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Cross-cultural Issues in Research On Child Mental Health
CULTURAL AND SOCIETAL INFLUENCES IN CHILD AND ADOLESCENT PSYCHIATRY
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CROSS-CULTURAL ISSUES IN RESEARCH ON CHILD MENTAL HEALTH Beat Mohler, MD, MPH
During the past two decades, research in child psychiatry started to move beyond the investigation of selected clinical groups and beyond epidemiologic studies of populations of just one ethnic or cultural identity. There have been countless efforts to test complex interrelationships between biologic and psychologic factors, environmental factors and mental health outcomes. However, all these research efforts show only limited success when selected populations are investigated or when population-level factors on child mental health are not included in research models. The question of whether research findings apply to children from different countries or different cultural backgrounds unfortunately cannot be answered by most of the past research. Because of their limited generalizability, only few research findings on child development and child mental health have been applied in broader research or intervention projects. Most investigators agree that more cross-cultural research is necessary. More culturally sensitive investigations and knowledge on unbiased national and cultural differences in child development and mental health are needed. 3, 16, 19, 29 Qualitative approaches, psychoanalysis and ethnology in the past, and ethnographic or ethnopsychologic investigations in the past decades have led to better understanding of children growing up in different cultures and have made descripltive comparisons
From the Department of Child Psychiatry, University of Basel, Basel, Switzerland; and the Department of Maternal and Child Health, Harvard School of Public Health, Boston, Massachusetts
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between countries and socioculturally distinct groups possible. It is only recently that quantitative research methods in child psychiatry and psychology have been translated and validated in different populations. Empirically grounded cross-national comparisons of the prevalence of child mental health symptoms and disorders have been published. 4 , 74, 7 Still, even if an increase in international communication and collaboration in research on child mental health can be observed, little has been achieved in developing a true understanding of the factors that influence mental health and the ill health of children who grow up in different countries or in different sociocultural environments. Most of the recently conducted research in the field is still lacking cross-culturally valid and culturally sensitive methods and appropriate interpretation of the data.3, 4, 7, 16 Researchers still do not know whether some aspects of child development and mental health are truly universal or independent of cultural environment or whether some indicators for risk, resilience, or disorder of child and adolescent mental health are specific in a certain environment or for a distinct social group. Nature-nurture debates have created distinctly different positions on the importance of or the interest in culture as a factor in child health and development. Even if most mental health researchers support basically more complex biopsychosocial models, their research reflects often distinct positions based on either more biologically (genetically) or psychosociologically oriented models. A stronger segregation in research approaches seems to be enforced by recent developments in biologic and genetic research and in advances in psychopharmacology. However, authors of research papers often do not state or discuss which orientation or which concept of culture they applied. This article focuses in the first part on the theoretical and conceptual issues involved in cross-cultural research on child mental health. Different positions and approaches of researchers toward culture in child development, mental disorders, and research methods are described. The concept of culture is discussed in the context of national and crossnational child mental health research. Theoretical and practical challenges in cross-cultural research in child psychiatry and corresponding theoretical and methodologic approaches are presented and discussed. CULTURE AS A CONCEPT IN CHILD PSYCHIATRIC RESEARCH
Most reviewed articles on cross-cultural issues in child mental health neither describe nor discuss their author's concepts of culture. One reason for this lack might be the complex multidimensional nature of culture as a concept. It is difficult to define culture more specifically than just as a general population-level factor. Researchers also might be confident that everybody knows what is meant by culture (i.e., how people define and differentiate one cultural group from the other). If
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people are categorized into cultural groups and if potential culturebound factors or culture-specific manifestations of behavior are integrated into research models on child and adolescent mental health, however, some reflections and decisions on possible concepts of culture should be made. There are various definitions of culture published in the psychologic, ethnologic and sociologic literature. They vary according to the author's background and interest in specific aspects of culture. In a summary of this literature, Berry et aP describe three main conceptualizations of culture. First, culture as a set of conditions shapes observable or measurable differences in behavior. Based on this view, differences in child development and mental health are an effect of differences in cultural environment. A child's development is conditioned by being born into a distinct cultural group. This concept implies that culture itself cannot be measured. It can be observed only through its effect on people's behavior, values, and artifacts. Social scientists who use this concept often analyze different contexts such as language, relationships, or schools and neighborhoods to explain differences in behavior by differences in environmental condition.3 Second, culture as a system considers relationships, psychologic traits, and social functions as inseparable from the context of culture.3 In this view, comparisons between cultures do not make sense, because each instance of human behavior or development is part of the culture itself. Human behavior cannot be assessed separately but only can be analyzed and understood within the corresponding culture. A scientific approach using the concept of culture as a system only can be descriptive in nature if behavior is compared between different sociocultural groups. Third, cultures as action theories describe individual change, development, and actions as a dialectic process between the individual and his or her physical and social environment.3 The individual's actions, goals, and intentions are not only influenced by the sociocultural context but they also reflect and shape culture. Within this conceptualization, culture becomes a conditional part of any observable behavior. This concept implies complex theoretical models of behavior and environment. As in culture as a system, culture and behavior practically cannot be disentangled. Another way to distinguish concepts of culture is by more implicit or more explicit contents. The three conceptualizations described above focus more on either observable (i.e., explicit) patterns of culture (behavior, artifacts) or underlying ideas and meanings (i.e., implicit patterns) (values, motivation).3 Some authors tend to integrate these approaches into a multidimensional concept of culture. In practice, however, it is not possible to test scientifically this kind of holistic concept. Researchers with a multidimensional approach to culture usually consider and test only certain aspects of their concept of culture, depending on the underlying research question or the specialty of the investigators. All of these psychologic concepts of culture assume a strong relationship between culture and behavior. As is discussed in the section on orientations in research, however, child mental health professionals'
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research models consider different views as to whether culture plays an important role in shaping child development and mental health. Publications on cross-cultural issues in child mental health often use culture as a synonym for country of residency or ethnicity or race. Marsella16 describes this problem as early as 1988. A review of the recent literature suggests that these problems might have become even more prevalent, however. Using culture, nationality, and ethnicity interchangeably is confusing and leads to additional classification biases not considered in analysis and discussions of most of the reviewed papers. Given the previous definitions of culture, countries (i.e., politically and geographically defined entities) often cannot be considered culturally uniform units. Ethnicity reflects primarily a shared biologic past (offspring from a distinct racial group) and only partially a shared cultural past.3 Ethnic groups are often not as culturally homogeneous as expected. For example, this is the case with the ethnic term Latinos often used in US public data and research. The term Latino encompasses all Spanishspeaking populations from Mexican, Cuban, Puerto Rican, other Central and South American, and European origin. Although they share some common language features and certain values and norms about family and spirituality, these people differ distinctly in many other cultural aspects. 21 Within ethnic groups such as Latinos, African Americans, or Asian Americans, people differ not only in culture of origin. Different pathways of migration and acculturation also lead to significant differences in cultural outcomes of these racially related groups. Ethnic groups as they are classified in research mostly do not represent distinct cultural groups and dilute the observable cross-cultural differences in child behavior or child mental health. Theoretically, ethno-culturally distinct groups are expected to carry their cultural values and habits in the present and into the future and share their cultural past. Practically, this is only the case in more isolated populations. Migration always contributes to a mix of cultures and changes in culture through adaptation between the immigrant cultural group and the host culture. 21 Recent globalization of markets and communication and increasing proportions of immigrant populations in most countries have led to more multicultural environments within geographic or political boundaries. Residency of a country should be used more carefully as an indicator for a distinct culture or as a person-level indicator for influences by the historically dominant culture of the country. If we are aware of the variety and segregation of cultural groups within national or regional boundaries, cross-cultural issues are as much or even more of interest in national or regional studies on child and adolescent mental health. In populations with significant numbers of immigrants, one becomes aware of the time-dependent and multidimensional nature of culture. Migration changes culture of the host country and the culture of origin within the immigrant populations. Differences in cultural identity and corresponding conflicts of immigrant parents and their children demonstrate the complex but ultimately plastic nature of culture.
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ORIENTATIONS IN RESEARCH
Research on child mental health uses categorical, dimensional, or mixed concepts of health, ill health, and risk and resilience factors. Internationally agreed definitions of categories of health or ill health are helpful for clinical purposes, and they are useful in cross-cultural research. International research on psychiatric disorders-mostly investigations of adults, few of children-revealed culture-specific patterns, however, especially for affective and reactive disorders, and described the existence of culture-specific syndromes. 4, s, 16' 30 In their latest versions, international classification systems (DSM, ICD) tried to integrate some of the observed cultural aspects into their taxonomy. There is still widespread criticism of the existing categorical approach as being culturally biased, however, and not as useful for cross-cultural research. The existing classification systems are mainly influenced by concepts and experiences of researchers and clinicians from European culture. 16 Even if diagnosis-driven approaches are useful to compare prevalence across populations, they reveal major disadvantages in cross-cultural research. Authors who reviewed research projects on child mental health critically conclude that results are difficult or sometimes impossible to compare. 4, 16' 30 Different methods often have been used, or the translated diagnostic interviews have not been tested appropriately in the corresponding cultural groups. If syndrome classifications are needed, quantitative and qualitative taxonomy, which has been developed empirically within and across cultures, is much more useful. The more mental health outcomes are simplified primarily through classifications, the more the outcomes are influenced through culturally biased classification. In crosscultural research, the use of dimensional concepts and scales is highly preferred. 4' 27 Starting with large numbers of possible items that correspond to the culture-specific pool of symptoms reduces the risk for cultural biases. Culture-specific or universal clusters of symptoms or disorder classifications then can be developed based on the testing of the scales within and across cultures. Researchers assign different importance to possible transmission mechanisms of behavior or mental health. Genetic or biologic transmission and cultural transmission are the two main mechanisms through which individual behavior can be shaped across generations and within populations over time. These population-level transmission mechanisms play the most important role in observable cross-population difference. 3 Additional contextual factors such as ecologic and acculturation influences are important influences to consider on an individual or subgroup level. They are less important when one investigates population-level differences in child and adolescent mental health. Literature on cross-cultural psychology and psychiatry distinguishes among three different approaches toward the importance and role of culture.3 First, researchers with an absolutist orientation assume that biologic factors underlying behavior are most important and cultural factors
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have only limited influence on mental health outcomes. An absolutist orientation defines behavior and child mental health as context independent. Researchers with this approach define and develop their methods as culturally independent. Based on this assumption, methods and research instruments can be standardized and applied in any environment without adaptations. Second, a relativist orientation reflects a strong focus on environmental or cultural factors underlying human behavior. Observed differences between populations are caused by significant cultural differences. Researchers who use this approach derive methods within cultural concepts and norms and investigate child and adolescent mental health usually only within specific populations. From a relativist standpoint, there is no context-independent understanding of human behavior. Generalizations on factors that influence child mental health cannot be derived. Third, investigators with a universalist position integrate biologic or genetic and cultural or environmental factors into their concepts on human behavior. They assume universal, generalizable basic features of development and mental health; however, observable behavior is considered to be influenced by culture. Universalists' models on human development try to integrate processes and interactions between biology and environment as the most significant influencing factors. Based on this approach, concepts of mental health mostly cannot be context free, although generalized aspects of underlying mechanisms of risk, protective, and resilience factors might be defined. This universalist approach is the one most often chosen in recent investigations on child mental health. Unfortunately, the specifics of these concepts are usually not described or discussed in published research. Another way to define one's position toward the cultural groups to be investigated is to distinguish between etic and emic viewpoints. An investigator with an emic approach assumes concepts to be valid limited to cultural boundaries. 3 ' 29 Cross-cultural comparisons between projects based on emic viewpoints would have only descriptive nature and theoretically could not lead to any generalizations. Using the three categories described previously, a relativist would be considered as using an eminic viewpoint. On the other hand, any true comparisons of child mental health across cultures are based on an etic assumption. Using this approach, concepts of mental health and corresponding methodologies are assumed to be valid within and across cultures. 3, 29 Berry3 describes that absolutists, who consider biologic and genetic factors most important for observed differences in child development and mental health, are using an imposed etic approach. Universalists, who integrate biologic and environmental factors into their models, would need to derive their etic assumptions through adapting methods and concepts to different cultural environments and through distinguishing generalizable and culture-specific factors (derived etic). Unfortunately, investigators usually do not describe and discuss
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their definition and approach toward culture. Most researchers seem to assume that at least some cultural factors are important enough to be controlled for, and they often test whether instruments used in crosscultural or cross-national research must be adapted for the different cultural or subcultural environments. The theoretical and methodologic work required to fulfill the assumptions of this universalist and derived etic approach, however, is challenging. As is discussed in the next section, international and cross-cultural research methods and practice only started to take their first steps in this direction during the past decade.
TRANSLATION AND TESTING OF CROSS-CULTURAL EQUIVALENCE OF MEASURES
Several authors listed methodologic recommendations for crosscultural psychiatric research. 3• 4• 7• 16 • 24 These recommendations include instrument development and translation and testing of psychometric properties in each culture. Flaherty et aF suggest a stepwise validation for cultural equivalence of measures. Only by achieving equivalence in the five different dimensions can an instrument be considered crossculturally equivalent.
Cross-cultural Equivalence of Measures;
1. 2. 3. 4. 5.
Content equivalence Semantic equivalence Technical equivalence Criterion equivalence Conceptual equivalence
The following discussion describes the concept of these five dimensions of cross-cultural equivalence and discusses the methods that are necessary to test or achieve optimal equivalence in these dimensions. Content equivalence is achieved if each item is significant for the assessed phenomena in each culture. This can be achieved through discussions on the relevance of items in culture-specific expert panels or focus groups. 4 In research on child mental health, it is mostly unrecognized that the children and adolescents themselves can contribute significantly as experts on concepts and contents of measures.17 Within the possible quantitative approaches to test for content equivalence and content validity, factor analysis is the most often used method in crosscultural psychiatric research. Within each population, hypothesized or factor analytically developed structures of scales can be tested. The
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corresponding grouping of items or composition of scales then can be compared among the different cultural groups. Symptom scales, as for the Child Behavior Checklist (CBBCL),2 have been derived empirically through factor-analytic approaches. Comparisons of factor analytically derived scales among different cultural groups are most often described as cross-cultural validation approaches in published research. 1• 25 Equivalence of factor structure does not guarantee that true content validity within populations and content equivalence is achieved, however. As is shown later, results from factor analysis are used not only to support validity and equivalence of content but also to test and compare concepts. The previously described qualitative approach to develop and compare culturally specific pools of significant items, which would be crucial to achieving content validity and equivalence, is extensively missing in published work. Reviewed cross-cultural research often satisfies the following two dimensions of measure equivalence. Semantic equivalence of measures is achieved using translationback-translation methods. Bird4 suggested combining the more mechanical translation-back-translation processes with panels of experts who are familiar with both cultures to guarantee a higher level of idiomatic equivalence of items. Technical equivalence is achieved easily by using the same method of assessment, for example, interview (instead of questionnaire) in both cultures. Paper-and-pencil methods are more often problematic in crosscultural research. The observed results are at risk of being biased significantly by differences in literacy levels. Criterion equivalence is achieved if the threshold to endorse an item is the same for each cultural group. This process requires gathering knowledge on population norms of behavior or psychologic symptoms. Information from ethnographic research can contribute to understanding similarities or differences in these norms. The already mentioned focus groups with experts (professionals) and groups with children and adolescents or parents are valuable additional qualitative methods to investigate norms and test and achieve criterion equivalence. Conceptual equivalence is achieved if the measure assesses the same theoretical construct in each culture. This process requires a major theoretical step, namely, to define and model the underlying construct and corresponding hypotheses in each culture and to compare these across cultures. Quantitative approaches are able to test conceptual equivalence only indirectly.7 Conceptual validity in both cultures can be supported by equivalent item composition and interitem correlation, item functioning and scale structure, and external validation of the measure. The latter supports conceptual equivalence if both cultures reveal similar correlation between the measure and other known related constructs. Equivalence of item composition and structure is tested through factor-analytic approaches such as principal component analysis 10• 25 or structural equation modeling.11 Item response models such as Rasch
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models allow for testing and comparing not only the composition and structure of scales but also the differential functioning of singular items. This technique is well established for ensuring measurement equivalence in psychologic research, and it has been used recently as part of international approaches to validate translated scales in psychiatric epidemiology.6, 3, 18 Overall, validity within cultures and equivalence across cultures is best approached through a combination of multiple qualitative and quantitative analytic techniques. 8 MODELING CULTURAL FACTORS AND MENTAL HEALTH
A scientific model that includes cultural factors and child mental health outcomes can be developed only after defining importance and concept of culture, Weisz et al suggested two major models repeatedly in the literature, 27- 29 The problem-suppression model2°, 28 , 29 suggests that cultural factors influence child behavior and development of mental disorders directly, As demonstrated in Figure 1, this model assumes an individual level relationship between culture and child mental health. Development and mental health are shaped by the child's experience of cultural norms, which support acceptable and suppress unacceptable behavior, A second suggested model, the adult-distress threshold model, assumes a major effect of culture on adults' experience and beliefs regarding children and on adults' corresponding responses to perceived distressful child behavior.20 ' 27- 29 Figure 1 shows that this model's focus is
Personality Self Resilience
~
I\
~
b ~ /fr ~He_alth~ Mental
Adult: - Perception/Experience - Distress ·Parenting
Figure 1. Modeling culture and child mental health . 1 = Pathway of problem-suppression model; 2 = pathway of adult-distress-threshold model.
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on cultural factors and influences on an environmental level. The child is only indirectly influenced by culture through the environment's perception (family, school, other institutions and other adults, peers) and reactions (conditioned by culture-specific threshold of distress). Both of these models focus primarily on cultural norms and values. This is based on a culture as a set of conditions concept (see previous discussion). Because the child's behavior and mental health are a reflection of cultural norms and values, differences in child behavior and development of mental disorders can be best understood by assessing cultural norms and their effect in different cultural groups. The adultdistress-threshold model demonstrates the importance of adult (parent, teacher) perception of child behavior for cross-cultural research. Culture has an influence on parent's perception, which influences the child's development and mental health. Culture also influences the difference between self-reports and parent reports of child mental health. 14 Scientific models should try to incorporate cultural factors on individual and group levels and as related (correlated) variables of other known risk, protective, and resilience factors on child mental health. Research models should guarantee that effects of cultural factors are controlled for informant, age, and gender. The problem-suppression and adult-distress threshold models ignore culture as determining personality or self and the development of coping strategies. 16 As demonstrated in Figure 1, transgenerationally transmitted effects of culture on the development of resilience and specific coping strategies should be considered and investigated further. If theoretical concepts of culture are investigated and specified, corresponding research models will incorporate all the different levels of dependence between culture and environment, individual development, behavior, and personality or self. 16 EXAMPLES OF CROSS-CULTURAL RESEARCH
Cross-cultural investigations of adult psychopathology have a much longer history. The largest international research projects, especially by World Health Organization (WHO), focused on depressive and psychotic disorders. 16 Authors of these studies, which used standardized instruments, ended in a discourse between conclusions either focusing more on the universal biology-related aspects of disorders or more on the observed considerable variation of symptoms, course, and disorder outcome across cultures. The controversial results of these earlier studies suggested methodologic limitations. Only through improvements, especially in translation and equivalence of measures, could bias be disentangled from true cross-cultural differences. Certain evidence of cultural determination and experience of disorders could not be rejected, however. For depressive disorders, some investigators suggested culturally dependent preference of either somatization or cognitization of distress. 12• 16 Even less cross-cultural research has been conducted on child and
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adolescent mental health.4• 5• 20 The CBCL is the most widely translated instrument in child mental health research. 23 Child, parent, and teacher forms have been tested within and across multiple cultures.4• 20• 24• 26• 27 Research using the CBCL has been most influential toward empirically developed taxonomy, using a given basic set of items, and developing age- and gender-specific scales.2 Multiple cross-national studies developed and compared empirically derived syndromes1• 13• 22• 29 through factor or principal component analysis. Although only a limited range of countries and cultures have been investigated, it is possible to conclude that in several studies factor patterns, if controlled for informant, age, gender, and socioeconomic status, are often strikingly similar and might reveal certain universal aspects of child mental health. More recent studies seem to demonstrate even fewer differences in experience and prevalence of child mental health problems across cultures. For example, the Western expectation of men showing more externalizing behavior problems has been found in non-Western societies.9 As Weisz et al29 noted, however, the cross-cultural validity of syndromes in child psychopathology is far from having been investigated in depth. There are several limitations in past research on CBCL. Validation studies usually did not go beyond testing translation (semantic validity) through translation-back-translation methods and content and construct validity through factor analytic approaches. Most comparisons were conducted with US populations as a reference. 4 Scale development for translated measures also has been limited to the basic pool items developed within US populations. OUTLOOK
There is widespread consensus regarding the need for more international and cross-cultural studies on child mental health. Most published research findings, independent of whether they support cultural differences or universal patterns in child mental health, cannot persist if the applied methods are analyzed critically. These past limitations of crosscultural research methods in child mental health reflect the complexity of the concept of culture and the difficulty to test its entire direct and indirect multiple level effects on child development. Even if cross-national research advanced during the past two decades in its standards of translation and validation of measures, findings are far from being conclusive. Through increased international collaborations, instruments in child psychiatric research are more often translated, and data based on research projects using the methods are more easily available for cross-cultural comparisons. As the previous examples demonstrated, conclusions from these comparisons are based on the assumption that the translated instruments are equivalent, that unassessed sociocultural factors are not important, or that all influencing factors have been assessed. The latter is never the case, however, and all possible biases through limitations in methods
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should be discussed before arriving at conclusions of either true crosscultural differences or true universality of aspects in child mental health. Investigators often do not take into consideration the high probability that multiple unknown or unassessed variables contributed to some of the observed differences. Higher number of subjects in two environments or an integration of data from multiple studies through metaanalysis usually increases accuracy of statistical testing. As Berry et al3 pointed out, however, the likelihood of wrongly rejecting the null hypothesis (type I error) increases with expansion of data given when there are significant nonassessed factors that contribute to between-group differences. It must be assumed that this is often the case on cross-cultural studies. Malpass and Poortinga15 even suggested that the high probability of erroneously detecting differences between cultures questions the validity of cross-cultural research results. They conclude that alternative explanations for observed differences between cultures should be excluded empirically before accepting true crosscultural differences. A review of the literature suggests that future work should focus mainly on the improvement of earlier steps in research projects to ease the difficulty of adequately interpreting later findings. As has been discussed in this article, culture is mostly not conceptualized and operationalized in published works, and other population-level entities are often used inaccurately to indicate culture. Populations in industrialized and developing countries are affected significantly by migration and increased global communication of multiple cultural artifacts and values. The already difficult to grasp multidimensional concept of culture might become more complex within these changes. This leads to an even more pronounced need for researchers in the field of child mental health to understand and define a concept of culture and to operationalize child development and mental health in its context. Cross-cultural research on child mental health is still in its early childhood years, and much work must be done to develop more comprehensive research models and corresponding methods. For the theoretical work and for the development and testing of methods, more truly multidisciplinary approaches are needed. As long as researchers are not able to compare, discuss, and integrate theories and methods across research specialties, little significant success can be expected in cross-cultural work. Through the development of more mixed-method approaches using qualitative and quantitative methods, researchers might be able to reach more conclusive results in the future. Another needed step might be to lessen to some degree the inflexible, unchangeable nature of measures that are only translated, copied, or shortened but never adapted and improved through cross-cultural research. Continuous improvement of instruments can be achieved through its testing in different environments and corresponding adaptations of the original measure. Results from different cultural environments, including results on the primarily selected items and suggestions
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for adding new items, lead to stepwise changes and improvements in the original measure. Only by putting efforts into improving research approaches and methods on all the described levels can more information from crossnational and cross-cultural comparisons on child development and mental health be achieved. A clear conceptualization and operationalization of culture and validity and equivalence of methods are needed for future projects. Significant advances in interdisciplinary international research are needed to increase understanding of perception and norms of behavior and how risk, protective, and resilience factors are influencing child development and mental health in different cultural environments. References 1. Achenbach T, Verhulst F, Baron G, et al: A comparison of syndromes derived from the Child Behavior Checklist for American and Dutch boys aged 6-11 and 12-16. J Child Psycho! Psychiatry 28:437-453, 1987 2. Achenbach T: Manual for the Child Behavior Checklist/4-18 and 1991 profile. Burlington, University of Vermont, 1991 3. Berry J, Poortinga Y, Segall M, et al: Cross-cultural Psychology: Research and Applications. Cambridge, UK, Cambridge University Press, 1992 4. Bird H: Epidemiology of childhood disorders in a cross-cultural context. J Child Psycho! Psychiatry 37:35-49, 1996 5. Cederblad M: Behavioral disorders in children from different cultures. Acta Psychiatr Scand 78:85-92, 1988 6. Ellis B, Kimmel H: Identification of unique cultural response patterns by means of Item Response Theory. J Appl Psycho! 77:177-184, 1992 7. Flaherty J, Moises Gaviria F, Pathak D, et al: Developing instruments for cross-cultural psychiatric research. J Nerv Ment Dis 176:257-263, 1988 8. Gandek B, Ware J: Methods for validating and norming translations of health status questionnaires: The IQOLA Project approach. J Clin Epidemiol 51:953-959, 1998 9. Hackett R, Hackett L: Child psychiatry across cultures. Int Rev Psychiatry 11:225-235, 1999 10. Harman H: Modern Factor Analysis, ed 3 (revised). Chicago, University of Chicago Press, 1976 11. Keller S, Ware J, Bentler P, et al: Use of structural equation modeling to test the construct validity of the SF-36 Health Survey in ten countries: Results from the IQOLA project. J Clin Epidemiol 51:1179-1188, 1998 12. Kleinman A: Depression and neurasthenia in the People's Republic of China. Cult Med Psychiatry 6:1-80, 1982 13. Koot H, Van Den Oord J, Verhulst F, et al: Behavioral and emotional problems in young preschoolers: Cross-cultural testing of the validity of the Child Behavior Checklist/2- 3. J Abnorm Child Psycho! 25:183-196, 1997 14. Kuo M, Mohler B, Raudenbush S, et al: Assessing exposure to violence using multiple informations: Application of Hierarchical Linear Model. J Psycho! Psychiatry 41:10491056, 2000 15. Malpass R, Poortinga Y: Strategies for design and analysis. In Lonner W, Berry J (eds): Field Methods in Cross-cultural Research. Beverly Hills, Sage, 1986, pp 47-84 16. Marsella A: Cross-cultural research on severe mental disorders: Issues and findings. Acta Psychiatr Scand 78:7- 22, 1988 17. Mohler B, Earls F: Translation and cultural adaptation of an instrument on exposure to violence. Presented at the 14th Internation al Congress of the International Association of Child and Adolescent Psychiatry and Allied Professions. Stockholm, Sweden, August 2- 6, 1998
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18. Radzek A, Ware J, Bjomer J, et al: Comparison of Rasch and summated rating scales constructed from SF-36 physical functioning items in seven countries: Results from the IQOLA project. J Clin Epidemiol 51:1203-1214, 1998 19. Rogler L: The meaning of culturally sensitive research in mental health. Am J Psychiatry 146:296-303, 1989 20. Rousseau C, Drapeau A: Parent-child agreement on refugee children's psychiatric symptoms: A transcultural perspective. J Am Acad Child Adolesc Psychiatry 37:629636, 1998 21. Suarez-Orozco C, Suarez-Orozco M: Transformations: Immigration, Family Life, and Achievement Motivation among Latino Adolescents. Stanford, Stanford University Press, 1995 22. Verhulst F, Achenbach T, Althaus M, et al: A comparison of syndromes derived from the Child Behavior Checklist for American and Dutch girls aged 6-11 and 12- 16. J Child Psycho! Psychiatry 29:879-895, 1988 23. Verhulst F, Koot H: Child Psychiatric Epidemiology: Concepts, Methods, and Findings. Newbury Park, CA, Sage, 1992 24. Verhulst F, Achenbach T: Empirically based assessment and taxonomy of psychopathology: Cross-cultural applications. Eur Child Adolesc Psychiatry 4:61- 76, 1995 25. Ware J, Kosinski M, Gandek B, et al: The factor structure of the SF-36 Health Survey in 10 countries: Results from the IQOLA Project. J Clin Epidemiol 51:1159-1165, 1998 26. Weisz J, Suwanlert S, Chaiyasit W, et al: Over- and undercontrolled referral problems among children and adolescents from Thailand and the United States: The Wat and Wai of cultural differences. J Consult Clin Psycho! 55:719-726, 1987 27. Weisz J, Suwanlert S, Chaiyasit W, et al: Thai and American perspectives on overand undercontrolled child behavior problems: Exploring the Threshold Model among parents, teachers, and psychologists. J Consult Clin Psycho! 56:601-609, 1988 28. Weisz J, Suwanlert S, Chaiyasit W, et al: Epidemiology of behavioral and emotional problems among Thai and American children: Teacher reports for ages 6-11. J Child Psycho! Psychiatry 30:471-484, 1989 29. Weisz J, Eastman K: Cross-national research on child and adolescent psychopathology. In Verhulst F, Kooot H (eds): The Epidemiology of Child and Adolescent Psychopathology. Oxford, Oxford University Press, 1995, pp 442-65 30. Westermeyer J: National differences in psychiatric morbidity: Methodological issues, scientific interpretations and social implications. Acta Psychiatr Scand 78:23-31, 1988 Address reprint requests to
Beat Mohler, MD, MPH Department of Maternal and Child Health Harvard School of Public Health 677 Huntington Avenue Boston, MA 02115
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CROSS-CULTURAL ISSUES IN RESEARCH ON CHILD MENTAL HEALTH Beat Mohler, MD, MPH
During the past two decades, research in child psychiatry started to move beyond the investigation of selected clinical groups and beyond epidemiologic studies of populations of just one ethnic or cultural identity. There have been countless efforts to test complex interrelationships between biologic and psychologic factors, environmental factors and mental health outcomes. However, all these research efforts show only limited success when selected populations are investigated or when population-level factors on child mental health are not included in research models. The question of whether research findings apply to children from different countries or different cultural backgrounds unfortunately cannot be answered by most of the past research. Because of their limited generalizability, only few research findings on child development and child mental health have been applied in broader research or intervention projects. Most investigators agree that more cross-cultural research is necessary. More culturally sensitive investigations and knowledge on unbiased national and cultural differences in child development and mental health are needed. 3, 16, 19, 29 Qualitative approaches, psychoanalysis and ethnology in the past, and ethnographic or ethnopsychologic investigations in the past decades have led to better understanding of children growing up in different cultures and have made descripltive comparisons
From the Department of Child Psychiatry, University of Basel, Basel, Switzerland; and the Department of Maternal and Child Health, Harvard School of Public Health, Boston, Massachusetts
CHILD AND ADOLESCENT PSYCHIATRIC CLINICS OF NORTH AMERICA VOLUME 10 • NUMBER 4 • OCTOBER 2001
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between countries and socioculturally distinct groups possible. It is only recently that quantitative research methods in child psychiatry and psychology have been translated and validated in different populations. Empirically grounded cross-national comparisons of the prevalence of child mental health symptoms and disorders have been published. 4 , 74, 7 Still, even if an increase in international communication and collaboration in research on child mental health can be observed, little has been achieved in developing a true understanding of the factors that influence mental health and the ill health of children who grow up in different countries or in different sociocultural environments. Most of the recently conducted research in the field is still lacking cross-culturally valid and culturally sensitive methods and appropriate interpretation of the data.3, 4, 7, 16 Researchers still do not know whether some aspects of child development and mental health are truly universal or independent of cultural environment or whether some indicators for risk, resilience, or disorder of child and adolescent mental health are specific in a certain environment or for a distinct social group. Nature-nurture debates have created distinctly different positions on the importance of or the interest in culture as a factor in child health and development. Even if most mental health researchers support basically more complex biopsychosocial models, their research reflects often distinct positions based on either more biologically (genetically) or psychosociologically oriented models. A stronger segregation in research approaches seems to be enforced by recent developments in biologic and genetic research and in advances in psychopharmacology. However, authors of research papers often do not state or discuss which orientation or which concept of culture they applied. This article focuses in the first part on the theoretical and conceptual issues involved in cross-cultural research on child mental health. Different positions and approaches of researchers toward culture in child development, mental disorders, and research methods are described. The concept of culture is discussed in the context of national and crossnational child mental health research. Theoretical and practical challenges in cross-cultural research in child psychiatry and corresponding theoretical and methodologic approaches are presented and discussed. CULTURE AS A CONCEPT IN CHILD PSYCHIATRIC RESEARCH
Most reviewed articles on cross-cultural issues in child mental health neither describe nor discuss their author's concepts of culture. One reason for this lack might be the complex multidimensional nature of culture as a concept. It is difficult to define culture more specifically than just as a general population-level factor. Researchers also might be confident that everybody knows what is meant by culture (i.e., how people define and differentiate one cultural group from the other). If
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people are categorized into cultural groups and if potential culturebound factors or culture-specific manifestations of behavior are integrated into research models on child and adolescent mental health, however, some reflections and decisions on possible concepts of culture should be made. There are various definitions of culture published in the psychologic, ethnologic and sociologic literature. They vary according to the author's background and interest in specific aspects of culture. In a summary of this literature, Berry et aP describe three main conceptualizations of culture. First, culture as a set of conditions shapes observable or measurable differences in behavior. Based on this view, differences in child development and mental health are an effect of differences in cultural environment. A child's development is conditioned by being born into a distinct cultural group. This concept implies that culture itself cannot be measured. It can be observed only through its effect on people's behavior, values, and artifacts. Social scientists who use this concept often analyze different contexts such as language, relationships, or schools and neighborhoods to explain differences in behavior by differences in environmental condition.3 Second, culture as a system considers relationships, psychologic traits, and social functions as inseparable from the context of culture.3 In this view, comparisons between cultures do not make sense, because each instance of human behavior or development is part of the culture itself. Human behavior cannot be assessed separately but only can be analyzed and understood within the corresponding culture. A scientific approach using the concept of culture as a system only can be descriptive in nature if behavior is compared between different sociocultural groups. Third, cultures as action theories describe individual change, development, and actions as a dialectic process between the individual and his or her physical and social environment.3 The individual's actions, goals, and intentions are not only influenced by the sociocultural context but they also reflect and shape culture. Within this conceptualization, culture becomes a conditional part of any observable behavior. This concept implies complex theoretical models of behavior and environment. As in culture as a system, culture and behavior practically cannot be disentangled. Another way to distinguish concepts of culture is by more implicit or more explicit contents. The three conceptualizations described above focus more on either observable (i.e., explicit) patterns of culture (behavior, artifacts) or underlying ideas and meanings (i.e., implicit patterns) (values, motivation).3 Some authors tend to integrate these approaches into a multidimensional concept of culture. In practice, however, it is not possible to test scientifically this kind of holistic concept. Researchers with a multidimensional approach to culture usually consider and test only certain aspects of their concept of culture, depending on the underlying research question or the specialty of the investigators. All of these psychologic concepts of culture assume a strong relationship between culture and behavior. As is discussed in the section on orientations in research, however, child mental health professionals'
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research models consider different views as to whether culture plays an important role in shaping child development and mental health. Publications on cross-cultural issues in child mental health often use culture as a synonym for country of residency or ethnicity or race. Marsella16 describes this problem as early as 1988. A review of the recent literature suggests that these problems might have become even more prevalent, however. Using culture, nationality, and ethnicity interchangeably is confusing and leads to additional classification biases not considered in analysis and discussions of most of the reviewed papers. Given the previous definitions of culture, countries (i.e., politically and geographically defined entities) often cannot be considered culturally uniform units. Ethnicity reflects primarily a shared biologic past (offspring from a distinct racial group) and only partially a shared cultural past.3 Ethnic groups are often not as culturally homogeneous as expected. For example, this is the case with the ethnic term Latinos often used in US public data and research. The term Latino encompasses all Spanishspeaking populations from Mexican, Cuban, Puerto Rican, other Central and South American, and European origin. Although they share some common language features and certain values and norms about family and spirituality, these people differ distinctly in many other cultural aspects. 21 Within ethnic groups such as Latinos, African Americans, or Asian Americans, people differ not only in culture of origin. Different pathways of migration and acculturation also lead to significant differences in cultural outcomes of these racially related groups. Ethnic groups as they are classified in research mostly do not represent distinct cultural groups and dilute the observable cross-cultural differences in child behavior or child mental health. Theoretically, ethno-culturally distinct groups are expected to carry their cultural values and habits in the present and into the future and share their cultural past. Practically, this is only the case in more isolated populations. Migration always contributes to a mix of cultures and changes in culture through adaptation between the immigrant cultural group and the host culture. 21 Recent globalization of markets and communication and increasing proportions of immigrant populations in most countries have led to more multicultural environments within geographic or political boundaries. Residency of a country should be used more carefully as an indicator for a distinct culture or as a person-level indicator for influences by the historically dominant culture of the country. If we are aware of the variety and segregation of cultural groups within national or regional boundaries, cross-cultural issues are as much or even more of interest in national or regional studies on child and adolescent mental health. In populations with significant numbers of immigrants, one becomes aware of the time-dependent and multidimensional nature of culture. Migration changes culture of the host country and the culture of origin within the immigrant populations. Differences in cultural identity and corresponding conflicts of immigrant parents and their children demonstrate the complex but ultimately plastic nature of culture.
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ORIENTATIONS IN RESEARCH
Research on child mental health uses categorical, dimensional, or mixed concepts of health, ill health, and risk and resilience factors. Internationally agreed definitions of categories of health or ill health are helpful for clinical purposes, and they are useful in cross-cultural research. International research on psychiatric disorders-mostly investigations of adults, few of children-revealed culture-specific patterns, however, especially for affective and reactive disorders, and described the existence of culture-specific syndromes. 4, s, 16' 30 In their latest versions, international classification systems (DSM, ICD) tried to integrate some of the observed cultural aspects into their taxonomy. There is still widespread criticism of the existing categorical approach as being culturally biased, however, and not as useful for cross-cultural research. The existing classification systems are mainly influenced by concepts and experiences of researchers and clinicians from European culture. 16 Even if diagnosis-driven approaches are useful to compare prevalence across populations, they reveal major disadvantages in cross-cultural research. Authors who reviewed research projects on child mental health critically conclude that results are difficult or sometimes impossible to compare. 4, 16' 30 Different methods often have been used, or the translated diagnostic interviews have not been tested appropriately in the corresponding cultural groups. If syndrome classifications are needed, quantitative and qualitative taxonomy, which has been developed empirically within and across cultures, is much more useful. The more mental health outcomes are simplified primarily through classifications, the more the outcomes are influenced through culturally biased classification. In crosscultural research, the use of dimensional concepts and scales is highly preferred. 4' 27 Starting with large numbers of possible items that correspond to the culture-specific pool of symptoms reduces the risk for cultural biases. Culture-specific or universal clusters of symptoms or disorder classifications then can be developed based on the testing of the scales within and across cultures. Researchers assign different importance to possible transmission mechanisms of behavior or mental health. Genetic or biologic transmission and cultural transmission are the two main mechanisms through which individual behavior can be shaped across generations and within populations over time. These population-level transmission mechanisms play the most important role in observable cross-population difference. 3 Additional contextual factors such as ecologic and acculturation influences are important influences to consider on an individual or subgroup level. They are less important when one investigates population-level differences in child and adolescent mental health. Literature on cross-cultural psychology and psychiatry distinguishes among three different approaches toward the importance and role of culture.3 First, researchers with an absolutist orientation assume that biologic factors underlying behavior are most important and cultural factors
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have only limited influence on mental health outcomes. An absolutist orientation defines behavior and child mental health as context independent. Researchers with this approach define and develop their methods as culturally independent. Based on this assumption, methods and research instruments can be standardized and applied in any environment without adaptations. Second, a relativist orientation reflects a strong focus on environmental or cultural factors underlying human behavior. Observed differences between populations are caused by significant cultural differences. Researchers who use this approach derive methods within cultural concepts and norms and investigate child and adolescent mental health usually only within specific populations. From a relativist standpoint, there is no context-independent understanding of human behavior. Generalizations on factors that influence child mental health cannot be derived. Third, investigators with a universalist position integrate biologic or genetic and cultural or environmental factors into their concepts on human behavior. They assume universal, generalizable basic features of development and mental health; however, observable behavior is considered to be influenced by culture. Universalists' models on human development try to integrate processes and interactions between biology and environment as the most significant influencing factors. Based on this approach, concepts of mental health mostly cannot be context free, although generalized aspects of underlying mechanisms of risk, protective, and resilience factors might be defined. This universalist approach is the one most often chosen in recent investigations on child mental health. Unfortunately, the specifics of these concepts are usually not described or discussed in published research. Another way to define one's position toward the cultural groups to be investigated is to distinguish between etic and emic viewpoints. An investigator with an emic approach assumes concepts to be valid limited to cultural boundaries. 3 ' 29 Cross-cultural comparisons between projects based on emic viewpoints would have only descriptive nature and theoretically could not lead to any generalizations. Using the three categories described previously, a relativist would be considered as using an eminic viewpoint. On the other hand, any true comparisons of child mental health across cultures are based on an etic assumption. Using this approach, concepts of mental health and corresponding methodologies are assumed to be valid within and across cultures. 3, 29 Berry3 describes that absolutists, who consider biologic and genetic factors most important for observed differences in child development and mental health, are using an imposed etic approach. Universalists, who integrate biologic and environmental factors into their models, would need to derive their etic assumptions through adapting methods and concepts to different cultural environments and through distinguishing generalizable and culture-specific factors (derived etic). Unfortunately, investigators usually do not describe and discuss
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their definition and approach toward culture. Most researchers seem to assume that at least some cultural factors are important enough to be controlled for, and they often test whether instruments used in crosscultural or cross-national research must be adapted for the different cultural or subcultural environments. The theoretical and methodologic work required to fulfill the assumptions of this universalist and derived etic approach, however, is challenging. As is discussed in the next section, international and cross-cultural research methods and practice only started to take their first steps in this direction during the past decade.
TRANSLATION AND TESTING OF CROSS-CULTURAL EQUIVALENCE OF MEASURES
Several authors listed methodologic recommendations for crosscultural psychiatric research. 3• 4• 7• 16 • 24 These recommendations include instrument development and translation and testing of psychometric properties in each culture. Flaherty et aF suggest a stepwise validation for cultural equivalence of measures. Only by achieving equivalence in the five different dimensions can an instrument be considered crossculturally equivalent.
Cross-cultural Equivalence of Measures;
1. 2. 3. 4. 5.
Content equivalence Semantic equivalence Technical equivalence Criterion equivalence Conceptual equivalence
The following discussion describes the concept of these five dimensions of cross-cultural equivalence and discusses the methods that are necessary to test or achieve optimal equivalence in these dimensions. Content equivalence is achieved if each item is significant for the assessed phenomena in each culture. This can be achieved through discussions on the relevance of items in culture-specific expert panels or focus groups. 4 In research on child mental health, it is mostly unrecognized that the children and adolescents themselves can contribute significantly as experts on concepts and contents of measures.17 Within the possible quantitative approaches to test for content equivalence and content validity, factor analysis is the most often used method in crosscultural psychiatric research. Within each population, hypothesized or factor analytically developed structures of scales can be tested. The
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corresponding grouping of items or composition of scales then can be compared among the different cultural groups. Symptom scales, as for the Child Behavior Checklist (CBBCL),2 have been derived empirically through factor-analytic approaches. Comparisons of factor analytically derived scales among different cultural groups are most often described as cross-cultural validation approaches in published research. 1• 25 Equivalence of factor structure does not guarantee that true content validity within populations and content equivalence is achieved, however. As is shown later, results from factor analysis are used not only to support validity and equivalence of content but also to test and compare concepts. The previously described qualitative approach to develop and compare culturally specific pools of significant items, which would be crucial to achieving content validity and equivalence, is extensively missing in published work. Reviewed cross-cultural research often satisfies the following two dimensions of measure equivalence. Semantic equivalence of measures is achieved using translationback-translation methods. Bird4 suggested combining the more mechanical translation-back-translation processes with panels of experts who are familiar with both cultures to guarantee a higher level of idiomatic equivalence of items. Technical equivalence is achieved easily by using the same method of assessment, for example, interview (instead of questionnaire) in both cultures. Paper-and-pencil methods are more often problematic in crosscultural research. The observed results are at risk of being biased significantly by differences in literacy levels. Criterion equivalence is achieved if the threshold to endorse an item is the same for each cultural group. This process requires gathering knowledge on population norms of behavior or psychologic symptoms. Information from ethnographic research can contribute to understanding similarities or differences in these norms. The already mentioned focus groups with experts (professionals) and groups with children and adolescents or parents are valuable additional qualitative methods to investigate norms and test and achieve criterion equivalence. Conceptual equivalence is achieved if the measure assesses the same theoretical construct in each culture. This process requires a major theoretical step, namely, to define and model the underlying construct and corresponding hypotheses in each culture and to compare these across cultures. Quantitative approaches are able to test conceptual equivalence only indirectly.7 Conceptual validity in both cultures can be supported by equivalent item composition and interitem correlation, item functioning and scale structure, and external validation of the measure. The latter supports conceptual equivalence if both cultures reveal similar correlation between the measure and other known related constructs. Equivalence of item composition and structure is tested through factor-analytic approaches such as principal component analysis 10• 25 or structural equation modeling.11 Item response models such as Rasch
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models allow for testing and comparing not only the composition and structure of scales but also the differential functioning of singular items. This technique is well established for ensuring measurement equivalence in psychologic research, and it has been used recently as part of international approaches to validate translated scales in psychiatric epidemiology.6, 3, 18 Overall, validity within cultures and equivalence across cultures is best approached through a combination of multiple qualitative and quantitative analytic techniques. 8 MODELING CULTURAL FACTORS AND MENTAL HEALTH
A scientific model that includes cultural factors and child mental health outcomes can be developed only after defining importance and concept of culture, Weisz et al suggested two major models repeatedly in the literature, 27- 29 The problem-suppression model2°, 28 , 29 suggests that cultural factors influence child behavior and development of mental disorders directly, As demonstrated in Figure 1, this model assumes an individual level relationship between culture and child mental health. Development and mental health are shaped by the child's experience of cultural norms, which support acceptable and suppress unacceptable behavior, A second suggested model, the adult-distress threshold model, assumes a major effect of culture on adults' experience and beliefs regarding children and on adults' corresponding responses to perceived distressful child behavior.20 ' 27- 29 Figure 1 shows that this model's focus is
Personality Self Resilience
~
I\
~
b ~ /fr ~He_alth~ Mental
Adult: - Perception/Experience - Distress ·Parenting
Figure 1. Modeling culture and child mental health . 1 = Pathway of problem-suppression model; 2 = pathway of adult-distress-threshold model.
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on cultural factors and influences on an environmental level. The child is only indirectly influenced by culture through the environment's perception (family, school, other institutions and other adults, peers) and reactions (conditioned by culture-specific threshold of distress). Both of these models focus primarily on cultural norms and values. This is based on a culture as a set of conditions concept (see previous discussion). Because the child's behavior and mental health are a reflection of cultural norms and values, differences in child behavior and development of mental disorders can be best understood by assessing cultural norms and their effect in different cultural groups. The adultdistress-threshold model demonstrates the importance of adult (parent, teacher) perception of child behavior for cross-cultural research. Culture has an influence on parent's perception, which influences the child's development and mental health. Culture also influences the difference between self-reports and parent reports of child mental health. 14 Scientific models should try to incorporate cultural factors on individual and group levels and as related (correlated) variables of other known risk, protective, and resilience factors on child mental health. Research models should guarantee that effects of cultural factors are controlled for informant, age, and gender. The problem-suppression and adult-distress threshold models ignore culture as determining personality or self and the development of coping strategies. 16 As demonstrated in Figure 1, transgenerationally transmitted effects of culture on the development of resilience and specific coping strategies should be considered and investigated further. If theoretical concepts of culture are investigated and specified, corresponding research models will incorporate all the different levels of dependence between culture and environment, individual development, behavior, and personality or self. 16 EXAMPLES OF CROSS-CULTURAL RESEARCH
Cross-cultural investigations of adult psychopathology have a much longer history. The largest international research projects, especially by World Health Organization (WHO), focused on depressive and psychotic disorders. 16 Authors of these studies, which used standardized instruments, ended in a discourse between conclusions either focusing more on the universal biology-related aspects of disorders or more on the observed considerable variation of symptoms, course, and disorder outcome across cultures. The controversial results of these earlier studies suggested methodologic limitations. Only through improvements, especially in translation and equivalence of measures, could bias be disentangled from true cross-cultural differences. Certain evidence of cultural determination and experience of disorders could not be rejected, however. For depressive disorders, some investigators suggested culturally dependent preference of either somatization or cognitization of distress. 12• 16 Even less cross-cultural research has been conducted on child and
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adolescent mental health.4• 5• 20 The CBCL is the most widely translated instrument in child mental health research. 23 Child, parent, and teacher forms have been tested within and across multiple cultures.4• 20• 24• 26• 27 Research using the CBCL has been most influential toward empirically developed taxonomy, using a given basic set of items, and developing age- and gender-specific scales.2 Multiple cross-national studies developed and compared empirically derived syndromes1• 13• 22• 29 through factor or principal component analysis. Although only a limited range of countries and cultures have been investigated, it is possible to conclude that in several studies factor patterns, if controlled for informant, age, gender, and socioeconomic status, are often strikingly similar and might reveal certain universal aspects of child mental health. More recent studies seem to demonstrate even fewer differences in experience and prevalence of child mental health problems across cultures. For example, the Western expectation of men showing more externalizing behavior problems has been found in non-Western societies.9 As Weisz et al29 noted, however, the cross-cultural validity of syndromes in child psychopathology is far from having been investigated in depth. There are several limitations in past research on CBCL. Validation studies usually did not go beyond testing translation (semantic validity) through translation-back-translation methods and content and construct validity through factor analytic approaches. Most comparisons were conducted with US populations as a reference. 4 Scale development for translated measures also has been limited to the basic pool items developed within US populations. OUTLOOK
There is widespread consensus regarding the need for more international and cross-cultural studies on child mental health. Most published research findings, independent of whether they support cultural differences or universal patterns in child mental health, cannot persist if the applied methods are analyzed critically. These past limitations of crosscultural research methods in child mental health reflect the complexity of the concept of culture and the difficulty to test its entire direct and indirect multiple level effects on child development. Even if cross-national research advanced during the past two decades in its standards of translation and validation of measures, findings are far from being conclusive. Through increased international collaborations, instruments in child psychiatric research are more often translated, and data based on research projects using the methods are more easily available for cross-cultural comparisons. As the previous examples demonstrated, conclusions from these comparisons are based on the assumption that the translated instruments are equivalent, that unassessed sociocultural factors are not important, or that all influencing factors have been assessed. The latter is never the case, however, and all possible biases through limitations in methods
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should be discussed before arriving at conclusions of either true crosscultural differences or true universality of aspects in child mental health. Investigators often do not take into consideration the high probability that multiple unknown or unassessed variables contributed to some of the observed differences. Higher number of subjects in two environments or an integration of data from multiple studies through metaanalysis usually increases accuracy of statistical testing. As Berry et al3 pointed out, however, the likelihood of wrongly rejecting the null hypothesis (type I error) increases with expansion of data given when there are significant nonassessed factors that contribute to between-group differences. It must be assumed that this is often the case on cross-cultural studies. Malpass and Poortinga15 even suggested that the high probability of erroneously detecting differences between cultures questions the validity of cross-cultural research results. They conclude that alternative explanations for observed differences between cultures should be excluded empirically before accepting true crosscultural differences. A review of the literature suggests that future work should focus mainly on the improvement of earlier steps in research projects to ease the difficulty of adequately interpreting later findings. As has been discussed in this article, culture is mostly not conceptualized and operationalized in published works, and other population-level entities are often used inaccurately to indicate culture. Populations in industrialized and developing countries are affected significantly by migration and increased global communication of multiple cultural artifacts and values. The already difficult to grasp multidimensional concept of culture might become more complex within these changes. This leads to an even more pronounced need for researchers in the field of child mental health to understand and define a concept of culture and to operationalize child development and mental health in its context. Cross-cultural research on child mental health is still in its early childhood years, and much work must be done to develop more comprehensive research models and corresponding methods. For the theoretical work and for the development and testing of methods, more truly multidisciplinary approaches are needed. As long as researchers are not able to compare, discuss, and integrate theories and methods across research specialties, little significant success can be expected in cross-cultural work. Through the development of more mixed-method approaches using qualitative and quantitative methods, researchers might be able to reach more conclusive results in the future. Another needed step might be to lessen to some degree the inflexible, unchangeable nature of measures that are only translated, copied, or shortened but never adapted and improved through cross-cultural research. Continuous improvement of instruments can be achieved through its testing in different environments and corresponding adaptations of the original measure. Results from different cultural environments, including results on the primarily selected items and suggestions
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for adding new items, lead to stepwise changes and improvements in the original measure. Only by putting efforts into improving research approaches and methods on all the described levels can more information from crossnational and cross-cultural comparisons on child development and mental health be achieved. A clear conceptualization and operationalization of culture and validity and equivalence of methods are needed for future projects. Significant advances in interdisciplinary international research are needed to increase understanding of perception and norms of behavior and how risk, protective, and resilience factors are influencing child development and mental health in different cultural environments. References 1. Achenbach T, Verhulst F, Baron G, et al: A comparison of syndromes derived from the Child Behavior Checklist for American and Dutch boys aged 6-11 and 12-16. J Child Psycho! Psychiatry 28:437-453, 1987 2. Achenbach T: Manual for the Child Behavior Checklist/4-18 and 1991 profile. Burlington, University of Vermont, 1991 3. Berry J, Poortinga Y, Segall M, et al: Cross-cultural Psychology: Research and Applications. Cambridge, UK, Cambridge University Press, 1992 4. Bird H: Epidemiology of childhood disorders in a cross-cultural context. J Child Psycho! Psychiatry 37:35-49, 1996 5. Cederblad M: Behavioral disorders in children from different cultures. Acta Psychiatr Scand 78:85-92, 1988 6. Ellis B, Kimmel H: Identification of unique cultural response patterns by means of Item Response Theory. J Appl Psycho! 77:177-184, 1992 7. Flaherty J, Moises Gaviria F, Pathak D, et al: Developing instruments for cross-cultural psychiatric research. J Nerv Ment Dis 176:257-263, 1988 8. Gandek B, Ware J: Methods for validating and norming translations of health status questionnaires: The IQOLA Project approach. J Clin Epidemiol 51:953-959, 1998 9. Hackett R, Hackett L: Child psychiatry across cultures. Int Rev Psychiatry 11:225-235, 1999 10. Harman H: Modern Factor Analysis, ed 3 (revised). Chicago, University of Chicago Press, 1976 11. Keller S, Ware J, Bentler P, et al: Use of structural equation modeling to test the construct validity of the SF-36 Health Survey in ten countries: Results from the IQOLA project. J Clin Epidemiol 51:1179-1188, 1998 12. Kleinman A: Depression and neurasthenia in the People's Republic of China. Cult Med Psychiatry 6:1-80, 1982 13. Koot H, Van Den Oord J, Verhulst F, et al: Behavioral and emotional problems in young preschoolers: Cross-cultural testing of the validity of the Child Behavior Checklist/2- 3. J Abnorm Child Psycho! 25:183-196, 1997 14. Kuo M, Mohler B, Raudenbush S, et al: Assessing exposure to violence using multiple informations: Application of Hierarchical Linear Model. J Psycho! Psychiatry 41:10491056, 2000 15. Malpass R, Poortinga Y: Strategies for design and analysis. In Lonner W, Berry J (eds): Field Methods in Cross-cultural Research. Beverly Hills, Sage, 1986, pp 47-84 16. Marsella A: Cross-cultural research on severe mental disorders: Issues and findings. Acta Psychiatr Scand 78:7- 22, 1988 17. Mohler B, Earls F: Translation and cultural adaptation of an instrument on exposure to violence. Presented at the 14th Internation al Congress of the International Association of Child and Adolescent Psychiatry and Allied Professions. Stockholm, Sweden, August 2- 6, 1998
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18. Radzek A, Ware J, Bjomer J, et al: Comparison of Rasch and summated rating scales constructed from SF-36 physical functioning items in seven countries: Results from the IQOLA project. J Clin Epidemiol 51:1203-1214, 1998 19. Rogler L: The meaning of culturally sensitive research in mental health. Am J Psychiatry 146:296-303, 1989 20. Rousseau C, Drapeau A: Parent-child agreement on refugee children's psychiatric symptoms: A transcultural perspective. J Am Acad Child Adolesc Psychiatry 37:629636, 1998 21. Suarez-Orozco C, Suarez-Orozco M: Transformations: Immigration, Family Life, and Achievement Motivation among Latino Adolescents. Stanford, Stanford University Press, 1995 22. Verhulst F, Achenbach T, Althaus M, et al: A comparison of syndromes derived from the Child Behavior Checklist for American and Dutch girls aged 6-11 and 12- 16. J Child Psycho! Psychiatry 29:879-895, 1988 23. Verhulst F, Koot H: Child Psychiatric Epidemiology: Concepts, Methods, and Findings. Newbury Park, CA, Sage, 1992 24. Verhulst F, Achenbach T: Empirically based assessment and taxonomy of psychopathology: Cross-cultural applications. Eur Child Adolesc Psychiatry 4:61- 76, 1995 25. Ware J, Kosinski M, Gandek B, et al: The factor structure of the SF-36 Health Survey in 10 countries: Results from the IQOLA Project. J Clin Epidemiol 51:1159-1165, 1998 26. Weisz J, Suwanlert S, Chaiyasit W, et al: Over- and undercontrolled referral problems among children and adolescents from Thailand and the United States: The Wat and Wai of cultural differences. J Consult Clin Psycho! 55:719-726, 1987 27. Weisz J, Suwanlert S, Chaiyasit W, et al: Thai and American perspectives on overand undercontrolled child behavior problems: Exploring the Threshold Model among parents, teachers, and psychologists. J Consult Clin Psycho! 56:601-609, 1988 28. Weisz J, Suwanlert S, Chaiyasit W, et al: Epidemiology of behavioral and emotional problems among Thai and American children: Teacher reports for ages 6-11. J Child Psycho! Psychiatry 30:471-484, 1989 29. Weisz J, Eastman K: Cross-national research on child and adolescent psychopathology. In Verhulst F, Kooot H (eds): The Epidemiology of Child and Adolescent Psychopathology. Oxford, Oxford University Press, 1995, pp 442-65 30. Westermeyer J: National differences in psychiatric morbidity: Methodological issues, scientific interpretations and social implications. Acta Psychiatr Scand 78:23-31, 1988 Address reprint requests to
Beat Mohler, MD, MPH Department of Maternal and Child Health Harvard School of Public Health 677 Huntington Avenue Boston, MA 02115