found that the 5-HTTLPR (s) allele was associated with higher harm avoidance scores. The (s) variant of the 5-HT gene-linked functional polymorphic region was associated with depression; however, this relationship varied by ethnic group (Brummett, et al., 2008). African American adults with the 5-HTTLPR (s) allele had lower scores on neuroticism, whereas European American adults had higher scores (Gelertner, Kranzler, Coccaro, Siever, & New, 1998). There also is evidence that the effect of 5-HTTLPR polymorphism on CNS serotonergic function varies as a function of race. Williams et al. (2003) found a significant race by genotype interaction, indicating that homozygosity for the 5-HTTLPR (s) allele was associated with higher CSF 5-HIAA levels in African American adults, but with lower levels in European American adults. This research, however, has been limited to adult samples, and therefore research is needed in child and adolescent samples to determine if these results can be extended to youth. Pubertal status and changes in physical appearance were more strongly related to depression, as measured by the CDI, in European American girls than in ethnic minority girls in a large community sample (Siegel et al., 1999). Onset of puberty was associated with an increase in depressive symptoms in European American girls only and European American boys and pre-menarcheal girls had similar depression scores. In a national sample of African American and Latina American girls in grades 5–12, however, there were no menarche-associated differences in depressive symptoms, as measured by the CDI (Hayward, Gotlib, Schraedley, & Litt, 1999). Pubertal status may be a better predictor of depressive symptoms than chronological age for European American girls, but not African American or Latina Americans. Early and late pubertal maturation was associated with increased depression on the CDI in Latino American adolescents (Siegel et al., 1998; Siegel et al., 1999).

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Association between early menarche and depressive symptoms was not as pronounced for African American and European American youth compared to Latino American youth (Hayward et al., 1999). Early-maturing African American girls reported positive feelings about their bodies, whereas Latina American girls reported greater body dissatisfaction (Siegel et al., 1999). Nadeem & Graham (2005) found that early physically maturing African American and Latino American sixth grade youth, taking part in a longitudinal, schoolbased survey study on peer relations, reported elevated levels of depressed mood, measured by a short form of the CDI. Some research has examined self-reported and objective physiological arousal in relation to ethnicity. In a large sample of middle school students, African American adolescent boys self-reported higher levels of physiologic anxiety on the MASC compared to European American boys (McLaughlin et al., 2007). Latina American girls self-reported higher physiological anxiety than African American girls; however, as noted, the number of Latino adolescents was significantly larger than the other groups, which may have impacted results. In another study European American school children had significantly higher increases in pulse rate and systolic blood pressure during a behavioral task compared to African American children (Beidel et al., 1994), controlling for SES. It is possible that measurement differences could account for discrepant results (i.e., subjective compared to objective measures of physiological arousal). 6. Family processes and parenting Several parenting factors may be related to internalizing disorders in youth. In a secondary analysis of data collected as part of a longitudinal study of children and families in a large metropolitan area, African American elementary school-age children living in risky neighborhoods benefited from restrictive parenting, at least with regard to academic performance (Dearing, 2004); this finding did not to apply to European Americans. In a study of urban treatmentseeking adolescent girls, girls' self-reported perceptions of high maternal control was linked to fewer depressive symptoms on the Internalizing scale of the Youth Self-Report (YSR; Achenbach, 1991) in African Americans, but not Latina American or European Americans (Finkelstein, Donenberg, & Martinovich, 2001). Alternatively, no relationship was identified between perceived maternal control and depression among European American or Latina American adolescent girls (Finkelstein et al., 2001). Data from a longitudinal HIV prevention project indicated that increases in self-reported parent–child conflict and decreases in parent-reported parental monitoring were associated with increases in youth depressive symptomatology on a structured interview, among African American preadolescents (Sagrestano, Paikoff, Holmbeck, & Fendrich, 2003). Families in this sample were below the poverty level, and thus SES did not impact results. Theoretical literature posits that interpersonal connectedness, both at the family and community level, is highly valued in African American culture (Boyd-Franklin, 1989), and thus firm parenting may not be viewed as intrusive. Juang, Syed, and Takagi (2007) found that greater discrepancies between Chinese American adolescent and parent reports of parental control were related to higher levels of adolescent depressive symptoms, as measured by the CES-D in a high school sample. Low levels of depressive symptoms were reported in this sample, and therefore results may not apply to clinically depressed adolescents. Additionally, families in this study were either first or second generation immigrants, and thus results may not generalize to Chinese American adolescents whose families have been in the U.S. longer. In another study perceived family and peer support predicted fewer self-reported depressive and anxiety symptoms on the CDI and State Trait Anxiety Inventory for Children (STAI-C; Spielberger, 1973), respectively, in African American adolescents exposed to community violence (Gaylord-Harden, Ragsdale, Mandara, Richards, & Petersen,

2007). These data were collected in public schools within high crime neighborhoods, and therefore may not apply to adolescents who do not live in such neighborhoods. Low family cohesiveness, including lack of perceived support, was related to depression, as measured by the CES-D, in African American adolescents, but not in European American adolescents, independent of SES (Herman, Ostrander, & Tucker, 2007) in a sample recruited from an organization that coordinates medical care for low income-families. In a longitudinal study of childhood-onset mood disorders, child rearing disagreement and low levels of mother–child openness were associated with selfreported internalizing problems on the MASC and CDI for European American children, ages 6–9, but not African Americans (Vendlinski, Silk, Shaw, & Lane, 2006). A significant positive relationship was observed between levels of openness and anxiety symptoms on the MASC in African American children, but the relationship was negative for European American youth. In a low-income sample, warmth and openness between toddlers and parents, as measured by independent behavioral ratings, were less normative among African American mothers compared to European American mothers (Ispa et al., 2004). 7. Environmental/social risk factors Numerous factors contribute to ethnic differences in internalizing disorders in youth. Ethnic minority status is associated with poorer mental health status, specifically higher self-reported stress and depression on the CES-D (Brown et al., 2007). A substantially higher proportion of ethnic minority youth live in disordered neighborhoods, compared to European American children (McLoyd, 1998). As reviewed by Vargas & Willis (1994), ethnic minority youth are more likely to experience poverty, discrimination, violence, violent death, drug and alcohol abuse, and teenage pregnancy. Environmental and social conditions of ethnic minorities may predispose them to more internalizing symptoms, given that poorer surroundings are a social disadvantage and create exposure to more stressful life events (Ramos, Jaccard, & Guilamo-Ramos, 2003). In fact, in telephone interviews with a national probability sample of adolescents, Latino American and African American youth reported higher rates of exposure to violent events compared to European Americans, regardless of SES (Crouch, Hanson, Saunders, Kilpatrick, & Resnick, 2000). Thus, minority youth may have a differential vulnerability to stress, and in turn, to internalizing symptoms. Self-reported victimization was associated with increased depressive symptoms on the CDI for both Latino American and African American children in the 5th and 6th grades in an urban school survey study (Storch, Nock, MasiaWarner, & Barlas, 2003). Finally, ethnic minority children may be disproportionately represented among the economically disadvantaged. In the Add Health study, low SES predicted higher risk for the onset of depressive symptoms (Van Voorhees, et al., 2008). 8. Within ethnicity factors African Americans. Protective factors have been examined for African American youth, given the increased contextual risk factors in this population (Gaylord-Harden et al., 2007; Watt & Sharp, 2002). Several researchers have suggested that African American youth may exhibit strong family bonds (Choi, 2002; Watt & Sharp, 2002). As hypothesized by Choi (2002), African American youth may inherit cultural heritage and wisdom from their grandparents, which could provide a strong sense of ethnic identity. Additionally, African American youth may demonstrate strong social ties in the community. As reviewed by Watt and Sharp (2002), several studies have found that African American youth are more likely than European American youth to self-report church and religious supports. Based on these theories and some empirical evidence, stronger social and community supports may impact expression of internalizing symptoms in African American youth.

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A number of characteristics of African American youth, however, may be less adaptive. In a study of risk/protective factors for suicide in several predominantly African American high schools, African Americans were more likely to endorse a fatalistic view of life and an external locus of control, both of which were associated with poorer school achievement, depressive affect on the Reynolds Adolescent Depression Scale (RADS; Reynolds, 1987), greater risk for hopelessness, and suicidal behaviors (Spann, Molock, Barksdale, Matlin, & Puri 2006). As part of a longitudinal multi-site study, Natsuaki et al. (2007) found that self-reported stressful life events experienced at age eleven predicted depressive symptoms on the DISC-IV at age thirteen for African American youth, after adjusting for initial level of depressive symptoms. With regard to gender and internalizing symptoms, one schoolbased study found that African American boys in the third through fifth grades reported higher levels of depression, as measured by the CDI, compared to African American girls (Kistner et al., 2003). Among African American youth in grades five through nine from low-income, urban, predominantly African American schools, girls reported more depressive symptoms, as measured by the CDI (Carlson & Grant, 2008). In this sample boys self-reported more stress than girls, particularly major events, controllable events, exposure to violence, and sexual stressors. Girls reported higher use of expressing feelings as a method of coping with stress; however, this method was related to higher levels of internalizing symptoms on the YSR. Differential stress levels, as well as age, may be related to discrepant gender findings in depression. Latino Americans. Several studies have examined culture-specific factors in Latino American youth, given notable evidence that they present with higher rates of internalizing disorders (i.e., Roberts et al., 1997; Twenge & Nolen-Hoeksema, 2002). It has been theorized that one problem for many Latino American youth is confrontation with many ecological challenges related to immigration and living as ethnic minorities, which has implications for reporting symptoms (Varela et al., 2007). Thus, rates of internalizing disorders may underestimate actual prevalence rates. Although there is considerable diversity among the numerous countries encompassed within the Latino American category, it has been suggested (i.e., Choi, 2002) that there may be some general commonalities such as low education levels, and a fatalistic, pessimistic view toward life stress. In general, numerous theorists posit that Latino culture emphasizes emotional restraint, which is linked to a collectivistic ideal. The construct of simpatia is important and refers to a sense of empathizing with others, respecting them, and remaining agreeable, even if this requires personal sacrifice. As noted by Varela et al. (2007), Latino American youth likely are taught to place their needs secondary to the needs of the collective group and family. Thus, these youth may express more over-controlled or internalizing symptoms than youth in individualistic societies, where externalizing problems may be more prevalent (Varela et al., 2007). It is possible that an emphasis on self-regulation and control of emotions may stifle understanding and managing of internal states, which leads to internalizing problems (Varela et al., 2004). Psychological symptoms are viewed as indicative of social stigma and family shame in Latino culture, which has implications for internalizing disorders (Varela et al., 2004). Verbal expressions of negative emotions or psychological problems, including anxiety, may be viewed as signs of weakness of character, which leads to emotional restraint in order to circumvent social stigma (Varela et al., 2007). The term nervios (nerves) may be the preferable term to express emotional and somatic distress. This construct implies a transient condition that is “fixable” and is socially understood and accepted (Varela et al., 2004). The term ataque de nervious describes a wide range of negative emotional conditions, troubling states, and somatic distress, and likely is a socially acceptable means of describing an anxiety attack without the psychological implications.

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In a review of sex roles among Latinos it was noted that adolescent girls from Latino culture are socialized to be more emotionally demonstrative and verbally expressive than adolescent boys (Vazquez-Nuttall, Romero-Garcia, & de Leon, 1987). There may be a greater emphasis on femininity, dependency, and family obligations, whereas adolescent boys are permitted greater levels of autonomy (Umana-Taylor & Updegraff, 2007). Latina American girls may experience gender role confusion with exposure to American culture, which permits girls to be independent and active. The higher observed levels of depression among Latina American adolescent girls could be related to conflicting gender roles prescribed by Latino culture versus those prescribed by American culture. Latino adolescent boys may ascribe to the construct of machismo, in which masculinity and masculine traits are valued. Latino American adolescent boys may struggle with learning a new language, forming peer relationships, and adapting to the environment in a new culture. A concern that expressing emotional struggles will hurt their machismo could lead Latino American adolescent boys to express internal emotional struggles with aggressive and hostile behaviors or involvement in gangs. As suggested by Umana-Taylor and Updegraff (2007), an American mainstream culture orientation may be a particularly salient risk factor for internalizing symptoms among boys whereas a Latino cultural orientation may be an important protective factor for girls. Gender differences in internalizing disorders are similar to the extant literature. In a school sample Latina American second through sixth grade girls reported more worries on the RCMAS in both school and performance situations compared to boys (Silverman et al., 1995). Female gender and low support at school were risk factors for depression, as measured by the CES-D, in Latino American adolescents (Mikolajczyk et al., 2007). Umana-Taylor and Updegraff (2007) suggested that the process by which culturally-related stress is associated with adolescents' mental health may be similar for girls and boys, despite the varying incidence of depression by gender. Asian Americans. Significant differences in internalizing symptoms among Asian Americans are masked by subsuming diverse youth under the Asian American category. It has been suggested that some groups experience greater mental health needs than others (Lau, Jernewall, Zane, & Myers, 2002). These differences may be accounted for by discrepancies in immigration history, refugee status, trauma experience, and socioeconomic and acculturative stress (Lau et al., 2002). Thus, it is uncertain whether or not results from one study can be extended to other studies in which different groups of Asian Americans are included. Few studies have compared different groups of Asian American youths. In a secondary analysis of the Add Health data Filipino Americans had higher mean depression scores on the CES-D than Chinese American and European American youth, controlling for SES (Willgerodt & Thompson, 2006). There may be a number of important hypothesized similarities; nonetheless, among the different Asian American groups. Asian culture was built on Confucianism and collectivism, which stress conformity; therefore, deviancy from “normality” likely is not well tolerated (Choi, 2002). Youth from Asian cultures are relatively communalistic and value the well-being of others. The expression of emotions in public is believed to bring disgrace to an Asian family and thus, Asian American youth may suppress emotions. Asian youth are taught to find meaning in their behaviors and lives from satisfying others, especially family members (Choi, 2002). A remarkable problem for Asian American youth is the “Model Minority” myth (described by Wing, 2007), which suggests that Asian Americans are less likely to experience depression than adolescents of other ethnic groups. Asian American youth may be viewed as the model minority group due to perceived higher levels of academic and economic achievement. It has been hypothesized that Chinese students are taught that hard work, study, and high educational achievement are important forms of self-improvement (Dong, Yang, &

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Ollendick, 1994) and thus, level of academic achievement reflects the efforts of their family and country. This myth trivializes social and mental problems of Asian American adolescents and has been challenged (Choi, 2002; Willgerodt & Thompson, 2006). The myth could place undue pressure on Asian American youth to succeed academically, such that adolescents who fail to satisfy their parents with good grades in school become a shame to their parents, which may lead to anxiety and depression. Additionally, the pressure to succeed academically, together with self-identity problems associated with acculturation, creates pressure that could lead to increased levels of internalizing symptoms. Native Americans. Much less research regarding cultural factors and internalizing symptoms has been conducted with Native American youth. Depression is the most common diagnosis in American Indian adolescent girls seeking outpatient mental health services (Rieckmann, Wadsworth, & Deyhle, 2005). Interpersonal stress and depression may increase the risk for suicide in American Indian youth. Among Navajo adolescents in Navajo Nation schools, Rieckmann and colleagues found that predictors of decreased depression on the CDI were increased control and predictability, as well as limited duration of stressful encounters. Higher levels of cultural identity had a modest effect in terms of reducing depression. More research has examined anxiety symptoms in American Indian youth. In a study of Lakota children and adolescents in grades four through twelve, girls reported more worry on a worry inventory compared to boys (D'Andrea, 1994). Childhood behavioral inhibition was strongly associated with self-reported social anxiety in Lumbee American Indian adolescents in a cross-sectional, community-based study (West & Newman, 2007). Parental reports of behavioral inhibition in childhood predicted social anxiety in adolescence for girls only. Self-reported behavioral inhibition was more predictive of adolescent social anxiety symptoms than earlier inhibitions in school and other social situations. In boys, childhood fears and illness behaviors were predictive of general levels of anxiety, including common physiological symptoms. In girls, childhood behaviors predicted social anxiety in new situations with peers, fear of negative evaluation, and general social anxiety. It is important to note, however, that this study used retrospective reports of early childhood behaviors. As suggested by Rieckmann et al. (2005), Navajo cultural identity includes three key components: family, spirituality, and environment. Youth may be taught that neglecting responsibilities to spiritual beings may lead to feelings of sickness, anxiety, or depression. Navajo adolescents may experience mood disturbance if they are shunned by others due to lack of adherence to expectations. In general, the cultural values in the American Indian community are more accepting of reticence in new interpersonal encounters, which may present as social anxiety. One explanation for this acceptance is that historical experiences have necessitated a strong sense of community cohesion and separation from outsiders. 9. Cultural identity and acculturation A variety of factors influences vulnerability to internalizing disorders in ethnic minority youth. First, a strong cultural identification with a particular ethnic group may protect against internalizing symptomatology (Williams et al., 2002). In a school-based survey study, a negative relationship was found between depression, as measured by diagnostic interview, and ethnic identity among middle school adolescents from diverse ethnic groups (Roberts et al., 1999). Negative ethnic identity was associated with higher levels of selfreported depression in African American adolescents from a public high school (Arroyo & Zigler, 1995). The relationship between ethnic identity and social support may be important in reducing internalizing symptoms in African American youth (Gaylord-Harden et al., 2007). For CDI scores, ethnic identity accounted for more of the

variance in social support for boys, suggesting that the impact of ethnic identity may vary by gender. Among high-risk Mexican American youth, low self-esteem was a risk factor for internalizing symptoms on the YSR only among preadolescent and adolescent girls who reported minimal affiliation with Mexican culture (McDonald et al., 2005). Participants in this study were drawn from a larger study of high-risk youth enrolled in mental health services. McDonald and colleagues suggested that Latina American girls who are highly affiliated with Mexican culture have a collectivistic, interdependent sense of self and thus self-esteem, based on individual competencies and accomplishments, may be less relevant to their mental health. Stronger Japanese cultural identity was associated with lower self-reported anxiety on the STAI (Spielberger, Gorsuch, & Lushene, 1970) for Japanese American high school seniors but not for part-Japanese adolescents (Williams et al., 2002), in a cross-sectional sample of adolescents in Hawaii. Higher anxiety was reported among adolescents who did not self-identify as Japanese but participated in Japanese cultural events. Williams et al. (2005) found that Japanese American high school seniors had lower depression scores on the CES-D and reported a stronger Japanese culture identity compared with part-Japanese adolescents. It was suggested that identification with a cultural group may protect against anxiety and depression. Of note, this study included only high school seniors, who may have experienced additional stressors, such as impending graduation, and therefore, results may not generalize to all adolescents. Second, a bicultural orientation may be adaptive for at least some ethnic minority and immigrant youth (Gonzales, Knight, Birman, & Sirolli, 2004; Ho, 2007). In one study, using a convenience sample from an area in which Southeast Asians are significantly represented, bicultural orientation was related to lower self-reported traumarelated symptoms in Vietnamese American and Cambodian American adolescents, regardless of amount of exposure to violence and life stress (Ho, 2007). An additive effect of higher bicultural orientation was related to lower traumatic stress symptoms in the face of stress and violence. In the Add Health study, however, double minority female adolescents (Afro-Latino American) evidenced more depressive symptoms on the CES-D than European American, African American, and Latino Americans (Ramos et al., 2003). Afro-Latino American boys reported higher levels of negative affect than boys in all other ethnic groups. Unfortunately, this study did not examine cultural orientation, which could influence results. More research needs to be conducted to determine if the benefits of a bicultural orientation are robust across ethnic minority youth. Third, it has been posited that immigration and acculturation processes have a significant influence on the mental health of ethnic minority youth (Willgerodt & Thompson, 2006). There are a number of challenges associated with the process of acculturation that may compound the stress of immigration and ethnic minority status. Adjustment to American culture could intensify a number of processes for ethnic minority youth including identity exploration, generational conflicts, and the desire for autonomy that characterizes adolescent development in the U.S. Difficulty with these processes may lead to increased internalizing symptoms. Several recent studies of adolescents have found that language and acculturative stress affect the risk of depression, independent of ethnic status (Chen et al., 1998). Other research (i.e., Birman & Ritzler-Taylor, 2007) indicates that acculturation rates differ for immigrant parents and children and there can be a negative impact of American acculturation on adolescent and family adjustment. It was suggested that acculturation alienates immigrant youth from traditional supportive groups and could lead to internalization of damaging stereotypes of the larger culture (Birman & Ritzler-Taylor, 2007). One study, however, documented benefits of American acculturation with respect to self-reported school, peer, family, and psychological adjustment, for adolescents who had emigrated from Republics of the former Soviet Union within the last four years (Birman, Trickett, & Buchanan, 2005).

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Latino Americans. It has been suggested that for many Latino American youth there are differing role expectations in the home and school environments. Youth may experience stress related to parental expectations to adopt traditional Latino family and gender roles (Harrison, Wilson, Pine, Chan, & Buriel, 1990). Cultural theories posit that Mexican American parents utilize authoritarian approaches consistent with Mexican cultural values of devotion to family, unquestioning respect for parents, and suppression of individual goals in lieu of family goals (Chandler, Tsai, & Wharton, 1999), which may impact adjustment of immigrant youth to the larger culture. A significant positive relationship emerged between perceived discrimination and depressive symptoms, as measured by the CES-D, when Latino American boys endorsed high orientation toward mainstream culture (Umana-Taylor & Updegraff, 2007). Affiliation with Mexican culture, however, was not related to internalizing symptoms two years later, controlling for initial level of internalizing symptoms on the YSR (McDonald et al., 2005), which suggests a possible benefit of identification with minority culture. The risk of depressive symptoms, as measured by the CES-D, was higher in a group of Latino American adolescents with low scores on a measure of acculturation compared to a group with high scores on this measure (Mikolajczyk et al., 2007). Acculturation was positively correlated with psychosocial problems among a small community sample of Puerto Rican adolescents living in Connecticut (Meswick, 1992). These inconsistent results suggest a need for further research on acculturation. Discrepancies in acculturation between parents and youth may impact internalizing symptoms. More significant discrepancies are related to more mental health problems for Latino American youth (Cespedes & Huey, 2008). In a school-based survey study of Central American and Mexican American adolescents, girls reported greater differences in traditional gender role beliefs between themselves and parents, as well as higher levels of depression on the RADS-2 compared to boys (Cespedes & Huey, 2008). Gender role discrepancy was associated with higher youth depression, and the relationship was mediated by increases in self-reported family dysfunction. Asian Americans. Rates of acculturation are likely to differ by subgroup of Asian Americans. In one study Japanese American and Korean American youths self-reported higher acculturation than Chinese American and Southeast Asian American youths (Lau et al., 2002). As posited by Lau and colleagues, immigrant adolescents may acquire new language and culture faster than parents, and therefore, adolescents serve as translators and assist parents with understanding culture. This role reversal could threaten the traditional hierarchical relationship between parents and children and create conflict in Asian immigrant families. Asian American parents may encourage rapid behavioral acculturation so that youth may become interpreters and negotiators in the new culture (Lau et al., 2002). A notable source of conflict may be parents' disapproval of youths embracing American values and behaviors, which could be viewed as lax morality and disregard for native culture (Lau et al., 2002). Several family correlates of acculturation are related to internalizing symptoms. Greater adolescent and parent self-reported intergenerational discrepancies regarding autonomy were associated with more depressive symptoms, as measured by the CES-D, among Asian American late adolescents (Kim, Gonzales, Stroh, & Wang, 2006). Participants were recruited from community organizations and received questionnaires via mail. In this study higher acculturation of Hmong American adolescents predicted greater perceived acculturation gaps with their parents. A notable issue raised by Kim and colleagues is that immigrant parents may not be equipped to socialize children because parents grew up as part of the majority group in their native counties. In another study there was increased risk for suicidal behaviors with high intergenerational conflict among Asian American children and adolescents receiving outpatient mental health services (Lau et al., 2002). Asian American youths who

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reported lower acculturation evidenced greater risk for suicidality under conditions of high parent–child conflict in comparison to youths who reported higher acculturation. It was hypothesized that less acculturated Asian American youths may hold more collectivistic values involving the importance of filial piety, relationship harmony, and avoiding confrontation and conflict, which may be at odds with the larger culture (Lau et al., 2002). The timing of immigration and cultural marginalization also may be related to adjustment. Asian Americans who immigrate at an early age (i.e., less than 6 years old) or are American-born self-report quicker adjustment and internalization of American values and customs more so than adult Asian immigrants (Tsai & ChentsovaDutton, 2002), which is related to fewer self-reported internalizing symptoms. Cultural marginalization was related to depression in Korean American, Chinese American, and Japanese American adolescents from working class families (Kim et al., 2006). Depressive symptoms, as measured by the CES-D, were significantly positively related to marginality scores. In this study, adolescent symptoms were related to father's self-reported depression and father's American marginalization. It was suggested that fathers have more contact with the American culture through work, which may account for these results (Kim et al., 2006).

10. General problems with the research There are a number of notable problems in the literature reviewed. One significant concern is sampling bias, given that culture and ethnicity typically are considered post hoc (Safren et al., 2000), which can result in small numbers per group and insufficient power. A related concern is that European American youth usually are used as the control group (Safren et al., 2000), which emphasizes differences between groups rather than similarities among ethnic groups. Such use of a majority group can lead to over-interpretation of group differences as deficits in minority groups, and can minimize the significance of differences that occur within ethnic groups. Another problem is participation biases (Safren et al., 2000). Research participation is influenced by patterns of help-seeking behavior, which vary cross-culturally; members of ethnic minority groups may be less likely to participate in research. A similar problem is that research facility locations influence willingness and ability to participate in research. If facilities are not located in close proximity to ethnic minority neighborhoods, participation may be minimal. School-based studies may circumvent the problem of access to participation; however, as noted, ethnic minority families may be reticent to participate in research. A chief concern is the multidimensional nature of the ethnicity construct; it is only partially operationalized by demographic categories of ethnic status (Brown et al., 2007; Chen et al., 1998). Use of ethnicity as a categorical variable, which is fairly universal, reduces the quality of data. For example, a youth may self-identify as a member of one ethnic group, but have physical features that differ from those of a typical individual of that group. The youth therefore may have a different experience compared to other individuals of that group. A related issue is the relationship between dominant group membership and internalizing disorders. Across the literature, group membership is inconsistently defined (McLaughlin et al., 2007) and precious little research examines dominancy. Additionally, there is considerable heterogeneity among diverse ethnic groups (Nguyen et al., 2007), which masks results and precludes identification of critical sub-group differences. Additionally, many studies also fail to examine joint effects of ethnicity and gender (McLaughlin et al., 2007), despite strong evidence of gender differences in most ethnic groups. Lastly, examination of age groups differs across the literature (McLaughlin et al., 2007), which makes cross-study comparison difficult.

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Several additional problems deserve mention. First, there are no standard assessments utilized across studies, and there are different methods of characterizing functional impairment (Brown et al., 2007; Nguyen et al., 2007). Research tools may not adequately address concerns of members of ethnic minority groups, given differences in symptom presentation, which makes results difficult to interpret. Diagnostic instruments are less sensitive to cultural differences in the expression of depression and anxiety, which may result in underreporting (Chen et al., 1998). For example, as noted by Chen and colleagues, one problem with Western psychometric instruments is their inability to capture Chinese culture-specific expressions of symptoms. Furthermore, several anxiety syndromes exist across various cultures (Safren et al., 2000), but, none of these syndromes have been researched in youth. Future research should determine the presence or absence of these syndromes in youth in the U.S., given that the constructs of depression and anxiety in children and adolescents may differ somewhat cross-culturally. A significant confound throughout the literature is SES (Minsky et al., 2006; Nguyen et al., 2007; Siegel et al., 1998; Wight et al., 2005). Consideration of low SES is vital because it creates multiple environmental risk factors associated with internalizing symptoms. Low SES is associated with increased rates of depression in youth (Kessler, Zhao, Blazer, & Swartz, 1997), and minority groups are overrepresented in lower SES classes. SES accounts for a large proportion of the variance in depressed youth (Kennard et al., 2006). One method of disentangling low SES and culture is to compare individuals of that cultural group living in the U.S. with comparable individuals living in their country of origin, and several studies have done so (Canino & Roberts, 2001). 11. Recommendations There are three general recommendations based on the findings from this literature review. The first recommendation is to develop a research agenda that more fully elucidates factors that contribute to differential prevalence rates, vulnerabilities, and symptom expression of youth internalizing disorders in relation to ethnicity. Ethnicity must be considered actively in the planning and conducting of research, rather than in a post hoc manner, because such an approach limits the utility of findings. Related to this concern, it is imperative that efforts are made to recruit and include members of ethnic minority groups in research, given the sampling and recruitment biases that plague the current literature. Additional recruitment efforts will be required, given the stigma associated with the mental health system in some cultures. Several other areas of research are vital in order to better inform the literature on internalizing symptoms and ethnicity. The relationship between SES, internalizing symptoms, and ethnicity needs to be systematically explored. Although controlling for SES has not been associated with differential prevalence rates, other studies have found persistent differences across ethnic groups, despite controlling for SES. Numerous factors related to SES, such as psychosocial stressors and exposure to violence, need to be assessed. Additionally, both gender and age of youth must be considered, given their impact internalizing symptoms. Epidemiological research has not considered the relative impact of acculturation on prevalence rates or symptom expression of internalizing disorders in youth. Furthermore, research has yet to examine the impact of a bicultural orientation for ethnic minority youth, although there is preliminary evidence that such an orientation may be beneficial. With regard to biology, no research has examined individual differences in polymorphism distribution among different ethnic groups in pediatric samples, despite some initial evidence for differences in adult samples. In general, there is a paucity of research in the biological domain with regard to ethnicity and internalizing disorders. More research in this area is warranted and could potentially influence treatment-making decisions.

Another important issue is assessment of internalizing symptoms in youth. As noted in this literature review, there is some evidence that ethnicity is related to a differential experience of internalizing symptoms and therefore measures that have been developed to assess internalizing symptoms in youth may not be applicable to immigrant youth. Thus, it may be beneficial to develop measures that include constructs that are salient cross-culturally. One concern, however, is that use of the same instrument with youth across different cultures and countries may not be appropriate, given differences in symptom presentation, despite the obvious beneficial implications for crossstudy comparisons with using a central instrument. The second recommendation is to develop a better assessment method for race and ethnicity to be used in both research and clinical settings. As noted, there are a number of problems with using a categorical definition of ethnicity. There is considerable heterogeneity and diversity among ethnic groups, and therefore, differences in prevalence rates, vulnerabilities, and symptom expression may be masked when combining diverse youth. It is imperative that researchers utilize the same construct of ethnicity in order to promote cross-study comparisons. Related to assessment of the construct of ethnicity, issues of group dominance must be considered in relation to internalizing symptoms. For example, Asian American youth are members of the dominant ethnic group in Hawaii, and several studies have found similar rates of internalizing disorder between these youth and youth from other ethnic groups. In many continental states, however, Asian American youth are a minority and present with different symptoms than similar youth living in Hawaii. Lastly, it will be important to consider acculturation in relation to the definition of ethnicity because there appear to be dramatic differences between immigrant youth who are highly acculturated and those who adhere to values of their native country, particularly when those values are in stark contrast to those of the majority culture. Thus, consideration of the constructs of dominance and acculturation is warranted with regard to the definition of ethnicity. The third recommendation is to adjust therapeutic interventions for internalizing disorders in youth based on differential ethnic/ cultural needs. Given the different symptom expressions that exist across groups, interventions that have been empirically supported to be effective with European American youth may not be applicable to youths of other ethnic status. Most research studies have made a concerted effort to include ethnic minority youth in treatment outcome studies. Nonetheless, as noted in this review, there are dramatic differences in levels of acculturation and dominance that are not necessarily assessed for and considered in treatment outcome studies. A better definition of ethnicity would likely help in this regard. Based on the literature reviewed in this paper, it is imperative for treatment providers to consider the relative impact of a youth's culture and ethnicity in order to best guide treatment.

References Achenbach, T. M. (1991). Manual for the youth self-report and 1991 profile. Burlington: Department of Psychiatry, University of Vermont. Angold, A., Erkanli, A., Farmer, E. M. Z., Fairbank, J. A., Burns, B. J., Keelwe, G., et al. (2002). Psychiatric disorder, impairment, and service use in rural African American and European American youth. Archives of General Psychiatry, 59, 893−901. Arroyo, C. G., & Zigler, E. (1995). Racial identity, academic achievement, and the psychological well-being of economically disadvantaged adolescents. Journal of Personality and Social Psychology, 69, 903−914. Beck, A., Steer, R., & Brown, G. (1996). BDI-II manual. New York: The Psychological Corporation. Beidel, D. C., Turner, M. W., & Trager, K. N. (1994). Test anxiety and childhood anxiety disorders in African American and White school children. Journal of Anxiety Disorders, 8, 169−179. Birman, D., & Ritzler-Taylor, T. (2007). Acculturation and psychological distress among adolescent immigrants from the former Soviet Union: Exploring the mediating effect of family relationships. Cultural Diversity and Ethnic Minority Psychology, 13, 337−346. Birman, D., Trickett, E. J., & Buchanan, R. (2005). A tale of two cities: Replication of a study on the acculturation and adaptation of immigrant adolescents from the

E.R. Anderson, L.C. Mayes / Clinical Psychology Review 30 (2010) 338–348 former Soviet Union in a different community context. American Journal of Community Psychology, 35, 87−101. Boyd-Franklin, N. (1989). Five key factors in the treatment of Black families. Journal of Psychotherapy and the Family, 6, 53−69. Brown, J. S., Meadows, S. O., & Elder, G. H., Jr. (2007). Race–ethnic inequality and psychological distress: Depressive symptoms from adolescence to young adulthood. Developmental Psychology, 43, 1295−1311. Brummett, B. H., Boyle, S. H., Siegler, I. C., Kuhn, C. M., Ashley-Koch, A., Jonassaint, C. R., Zuchner, S., Collins, A., & Williams, R. B. (2008). Effects of environmental stress and gender on associations among symptoms of depression and the serotonin transporter gene linked polymorphic region (5-HTTLPR). Behavioral Genetics, 38, 34−43. Carlson, G. A., & Grant, K. E. (2008). The roles of stress and coping in explaining gender differences in risk for psychopathology among African American urban adolescents. The Journal of Early Adolescence, 28, 375−404. Canino, G., & Roberts, R. E. (2001). Suicidal behavior among Latino youth. Suicide and Life-threatening Behavior, 31, 122−131. Cespedes, Y. M., & Huey, S. J., Jr. (2008). Depression in Latino adolescents: A cultural discrepancy perspective. Cultural Diversity and Ethnic Minority Psychology, 14, 168−172. Chandler, C. F., Tsai, Y. M., & Wharton, R. (1999). Twenty years after: Replicating a study of Anglo- and Mexican-American cultural values. Social Science Journal, 36, 353−367. Chen, I. R., Roberts, R. E., & Aday, L. A. (1998). Ethnicity and adolescent depression: The case of Chinese Americans. Journal of Nervous and Mental Disease, 186, 623−630. Choi, H. (2002). Understanding adolescent depression in ethnocultural context. Advances in Nursing Science, 25, 71−85. Choi, H., & Park, C. G. (2006). Understanding adolescent depression in an ethnocultural context: Updated with empirical findings. Advances in Nursing Science, 29, E1−E12. Chorpita, B. F., Tracey, S. A., Brown, T. A., Collica, T. J., & Barlow, D. H. (1997). Assessment of worry in children and adolescents: An adaptation of the Penn State Worry Questionnaire. Behavior Research and Therapy, 35, 569−581. Crouch, J. L., Hanson, R. F., Saunders, B. E., Kilpatrick, D. G., & Resnick, H. S. (2000). Income, race/ethnicity, and exposure to violence in youth: Results from the National Survey of Adolescents. Journal of Community Psychology, 28, 625−641. D'Andrea, M. (1994). The concerns of Native American youth. Journal of Multicultural Counseling and Development, 22, 173−181. Dearing, E. (2004). The developmental implications of restrictive and supportive parenting across neighborhoods and ethnicities. Applied Developmental Psychology, 25, 555−575. Dong, Q., Yang, B., & Ollendick, T. H. (1994). Fears in Chinese children and adolescents and their relations to anxiety and depression. Journal of Child Psychology & Psychiatry, 35, 351−363. Edman, J. L., Andrade, N. N., Glipa, J., Foster, J., Danko, G. P., Yates, A., Johnson, R. C., McDermott, J. F., & Waldron, J. A. (1998). Depressive symptoms among Filipino American adolescents. Cultural Diversity and Mental Health, 4, 45−54. Ferrell, C. B., Beidel, D. C., & Turner, S. M. (2004). Assessment and treatment of socially phobic children: A cross-cultural comparison. Journal of Clinical Child and Adolescent Psychology, 33, 260−268. Finkelstein, J. S., Donenberg, G. R., & Martinovich, Z. (2001). Maternal control and adolescent depression: Ethnic differences among clinically referred girls. Journal of Youth and Adolescence, 30, 155−171. Gaylord-Harden, N. K., Ragsdale, B. L., Mandara, J., Richards, M. H., & Petersen, A. C. (2007). Perceived support and internalizing symptoms in African American adolescents: Selfesteem and ethnic identity as mediators. Journal of Youth and Adolescence, 36, 77−88. Gelertner, J., Kranzler, H., Coccaro, E. F., Siever, L. J., & New, A. S. (1998). Serotonin transporter protein gene polymorphism and personality measures in African American and European American subjects. American Journal of Psychiatry, 155, 1332−1338. Ginsburg, G. S., & Silverman, W. K. (1996). Phobic and anxiety disorders in Hispanic and Caucasian youth. Journal of Anxiety Disorders, 10, 517−528. Glover, S. H., Pumariega, A. J., Holzer, C. E., III, Wise, B. K., & Rodriguez, M. (1999). Anxiety symptomatology in Mexican-American adolescents. Journal of Child and Family Studies, 8, 47−57. Gonzales, N. A., Knight, G. P., Birman, D., & Sirolli, A. A. (2004). Acculturation and enculturation among Latino youth. In K. I. Maton, C. J. Schellenbach, B. J. Leadbeater, & A. L. Solarz (Eds.), Investing in children, youth, families, and communities: Strengthsbased research and policy (pp. 285−302). Washington, DC: American Psychological Association. Greenberger, E., & Chen, C. (1996). Perceived family relationships and depressed mood in early and late adolescence: A comparison of European and Asian Americans. Developmental Psychology, 32, 707−716. Guerrero, A. P. S., Hishinuma, E. S., Andrade, N. N., Bell, C. K., Kurahara, D. K., Lee, T. G., Turner, H., Andrus, J., Yuen, N. Y. C., & Stokes, A. J. (2003). Demographic and clinical characteristics of adolescents in Hawaii with obsessive–compulsive disorder. Archives of Pediatric and Adolescent Medicine, 157, 665−670. Harrison, A. O., Wilson, M. N., Pine, C. J., Chan, S. Q., & Buriel, R. (1990). Family ecologies of ethnic minority children. Child Development, 61, 347−362. Hayward, C., Gotlib, I. H., Schraedley, P. K., & Litt, I. F. (1999). Ethnic differences in the association between pubertal status and symptoms of depression in adolescent girls. Journal of Adolescent Health, 25, 143−149. Herman, K. C., Ostrander, R., & Tucker, C. M. (2007). Do family environments and negative cognitions of adolescents with depressive symptoms vary by ethnic group? Journal of Family Psychology, 21, 325−330. Ho, J. (2007). Community violence exposure of Southeast Asian American adolescents. Journal of Interpersonal Violence, 23, 136−146.

347

Ispa, J. M., Fine, M. A., Halgunseth, L. C., Harper, S., Robinson, J., Boyce, L., et al. (2004). Maternal intrusiveness, maternal warmth, and mother–toddler relationship outcomes: Variations across low-income ethnic and acculturation groups. Child Development, 75, 1613−1631. Juang, L. P., Syed, M., & Takagi, M. (2007). Intergenerational discrepancies of parental control among Chinese American families: Links to family conflict and adolescent depressive symptoms. Journal of Adolescence, 30, 965−975. Katsuragi, S., Kunugi, H., Sano, A., Tsutsumi, T., Isogawa, K., Nanko, S., & Akiyoshi, J. (1999). Association between serotonin transporter gene polymorphism and anxiety-related traits. Biological Psychiatry, 45, 368−370. Kaufman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C., Moreci, P., Williamson, D., & Ryan, N. (1997). Schedule for Affective Disorders and Schizophrenia for School-Age Children—Present and Lifetime Version (K-SADS-PL): Initial reliability and validity data. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 980−988. Kennard, B. D., Mahtani, S. S., Hughes, J. L., Patel, P. G., & Emslie, G. J. (2006). Cognitions and depressive symptoms among ethnic minority adolescents. Cultural Diversity and Ethnic Minority Psychology, 12, 578−591. Kessler, R. C., Zhao, S., Blazer, D. G., & Swartz, M. (1997). Prevalence, correlates, and course of minor depression and major depression in the national comorbidity survey. Journal of Affective Disorders, 45, 19−30. Kim, S. Y., Gonzales, N. A., Stroh, K., & Wang, J. J. -L. (2006). Parent–child cultural marginalization and depressive symptoms in Asian American family members. Journal of Community Psychology, 34, 167−182. Kistner, J. A., David, C. F., & White, B. A. (2003). Ethnic and sex differences in children's depressive symptoms: Mediating effects of perceived and actual competence. Journal of Clinical Child and Adolescent Psychology, 32, 341−350. Kistner, J. A., David-Ferdon, C. F., Lopez, C. M., & Dunkel, S. B. (2007). Ethnic and sex differences in children's depressive symptoms. Journal of Clinical Child and Adolescent Psychology, 36, 171−181. Kovacs, M. (1992). Children's depression inventory manual. North Tonawanda, NY: Multi-Health Systems. Last, C. G., & Perrin, S. (1993). Anxiety disorders in African American and white children. Journal of Abnormal Child Psychology, 21, 153−164. Lau, A. S., Jernewall, N. M., Zane, N., & Myers, H. F. (2002). Correlates of suicidal behaviors among Asian American outpatient youths. Cultural Diversity and Ethnic Minority Psychology, 8, 199−213. March, J. S., Parker, J. D., Sullivan, K., Stallings, P., & Connors, C. K. (1997). The Multidimensional Anxiety Scale for Children (MASC): Factor structure, reliability, and validity. Journal of the American Academy of Child & Adolescent Psychiatry, 36, 554−565. McDonald, E. J., McCabe, K., Yeh, M., Lau, A., Garland, A., & Hough, R. L. (2005). Cultural affiliation and self-esteem as predictors of internalizing symptoms among Mexican American adolescents. Journal of Clinical Child and Adolescent Psychology, 34, 163−171. McLaughlin, K. A., Hilt, L. M., & Nolen-Hoeksema, S. (2007). Racial/ethnic differences in internalizing and externalizing symptoms in adolescence. Journal of Abnormal Child Psychology, 35, 801−816. McLoyd, V. C. (1998). Socioeconomic disadvantage and child development. American Psychologist, 53, 185−204. Meswick, S. (1992). Migration, health, and social stress among Puerto Rican adolescents. In A. N. Ambert, & M. D. Alvarez (Eds.), Puerto Rican children on the mainland: Interdisciplinary perspectives (pp. 275−298). New York: Garland. Mikolajczyk, R. T., Bredehorst, M., Khelaifat, N., Maier, C., & Maxwell, A. E. (2007). Correlates of depressive symptoms among Latino and non-Latino white adolescents: Findings from the 2003 California Health Interview Survey. BioMed Central Public Health, 7, 21. Minsky, S., Petti, T., Gara, M., Vega, W., Lu, W., & Kiely, G. (2006). Ethnicity and clinical psychiatric diagnoses in childhood. Administrative Policy in Mental Health & Mental Health Services Research, 33, 558−567. Murakami, F., Shimomura, T., Kotani, K., Ikawa, S., Nanba, E., & Adachi, K. (1999). Anxiety traits associated with a polymorphism in the serotonin transporter gene regulatory region in the Japanese. Journal of Human Genetics, 44, 15−17. Nadeem, E., & Graham, S. (2005). Early puberty, peer victimization, and internalizing symptoms in ethnic minority youth. The Journal of Early Adolescence, 25, 197−222. Natsuaki, M. N., Ge, X., Brody, G. H., Simons, R. L., Gibbons, F. X., & Cutrona, C. E. (2007). African American children's depressive symptoms: The prospective effects of neighborhood disorder, stressful life events, and parenting. American Journal of Community Psychology, 39, 163−176. Nguyen, L., Huang, L. N., Arganza, G. F., & Liao, Q. (2007). The influence of race and ethnicity on psychiatric diagnoses and clinical characteristics of children and adolescents in children's services. Cultural Diversity and Ethnic Minority Psychology, 13, 18−25. Ollendick, T. H. (1983). Reliability and validity of the Revised Fear Survey Schedule for Children (FSSC-R). Behavior Research and Therapy, 21, 685−691. Pang, V. O. (1991). The relationship of test anxiety and math achievement to parental values in Asian-American and European-American middle school students. Journal of Research and Development in Education, 24, 1−10. Pina, A. A., & Silverman, W. K. (2004). Clinical phenomenology, somatic symptoms, and distress in Hispanic/Latino and European American youths with anxiety disorders. Journal of Clinical Child and Adolescent Psychology, 33, 227−236. Pynoos, R. S., Frederick, C., Nader, K., Arroyo, W., Steinberg, A., Eth, S., Munez, F., & Fairbanks, L. (1987). Life threat and posttraumatic stress in school age children. Archives of General Psychiatry, 44, 1057−1063. Radloff, L. S. (1991). The use of the Center for Epidemiologic Studies Depression Scale in adolescents and young adults. Journal of Youth and Adolescence, 20, 149−166.

348

E.R. Anderson, L.C. Mayes / Clinical Psychology Review 30 (2010) 338–348

Ramos, B., Jaccard, J., & Guilamo-Ramos, V. (2003). Dual ethnicity and depression symptoms: Implications of being Black and Latino in the U.S. Hispanic Journal of Behavioral Sciences, 25, 147−173. Reynolds, W. W. (1987). Reynolds Adolescent Depression Scale: Professional manual. Odessa, FL: Psychological Assessment Resources. Reynolds, C. R., & Richmond, B. O. (1978). What I think and feel: A revised measure of children's manifest anxiety. Journal of Abnormal Child Psychology, 6, 271−280. Rieckmann, T. R., Wadsworth, M. E., & Deyhle, D. (2005). Cultural identity, explanatory style, and depression in Navajo adolescents. Cultural Diversity and Ethnic Minority Psychology, 10, 365−382. Roberts, R. E., Phinney, J. S., Masse, L. C., Chen, Y. R., Roberts, C. R., & Romero, A. (1999). The structure of ethnic identity of young adolescents from diverse ethnocultural groups. Journal of Early Adolescence, 19, 301−322. Roberts, R. E., Roberts, C. R., & Chen, Y. R. (1997). Ethnocultural differences in prevalence of adolescent depression. American Journal of Community Psychology, 25, 95−110. Safren, S. A., Gonzalez, R. E., Horner, K. J., Leung, A. W., Heimburg, R. G., & Juster, H. R. (2000). Anxiety in ethnic minority youth: Methodological and conceptual issues and review of the literature. Behavior Modification, 24, 147−183. Sagrestano, L. M., Paikoff, R. L., Holmbeck, G. N., & Fendrich, M. (2003). A longitudinal examination of familial risk factors for depression among inner-city African American adolescents. Journal of Family Psychology, 17, 108−120. Saluja, G., Iachan, R., Scheidt, P. C., et al. (2004). Prevalence of and risk factors for depressive symptoms among young adolescents. Archives of Pediatric Adolescent Medicine, 158, 760−765. Schraedley, P. K., Gotlib, I. H., & Hayward, C. (1999). Gender differences in correlates of depressive symptoms in adolescents. Journal of Youth and Adolescence, 25, 98−108. Shaffer, D., Fisher, P., Piacentini, J., Conners, C. K., Schwab-Stone, M., Cohen, P., et al. (1993). The Diagnostic Interview Schedule for Children Revised Version (DISC-R): I. Preparation, field testing, inter-rater reliability and acceptability. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 643−650. Siegel, J. M., Aneshensel, C. S., Taub, B., Cantwell, D. P., & Driscoll, A. K. (1998). Adolescent depressed mood in a multiethnic sample. Journal of Youth and Adolescence, 27, 413−427. Siegel, J. M., Yancey, A. K., Aneshensel, C. S., & Schuler, R. (1999). Body image, perceived pubertal timing, and adolescent mental health. Journal of Adolescent Health, 25, 155−168. Silverman, W. K., & Albano, A. M. (1996). Anxiety Disorders Interview Schedule for DSMIV: Child version [clinician manual]. San Antonio: The Psychological Corporation. Silverman, W., Fleisig, W., Rabian, B., & Peterson, R. (1991). The Childhood Anxiety Sensitivity Index. Journal of Clinical Child Psychology, 20, 162−168. Silverman, W. K., La Greca, A. M., & Wasserstein, S. (1995). What do children worry about? Worries and their relation to anxiety. Child Development, 66, 671−686. Spielberger, C. D. (1973). Manual for the State-Trait Anxiety Inventory for Children. Palo Alto, CA: Consulting Psychologists Press. Spielberger, C., Gorsuch, R., & Lushene, R. (1970). Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press. Spann, M., Molock, S. D., Barksdale, C., Matlin, S., & Puri, R. (2006). Suicide and African American teenagers: Risk factors and coping mechanisms. Suicide and Life-threatening Behavior, 36, 553−568. Storch, E. A., Nock, M. K., Masia-Warner, C., & Barlas, M. E. (2003). Peer victimization and social–psychological adjustment in Hispanic and African American children. Journal of Child and Family Studies, 12, 439−452. Suarez-Morales, L., & Bell, D. (2006). Relation of childhood worry to informationprocessing factors in an ethnically diverse community sample. Journal of Clinical Child and Adolescent Psychology, 35, 136−147. Treadwell, K. R. H., Flannery-Schroeder, E. C., & Kendall, P. C. (1995). Ethnicity and gender in relation to adaptive functioning, diagnostic status, and treatment outcome in children from an anxiety clinic. Journal of Anxiety Disorders, 9, 373−383.

Tsai, J. L., & Chentsova-Dutton, Y. (2002). Models of cultural orientation: Differences between American born and overseas-born Asians. In K. S. Kurasaki, S. Okazaki, & S. Sue (Eds.), Asian American mental health: Assessment theories and methods (pp. 95−105). NY: Kluwer Academic/Plenum. Twenge, J. M., & Nolen-Hoeksema, S. (2002). Age, gender, race, socioeconomic status, and birth cohort differences on the children's depression inventory: A metaanalysis. Journal of Abnormal Psychology, 4, 578−588. Umana-Taylor, A., & Updegraff, K. A. (2007). Latino adolescents' mental health: Exploring the interrelations among discrimination, ethnic identity, cultural orientation, selfesteem, and depressive symptoms. Journal of Adolescence, 30, 549−567. Van Voorhees, B. W., Paunesku, D., Kuwabara, S. A., Basu, A., Gollan, J., Hankin, B. L., Melkonian, S., & Reinecke, M. (2008). Protective and vulnerability factors predicting new-onset depressive episode in a representative of U.S. adolescents. Journal of Adolescent Health, 42, 605−616. Varela, R. E., Vernberg, E. M., Sanchez-Sosa, J. J., Riveros, A., Mitchell, M., & Mashunkashey, J. (2004). Anxiety reporting and culturally associated interpretation biases and cognitive schemas: A comparison of Mexican, Mexican American and European American families. Journal of Clinical Child and Adolescent Psychology, 33, 237−247. Varela, R. E., Weems, C. F., Berman, S. L., Hensley, L., & Rodriguez de Bernal, M. C. (2007). Internalizing symptoms in Latinos: The role of anxiety sensitivity. Journal of Youth and Adolescence, 36, 429−440. Vargas, L. A., & Willis, D. J. (1994). Introduction to the special section: New directions in the treatment and assessment of ethnic minority children and adolescents. Journal of Clinical Child Psychology, 23, 2−4. Vazquez-Nuttall, E., Romero-Garcia, I., & de Leon, B. (1987). Sex roles and perceptions of femininity and masculinity of Hispanic women: A review of the literature. Psychology of Women Quarterly, 11, 409−425. Vendlinski, M., Silk, J. S., Shaw, D. S., & Lane, T. J. (2006). Ethnic differences in relations between family process and child internalizing problems. Journal of Child Psychology and Psychiatry, 47, 960−969. Watt, T. T., & Sharp, S. F. (2002). Race differences in strains associated with suicidal behavior among adolescents. Youth Society, 34, 232−256. Weems, C. F., Hayward, C., Killen, J. D., & Taylor, C. B. (2002). A longitudinal investigation of anxiety sensitivity in adolescence. Journal of Abnormal Psychology, 111, 471−477. West, A. E., & Newman, D. L. (2007). Childhood behavioral inhibition and the experience of social anxiety in American Indian adolescents. Cultural Diversity and Ethnic Minority Psychology, 13, 197−206. Wight, R. G., Aneshensel, C. S., Botticello, A. L., & Sepulveda, J. E. (2005). A multilevel analysis of ethnic variation in depressive symptoms among adolescents in the U.S. Social Science & Medicine, 60, 2073−2084. Willgerodt, M. A., & Thompson, E. A. (2006). Ethnic and generational influences on emotional distress and risk behaviors among Chinese and Filipino American adolescents. Research in Nursing & Health, 29, 311−324. Williams, J. K. Y., Else, I. R. N., Hishinuma, E., Goebert, D., Chang, J. Y., Andrade, N., & Nishimura, S. T. (2005). A confirmatory model for depression among Japanese American and part-Japanese American adolescents. Cultural Diversity and Ethnic Minority Psychology, 11, 41−56. Williams, J. K. Y., Goebert, D., Hishinuma, E., Miyamoto, R., Anzai, N., Izutsu, S., Yanagida, E., Nishimura, S., Andrade, N., & Baker, F. M. (2002). A conceptual model of cultural predictors of anxiety among Japanese American and part-Japanese American adolescents. Cultural Diversity and Ethnic Minority Psychology, 8, 320−333. Williams, R. B., Marchuk, D. A., Gadde, K. M., Barefoot, J. C., Grichnik, K., Helms, M. J., Kuhn, C. M., Lewis, J. G., Schanberg, S. M., Stafford-Smith, M., Suarez, E. C., Clary, G. L., Svenson, I. K., & Siegler, I. C. (2003). Serotonin-related gene polymorphisms and central nervous system serotonin function. Neuropsychopharmacology, 28, 533−541. Wing, J. Y. (2007). Beyond black and white: The model minority myth and the invisibility of Asian American students. The Urban Review, 39, 455−487.