Exposure to Violence and Mental Health Among Chinese American Urban Adolescents

Journal of Adolescent Health 39 (2006) 73–79

Original article

Exposure to Violence and Mental Health Among Chinese American Urban Adolescents Emily J. Ozer, Ph.D.a,* and Kristen L. McDonald, M.A.b b

Abstract

a School of Public Health, University of California-Berkeley, Berkeley, California Department of Psychology, University of Massachusetts at Amherst, Amherst, Massachusetts Manuscript received March 23, 2005; manuscript accepted September 29, 2005

Purpose: This cross-sectional study examined exposure to violence as a predictor of mental health and perpetration of violence in a sample of 71 Chinese American young adolescents from nine urban middle schools. Methods: Separate hierarchical multiple regressions were used to predict self-reported symptoms of depression and post-traumatic stress disorder (PTSD), perpetration of violence, and teacherreported symptoms of anxiety, depression, and adaptive functioning. Results: After controlling for daily hassles, exposure to violence uniquely predicted higher selfreported PTSD and depressive symptoms. After controlling for prior academic achievement and daily hassles, exposure to violence uniquely predicted more perpetration of violence. Conclusions: Our study suggests that exposure to violence is associated with worse mental health and more perpetration of violence among Chinese American adolescents living in urban areas. © 2006 Society for Adolescent Medicine. All rights reserved.

There has been little research on the physical and mental health of Asian American youth [1,2]. Despite the stereotypical view of Asian American adolescents as high achievers with few psychological difficulties [3], recent research reveals a more differentiated population showing a range of achievement, mental health, and engagement in health risk behaviors [2,4]. Representative U.S. data from the Youth Risk Behavior Survey indicate that 27% of Asian American high school students reported engaging in a physical fight in the prior year, and 11.5% reported carrying a weapon such as a gun, knife, or club in the prior month [5]. In the prior year, 28% of Asian American high school students reported depressed feelings serious enough to disrupt their usual activities, 19% reported making a suicide plan, and 11% reported making at least one suicide attempt. Large-scale survey data typically use the category of “Asian American,” combining across groups such as Chinese, Filipino, Asian Indian, Korean, Vietnamese, and Paci-

fic Islanders that differ on characteristics including language, religion, cultural practices, socioeconomic status, and immigration history. Research with more homogeneous groups holds stronger promise for understanding the determinants of adolescent health than approaches that investigate questions for Asian Americans generally. There is a particular need for research on factors that influence the health of adolescents from Asian American backgrounds that have a large enough sample of one ethnic group to utilize a within-group design. Leaders in the study of adolescent development and mental health have strongly emphasized the need for within-group research designs to study the mental health of understudied ethnic minority groups on their own terms, not in comparison to other cultural groups [6 – 8]. Thus, a within-group approach is now viewed by developmental scientists as important for building a basic empirical knowledge base about the determinants of mental health in understudied groups. Focus on Chinese Americans

*Address correspondence to: Dr. Emily J. Ozer, University of California at Berkeley School of Public Health, 140 Warren Hall #7360, Berkeley, CA 94720-7360. E-mail address: [email protected]

Chinese Americans are the largest ethnic group of Asian Americans, numbering more than 2.3 million [9]. Chineseorigin Americans have a long history in the U.S., with an

1054-139X/06/$ – see front matter © 2006 Society for Adolescent Medicine. All rights reserved. doi:10.1016/j.jadohealth.2005.09.015

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initial period of immigration in the late 19th century linked to the California Gold Rush. Racial quotas enacted in 1882 that severely limited Chinese immigration ended in 1965, at which time a new wave of immigration began. According to the 2000 U.S. census, 96% of Asian Americans live in metropolitan areas. The largest populations of Asian Americans reside in California and New York, and at least 1 million Chinese Americans live in U.S. cities [9]. Thus, a substantial number of Chinese American youth grow up in urban settings. Determinants of mental health among Chinese American youth Family and school factors. Most research on Chinese American youth has sought to explain overall high levels of academic achievement, with attention to the roles of cultural values, indigenous parenting styles, and peer norms [10,11]. This research emphasizes academic achievement and familial obligation as central values in families that adhere to Chinese traditions. In the domain of mental health, dominant clinical perspectives highlight the importance of traditional Confucian values regarding role relationships, sense of social order, and constraints on direct or confrontational communication that may cause shame or loss of “face” [12,13]. There is expected to be variability within and across families, however, in the extent to which Chinese American families and youth exemplify traditional values and practices. Varying levels of Confucian values regarding collectivism and filial piety have been shown in mainland China, Singapore, and Hong Kong, further highlighting the need to avoid over-generalization in dynamic societies and particularly among immigrant youth [10]. Consistent with the value of filial piety, Chinese-American adolescents in New York City report spending less time with peers and more time on familial obligations than do their European American counterparts [14]. Several studies have examined acculturative stress and conflict as immigrant Chinese American youth balance traditional values and expectations of parents versus the more individualistic expectations of the majority culture. Although higher rates of depressive symptoms among Chinese American adolescents than European Americans were found in several small samples, in-depth research suggests that day-to-day balancing of family obligations and other activities is not a major source of emotional distress [14]. Like the study of developmental psychopathology in other groups, the major theoretical frameworks underlying the study of the mental health of Chinese American youth emphasize the impact of potentially stressful events and chronic conditions on psychological distress and symptoms [15]. The large adolescent mental health literature in general provides much evidence for the cumulative effect of a range of discrete stressful events (e.g., physical assault, death of a relative, terrorist attack) and chronic low-grade “daily has-

sles” on youth [16]. This research also demonstrates substantial variability in psychological response to stressful events, with some protection afforded by characteristics of the youth and their coping efforts, as well as support resources available in domains such as the family and school [15,17,18]. Urban neighborhood context. The small but growing literature on the mental health of Chinese American youth has investigated the impact of stressors related to family and school domains, but has not explored the potential role of stressors related to adolescents’ neighborhood context. Extensive research has documented the negative impact of exposure to violence on the mental health of urban youth, but this research has focused almost exclusively on African Americans and Latinos [19 –22]. This literature provides strong evidence that exposure to violence is associated with anxiety, depression, post-traumatic stress disorder (PTSD), and aggression [19,23,24]. Despite the fact that many Chinese American youth grow up in urban areas, there has been no investigation of the relationship of exposure to violence to mental health in this population. Is exposure to violence expected to be a meaningful determinant of the psychological functioning of Chinese American adolescents? Paradoxically, traditional cultural practices for Chinese American youth could serve to both increase and reduce the risk for psychological symptoms related to exposure to violence. First, findings that Chinese American youth spend more time at home and involved in familial responsibilities could lead to reduced exposure to violence, which often occurs outside of school and home settings [14]. Prior research with a multi-ethnic urban sample, however, indicates that Asian-American adolescents reported more victimization by violence than did Latinos and African Americans [25]. Second, the strong relationships and relatively large amount of family time that characterize some Chinese American families could serve as a support resource to assist adolescents in coping with violence and other stressors. If family communication patterns avoid direct discussion of emotionally distressing and potentially shameful topics [12,13], however, adolescents may feel constrained from sharing these experiences and seeking support. Perceived constraints for discussing violent events and lower family support were associated with more symptoms of PTSD in prior research [20,25]. Further, the high cost of living in cities with large Chinese American communities (e.g., New York, San Francisco, Los Angeles, Seattle) may create an employment burden for parents and other adult family that could reduce the opportunities for support. Hypotheses The present study uses a within-group, cross-sectional design to test hypotheses regarding the relationship between exposure to violence and psychological functioning for

E.J. Ozer et al. / Journal of Adolescent Health 39 (2006) 73–79

young Chinese American adolescents in an urban community. We hypothesized that higher levels of exposure to violence would be associated with worse functioning in terms of internalizing symptoms (symptoms of anxiety, depression, and PTSD), perpetration of violence, and adaptive functioning in the classroom for our adolescent sample. In light of prior research evidence for the negative impact of daily hassles on the mental health of urban youth [16,26,27], we expected that daily hassles across neighborhood, school, family, and peer domains would also be important contributors to the psychological well-being of Chinese American adolescents. The hassles examined here— pertaining to limited financial resources, limited recreational opportunities, conflicts in family and peer relationships, and academic pressure—are conceptualized as existing sources of stress for these urban teens rather than as mediators of the effects of exposure to violence. The central focus of this research is to assess if exposure to discrete violent events is associated with more psychological symptoms, over and above the effects of existing levels of daily hassles. The relationship between exposure to violence and mental health was tested after further controlling for adolescents’ gender, age, country of origin, and prior academic achievement. Controlling for academic achievement helped ensure that teachers’ ratings of students’ mental health were not unduly influenced by students’ academic performance. Methods Participants Participants for this study were 71 Chinese American seventh graders (median age ⫽ 12 years; 32 male, 39 female) who were part of a larger study of ethnically diverse seventh grade students from a major metropolitan school district in California [25]. Schools that participated in the study reflected the range of district schools with respect to location, student achievement, proportion of students receiving free lunches, and student ethnicity, and did not differ from non-participating schools on those characteristics. To maximize representativeness, students were recruited from mandatory academic classes. The study was approved by the UC-Berkeley Committee for the Protection of Human Subjects. A parental consent and adolescent assent form in English and Chinese were given to students; 60% indicated positive consent and participated in the study. This rate is comparable to or higher than prior schoolbased studies of urban adolescents [21,28,29]. Procedure Data collection. Students completed a 45-minute survey in classes, with the research team providing individualized attention to students requiring assistance. Students’ district ID numbers were used to identify surveys and link surveys with teachers’ rating forms.

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Measures completed by adolescents Demographics. Adolescents reported age, gender, and primary ethnic identification. Exposure to violence. Exposure to violence in the previous six months was assessed by eight items from the Direct Exposure subscale of the Children’s Report of Exposure to Community Violence [30]. Key exposure items that assessed adolescents’ experiences of witnessing and being directly victimized by interpersonal violence were selected (alpha ⫽ .76). Adolescents indicated the frequency of experiencing violent events “in real life,” such as being beaten up and seeing others physically assaulted, shot, stabbed, or killed. Daily hassles. The 28-item Daily Hassles Scale [31], a scale developed for use with urban adolescents, was used to assess non-traumatic stressors within and across neighborhood, school, family, and peer domains in the prior six months (alpha ⫽ .81); e.g., “pressure to do well in school,” “not having enough nice clothes to wear,” “parents not home as much,” and “friends bugging you to party.” One item, being scared by someone in your neighborhood, was deleted because of potential confounding with the dependent variable of anxiety symptoms. Depressive symptoms. Depressive symptoms in the prior two weeks were assessed with the 10-item short form (alpha ⫽ .75) of the Children’s Depression Inventory (CDI) [32]. The CDI short form correlates .89 with the full scale, and demonstrates excellent properties for identifying clinically distressed youth. PTSD symptoms. Trauma-related symptoms in the prior two weeks were assessed by the post-traumatic stress, dissociation, and anxiety scales of the Trauma Symptom Checklist for Children (TSCC) [33]. The three subscales were strongly intercorrelated (r ⫽ .64 –.79) and were combined to form one PTSD symptom scale (alpha ⫽ .89). The TSCC was normed on samples with large numbers of ethnic minority adolescents, and is strongly correlated with children’s self-report of behavioral problems as measured by the Child Behavior Checklist [34,35]. Perpetration of violence. The perpetration of violence scale developed by the National Longitudinal Study of Adolescent Health was used (six items; alpha ⫽ .70). Adolescents reported the frequency of committing acts of aggression in the prior six months, including fighting, injuring another person in a fight, and using a weapon to get something from someone. Measures from school personnel or records School achievement. Students’ grade point average for the two semesters before their participation in the study were obtained from school records.

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Table 1 Percentage of sample exposed to specific violent events in past six months

Seen stranger chased Seen stranger shot, stabbed, killed Seen somebody known beat up Seen somebody known chased or robbed Been in fight Been chased or robbed Been shot at or stabbed Somebody known shot at or stabbed Any violent incident One violent event Two or more violent events

Percentage

n

27% 9% 36% 24% 37% 11% 1% 21% 75% 15% 60%

19 6 25 16 25 8 1 14 55 11 44

ables are shown in Table 2. Teachers’ report of adolescents’ anxiety/depressive symptoms was not significantly associated with adolescents’ self-report of PTSD symptoms or depressive symptoms; teachers’ report of adaptive functioning in the classroom was negatively associated with adolescents’ self-report of PTSD symptoms (r ⫽ ⫺.24, p ⬍ .05). Separate hierarchical multiple regressions were used to statistically predict adolescents’ current psychological functioning with respect to self-reported depressive symptoms, PTSD symptoms, and aggression; and teacher reports of adaptive functioning and anxiety/depression. Demographic and academic achievement variables that showed significant zero-order correlations with dependent variables were included as control variables in the regression analyses; recent exposure to violence was included in the equation after these control variables and daily hassles. Regression analyses are shown in Table 3.

Note: Percentages have been rounded to the nearest whole number.

Immigration status. Students’ places of birth were obtained from school records.

Predicting psychological functioning Demographics. There were no differences in adolescents’ self-reported symptoms or teacher-reported symptoms by gender, age, immigration status, or prior academic achievement. More perpetration of violence was reported by those with lower prior academic achievement (r ⫽ ⫺.40, p ⬍ .001), but there were no significant differences in perpetration of violence by gender, age, or immigration status. Teachers reported higher levels of adaptive functioning for girls (r ⫽ .33, p ⬍ .01) and students with higher prior achievement (r ⫽ .76, p ⬍ .001).

Teacher assessment of adolescents. Teachers completed two subscales of the Teacher Report Form (TRF): (a) adaptive functioning, i.e., how hard the student is working, how appropriately he/she is behaving, how much he/she is learning, and how happy he/she is (alpha ⫽ .90); and (b) anxiety/ depressive symptoms (18 items; alpha ⫽ .89) [36]. The TRF has been used extensively to identify distressed youth. Results Descriptive statistics and analytic strategy

Self-reported symptoms and violence perpetration. After controlling for adolescents’ experiences of daily hassles across neighborhood, school, family, and peer domains, recent exposure to violence uniquely predicted higher selfreported PTSD (B ⫽ .38, p ⬍ .001) and depressive symptoms (B ⫽ .30, p ⬍ .05). After controlling for prior academic achievement and daily hassles, recent exposure to violence uniquely predicted more perpetration of violence (B ⫽ .29, p ⬍ .05). The combination of exposure to vio-

Most of these young adolescents (55 of 73, or 75%) reported either direct or indirect experience of at least one violent incident in the prior six months (Table 1). This figure includes any direct involvement as a perpetrator or victim in a fight or physical attack, witnessing of an attack on a stranger or known person, or having a person known to them shot or stabbed. Correlations, means, and standard deviations for all vari-

Table 2 Intercorrelations among key study variables 1 1. 2. 3. 4. 5. 6. 7.

Academic achievement Exposure to violence Daily hassles Depressive symptoms PTSD symptoms Perpetration of violence Teacher-rated symptoms of anxiety and depression 8. Teacher-rated adaptive functioning Mean SD Note: * p ⬍ .05; ** p ⬍ .01.

2

3

4

5

6

7

8

–

⫺.29* –

⫺.27* .32** –

⫺.07 .41** .46** –

⫺.17 .51** .54** .53** –

⫺.40** .60** .44** .33** .51** –

⫺.11 ⫺.13 ⫺.06 .17 ⫺.05 ⫺.01 –

.76** ⫺.35** ⫺.30* ⫺.09 ⫺.24* ⫺.45** ⫺.06

3.38 .66

1.92 2.72

8.13 4.90

2.80 2.53

17.47 12.49

1.06 1.56

3.44 4.39

– 20.55 4.84

– – .05 ⫺.14 0

.02

– –

– – ⫺.02 ⫺.02 .27ⴱ .42ⴱⴱ ⫺.15 ⫺.14 Note: ⴱ p ⬍ .05; ⴱⴱ p ⬍ .01. Standardized beta’s (␤) are from final model with all variables entered. Control variables of gender and prior achievement were entered only for dependent variables with significant zero-order correlations.

.14ⴱⴱ .33ⴱⴱ .37 .38 – ⫺.15 .38ⴱⴱ .29ⴱ – .04 .22ⴱⴱ .08ⴱ – .04 .26ⴱⴱ .34ⴱ – – .42ⴱⴱ .38ⴱⴱ – – .29ⴱⴱ .13ⴱⴱ – – .29ⴱⴱ .42ⴱⴱ – – .34ⴱⴱ .30ⴱ – – .19ⴱⴱ .08ⴱ – – .19ⴱⴱ .27ⴱ Gender Prior achievement Daily hassles Exposure to violence

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lence and daily hassles was a powerful statistical predictor of self-reported depressive symptoms (27% of total variance), PTSD symptoms (42% of total variance), and aggression (34% of total variance).

.14ⴱⴱ .19ⴱⴱ .04 .01

␤ R2 change R2 total R2 change R2 total

␤ R2 total R2 change R2 total R2 total

R2 change

␤

PTSD symptoms Depressive symptoms

Table 3 Hierarchical regressions predicting psychological functioning

␤

Aggression

R2 change

Teacher-rated adaptive functioning

␤

Teacher-rated depression and anxiety

E.J. Ozer et al. / Journal of Adolescent Health 39 (2006) 73–79

Teacher report of anxiety/depression and adaptive functioning. After controlling for gender, academic achievement, and daily hassles, recent exposure to violence did not uniquely predict teachers’ ratings of anxiety/depressive symptoms or adaptive functioning. As shown in Table 1, students reporting more exposure to violence and daily hassles were rated as functioning less well by their teachers (r ⫽ ⫺.35, p ⬍ .01 for exposure to violence; r ⫽ ⫺.30, p ⬍ .05 for daily hassles); these relationships, however, did not remain statistically significant after controlling for the strong relationship between prior academic achievement and teacher-rated adaptive functioning. The total variance explained in teacher-rated adaptive functioning was 38%. None of the predictors examined here significantly predicted teachers’ ratings of anxiety/depression. Discussion This study is the first empirical investigation, to our knowledge, of the relationship between exposure to violence and psychological functioning among Chinese American youth. We found that a substantial proportion of the young adolescents in this non-referred, school-based sample had directly experienced or witnessed physical violence in the prior six months. Adolescents who experienced more violence reported more symptoms of depression and PTSD, as well as aggression. This relationship held even after controlling for a range of daily hassles frequently encountered by urban adolescents across neighborhood, school, family, and peer domains. Daily hassles were also strongly and uniquely associated with self-reported depression, PTSD, and perpetration of violence. These findings suggest that a substantial proportion of Chinese American adolescents do encounter threats to physical safety associated with some urban neighborhoods, and exposure to violence and other stressors is associated with worse mental health and a higher likelihood of perpetrating violence. These results are consistent with and extend prior research conducted with mainly African American and Latino adolescents that demonstrated the link between exposure to violence and symptoms of PTSD, depression, and aggression [16,19,21,22]. The association between more daily hassles and decrements in mental health is consistent with prior research with urban African American adolescents [20,27]. In the stress and coping literature, daily hassles has been examined for both independent effects on mental health as well as a mediator of the effects of major life events on mental health (cites). The unique, statistically significant contributions of exposure to violence and daily hassles found in this study

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provide evidence of independent associations with mental health. Strengths of this study’s design include its school-based, non-clinical sample of Chinese American adolescents, representative sampling of schools and students within schools, and the use of data from both adolescents and teachers. Studying Chinese American youth, rather than a more heterogeneous Asian American sample, likely reduced withingroup variability not associated with the relationships of research interest. As discussed earlier, the use of a withingroup design was highly appropriate for this initial investigation of the relationship between exposure to violence and functioning in this understudied population [6,7]. Because this research was cross-sectional, we cannot rule out an alternative interpretation to our findings that—rather than greater exposure to violence leading to more symptoms— more symptomatic students encounter more violence. Multiple prospective studies, however, confirm that exposure to violence leads to increases in symptoms and provide support for our interpretation of these cross-sectional findings [19,21,37]. In this study, exposure to violence strongly predicted self-reported symptoms and aggression but did not predict teachers’ ratings of anxiety/depression and adaptive functioning. Although the possibility of shared method variance accounting for significant findings across self-report measures cannot be ruled out, adolescents are considered to be the most sensitive reporters of their own internalizing symptoms [38] and low agreement among reporters of youth’s functioning is common, particularly for adolescents [39]. Our results suggest that many adolescents who reported symptoms did not express these symptoms in the classroom, or that most teachers did not notice. Teachers’ ratings of adaptive functioning were found to be most strongly related to adolescents’ prior academic achievement and gender: Higher achievers and girls were judged by their teachers as being more happy, behaving more appropriately, getting along with peers better, and learning more. There were no differences, however, in adolescents’ own reports of depressive or PTSD symptoms based on their gender or prior academic achievement. It is possible that teachers globally attributed other positive dimensions to students with good academic performance and did not differentiate between students’ academic performance and psychological functioning. If so, the potential implications of an over-generalized view of students could be an impaired ability to detect students in emotional distress and in need of support or referral. It should be noted that the scholastic grades used here were earned prior to the year in which the teachers instructed the students and rated their psychological functioning; thus it is not the case that grade point average was influenced by students’ current functioning. This study demonstrates that exposure to violence and daily hassles are robustly associated with depressive symptoms, PTSD symptoms, and perpetration of violence in a

school-based sample of young Chinese American adolescents. Although the focus of the overwhelming majority of research on violence and mental health has excluded Chinese American and other Asian American youth, these results suggest that violence may play a meaningful role in patterns of mental health and perpetration of violence among Chinese American youth who live in urban environments. Mental and physical health promotion efforts among urban Chinese American populations should consider assessing and preventing exposure to violence as part of their work. This study represents a first step in identifying the relevance of exposure to violence for the mental health of Chinese American youth. Next steps should elucidate the psychological processes by which Chinese American adolescents respond to exposure to violence, and how cultural practices and resources may influence these processes over time. Prospective research with a large school or community-based sample of Chinese American youth will facilitate further study. For example, such research could fruitfully build upon existing literature on parenting practices among Chinese American families [40] to explore how familial relationships and support might influence the impact of exposure to violence and other types of stressors on psychological functioning. Acknowledgment This research was supported by NIMH Grant 1RO3MH58014-01 to Emily J. Ozer. We thank Rhona S. Weinstein for her collaboration with the overall project, Marieka Schotland and the Community Violence Research Teams for their research assistance, and Judith Kell, Ritu Khanna, and Trish Bascom for their support in the schools. References [1] Greenberger E, Chen C. Perceived family relationships and depressed mood in early and late adolescence: a comparison of European and Asian Americans. Dev Psychol 1996;32(4):707–16. [2] Yip T, Fuligni A. Daily variation in ethnic identity, ethnic behaviors, and psychological well-being among American adolescents of Chinese descent. Child Dev 2002;73(5):1557–72. [3] Ying Y, Lee PA, Tsai JL. Asian American college students as model minorities: an examination of their overall competence. Cultur Divers Ethnic Minor Psychol 2001;7(1):59 –74. [4] Sue S, Sue DW, Sue L. Psychopathology among Asian Americans: a model minority? Cultur Divers Ment Health 1995;1(1):39 –51. [5] Centers for Disease Control and Prevention. Youth Risk Behavior Survey. Atlanta, GA: Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, 2003. [6] Betancourt H, Lopez SR. The study of culture, ethnicity, and race in American psychology. Am Psychol 1993;48(6):629 –37. [7] Cauce AM, Coronado N, Watson J. Conceptual, methodological, and statistical issues in culturally competent research. In: Hernandez M, Isaacs R, eds. Promoting Cultural Competence in Children’s Mental Health Services. Baltimore, MD: Brookes, 1998:305–29.

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