Kaohsiung J Med Sci November 2006 • Vol 22 • No 11 560
Previous studies have indicated that aboriginal adoles-cents experience more serious mental health problems than do adolescents living in the general population [1,2]. Aboriginal adolescents were found to demon-strate high rates of suicide compared to the statistical norm [3], feelings of sadness and hopelessness [4], recreational use of both licit and illicit substances [5], and disorderly conduct and aggressive behavior [1,6]. Multiple factors, including racial discrimination and
growing up under particularly stressful circumstances may lead to mental health problems among aborigi-nal adolescents [1], although the label of an ethnicity must be examined in conjunction with the subject’s socioeconomic status in order to take real lifestyle differences into account [7]. The aboriginal population of Taiwan is generally in regions in which deficien-cies in economic and social opportunities may increase the level of stress in their daily lives, such that the lives of many aboriginal adolescents are often plagued by such stressors [2]. It has previously been reported that an individual’s development, when examined, should be analyzed in the context of the cultural and/or societal mores of the time [8], and that such a frame-work is also applicable to the conduct of research on the psychopathology of such an individual, the Received: November 4, 2005 Accepted: August 22, 2006
Address correspondence and reprint requests to: Dr Mei-Sang Yang, School of Nursing, Kaohsiung Medical University, 100 Shih-Chuan 1stRoad, Kaohsiung 807, Taiwan.
E-mail: [email protected]
P
SYCHOPATHOLOGY OF
A
BORIGINAL AND
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BORIGINAL
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DOLESCENTS
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IVING IN THE
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OUNTAINOUS
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EGION OF
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OUTHERN
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AIWAN
Cheng-Fang Yen,1,2Chia-Chuang Hsu,3Shu-Chun Liu,1Chi-Fen Huang,1and Mei-Sang Yang4
1Department of Psychiatry, College of Medicine, and 4School of Nursing, Kaohsiung Medical
University, 2Department of Psychiatry, Kaohsiung Medical University Hospital, and
3Department of Psychiatry, Zuoying Armed Forces Hospital, Kaohsiung, Taiwan.
The aim of this study was to examine the hypothesis that Taiwanese aboriginal adolescents feature more severe psychopathology than non-aboriginal adolescents who live in the same mountainous region of southern Taiwan, and to test the hypothesis by controlling other individual and environ-mental factors. In this study, a total of 251 aboriginal and 79 non-aboriginal Taiwanese adolescents were enrolled. Their psychopathology was measured by the Symptom Checklist-90-Revised Scale; demographic and family characteristics, and their affinity with their peer group and with their school were also assessed. The results of the multiple regression analysis revealed that aboriginal adolescents feature more severe psychopathology than non-aboriginal adolescents, and indicated that females and adolescents perceiving higher levels of family conflict and lower family support were more likely to experience more severe psychopathology than those perceiving the contrary. Those who devise strategies to improve the mental health of adolescents living in impoverished regions must take into consideration their ethnicity, gender, and family context when devising such treatment strategies.
Key Words:aborigines, adolescent, psychopathology (Kaohsiung J Med Sci 2006;22:560–9)
results of much of which are influenced, to a great extent, by the macrolevel environment (e.g. medical, educational, and economic aspects). Thus, it would appear to be appropriate to examine the relationship between ethnicity and psychopathology by compar-ing the psychopathology of aboriginal adolescents with that of non-aboriginal analogs who live in the same geographical region.
Individual and environmental factors all contribute to the development of psychopathology among ado-lescents. Among the individual factors, female gender [9], older age [10], and a reduced level of religious belief [11] were associated with more severe psy-chopathology and/or problem behavior. Among envi-ronmental factors, family adversity, including low socioeconomic status, family disruption, family crim-inality, and poor family health have all been suggested to be responsible for increasing the risk of developing psychopathology among adolescents, while the pres-ence of family support has been reported to reduce the risk for an individual to internalize such symp-toms [6]. Feelings of connectedness to school were also significantly associated with adolescent emo-tional health [12]. Being able to discuss personal pro-blems with friends has been reported to be somewhat protective against attempting suicide among native adolescents [13]. When examining the association between ethnicity and psychopathology, it would appear appropriate for such confounding effects both individually and environmentally to be considered and controlled for.
The aboriginal minority group in Taiwan consists of 12 different tribes with a total population of around 456,000 individuals, representing approximately 2% of the population of Taiwan [14]. Most Taiwanese abo-rigines live in the central mountain regions and in the Eastern coastal valleys. In the process of industrializa-tion and economic development in Taiwan, the abo-riginal population has suffered a number of adverse impacts, in particular, being accorded an inferior socioeconomic status and suffering from the virtual destruction of the individual traditional tribal social organization. In general, the average household income of aborigines is far below that of the average for Taiwan farmers; their per capita income is lower than 50% of the population as a whole [15,16]. The health status of Taiwanese aborigines is also not as good as that of the rest of the Taiwanese population [17], with an average life expectancy 6–8 years shorter than that of
the general Taiwanese population [18]. The reduction of health disparities between Taiwanese aborigines and the general Taiwanese population constitutes a major national health objective.
Many aboriginal people have moved from their ancestral home to the cities in search of employ-ment opportunities, whereas a small number of non-aboriginal Taiwanese have moved to the mountainous regions of Taiwan in order to work in agriculture and related businesses. Such a social transformation pro-vides an opportunity to compare the psychopathol-ogy of aboriginal and non-aboriginal adolescents who live in the same mountainous regions characterized by poor economic and educational resources. The aim of this study was to examine the hypothesis that Taiwanese aboriginal adolescents feature more severe psychopathology than do non-aboriginal adolescents who live in the same mountainous region of southern Taiwan, and to test the hypothesis by controlling other individual and environmental factors.
M
ETHODSStudy sample
Adolescents from the three junior high schools in the study-selected mountainous region of Kaohsiung County in southern Taiwan were enrolled for partici-pation in this study. This mountain region is charac-terized by a rather low population density, generally inconvenient transportation and a general lack of medical resources. Adolescents in this region typi-cally live a very different lifestyle from those living in other more developed areas of Taiwan. There is no senior high school in this region, and those individu-als who want to continue their education after gradu-ating from junior high school have to make a long daily trip to attend a senior high school or move away from their hometown.
In April 2002, a total of 356 adolescents were attend-ing the three junior high schools that were contacted for participants for this study. First, we contacted the parents of the students in order to obtain consent for their children’s participation in this study. Following this, we explained the purpose and procedure of the study to the potentially participating adolescents in their classrooms and encouraged them to participate in the study. The study protocol was approved by the Institutional Review Board of Kaohsiung Medical
University. All subjects provided written informed consent prior to their participation in this study.
Assessment
Symptom Checklist-90-Revised Scale (90-R): The
SCL-90-R was designed for use as a descriptive measure of psychopathology [19]. The Chinese version of the SCL-90-R was used to measure the mental health status with a five-point rating scale ranging from “not at all” (0) to “extreme” (4) [20]. Its validity in assessing neurotic symptomatology of patients and psychopathology of adolescents in Taiwan has previously been established [20,21]. A higher total score on the SCL-90-R indicates that a subject has a poorer mental health status.
Adolescent Family and Social Life Questionnaire (AFSLQ): This study used five four-point subscales in
the AFSLQ to evaluate adolescents’ levels of family conflict (four items), family support (three items), the proportion of peers who exhibit delinquent behavior (seven items) and who use substances (five items), and connectedness to school (four items) [22], with Cronbach’s α values of 0.65 and 0.85. Higher subscale scores indicate a more severe level of family conflict, a lower level of family support, lower connectedness to school, and a greater number of peers who exhibit delinquent behavior and who use substances. Delin-quent behaviors include the behaviors of aggression to people, destruction of property, deceitfulness or theft, and serious violations of rules. Substances refer to alcohol, tobacco, areca quid, sedatives/hypnotics, and all illicit drugs. The AFSLQ also assesses parents’ alcohol consumption, where consumption of alcohol three times or more per week is labeled as “regular alcohol consumption”.
Social Status Rating Scale (SSRS): The SSRS classifies
subjects’ social status into five classes according to their educational level and occupation [23]. For statistical purposes, classes I to IV were labeled as “high social status” and class V as “low social status”.
We also ascertained the salient sociodemographic factors, including gender, age, ethnicity, frequency of attending religious activities, parents’ marital status, and number of siblings.
Procedure and statistical analysis
We invited the adolescents to complete all ques-tionnaires based on the explanations of the questions as provided by the research assistants and under their direction. Those who refused participation in
certain/all aspects of the questionnaire were entitled to leave the blank questionnaires on their desk. All the par-ticipants received a gift at the end of the assessment.
The associations between psychopathology and ethnicity, gender, religious belief, disruptive parenting, socioeconomic status, and parents’ education and regular alcohol consumption were examined using Student’s t test. Correlations between psychopathol-ogy and age, number of siblings, level of family con-flict and support, and affinity toward peer group and to school were examined using Pearson’s correlation. The associations between psychopathology and the factors indicated as being significantly influential as suggested by the results of the t test and Pearson’s correlation were further examined by means of step-wise multiple linear regression analysis. The scores on the SCL-90-R subscales were further compared between aboriginal and non-aboriginal adolescents by Mann–Whitney U test. A p value of less than 0.05 was considered to be statistically significant.
R
ESULTSA total of 330 adolescents (92.7% of the initially selected 356 adolescents who attended the three junior high schools) completed all questionnaires and the inter-view. Those who were absent from class on the sched-uled day of their participation (n= 15), those who refused to participate in this study or whose parents refused to allow them to participate (n= 8), or those who were not fully able to comprehend the content of the interview due to a below-average mental function (n=3) were excluded from study participation. Accord-ing to school records, there was no difference in eth-nicity or gender between the groups who participated and those who did not participate.
Among the 330 adolescents included in this study, 251 adolescents (125 boys) had a mean age of 14.8± 1.0 years and were aborigines, and 79 (33 boys) had a mean age of 14.4± 1.2 years and were non-aborigines. No difference in gender was found be-tween the two groups (χ2=1.552, p > 0.05), although the
aboriginal group proved to be somewhat older than the non-aboriginal group (t=–2.859, p<0.01). Among them, 121 participants (36.7%) seldom attended reli-gious activities, 88 (26.7%) had disruptive parenting, and 298 (90.3%) came from low socioeconomic status families. Seventy-six (23.0%) participants’ fathers and
34 (10.3%) participants’ mothers had received more than 9 years of education, and 57 (17.3%) participants’ fathers drank alcohol regularly. The mean number of siblings was 4.2± 1.9. The mean scores of family con-flict and support were 2.0±0.4 and 2.4±0.6, respec-tively. The mean scores of affinity for peer group and school were 2.1± 0.5 and 2.0 ± 0.4, respectively.
The correlates of psychopathology among adoles-cents examined by t test and Pearson’s correlation are presented in Table 1. The results indicated that adolescents who were aboriginal, who were female, who perceived a greater level of family conflict, who reported that they experienced a lower level of family
support, and who featured a lower affinity toward their peer group, were more likely to feature a more severe level of psychopathology. Age, religious com-mitment, disruptive parenting, socioeconomic status, parents’ education and alcohol drinking behavior, number of siblings, and affinity for school were not associated with psychopathology.
Significant variables as revealed by the t test and Pearson’s correlation were further analyzed using stepwise multiple linear regression analysis. By con-trolling for other factors, aboriginal adolescents still showed a more severe level of psychopathology than their non-aboriginal peers (β=0.133, t=2.736, p < 0.01). Table 1.Association between psychopathology and ethnicity, demographic and family characteristics, and affinity for peer group and school
Psychopathology Mean (SD) t r Ethnicity −2.215* Aboriginal 77.5 (49.1) Non-aboriginal 62.8 (58.4) Gender 6.209† Male 56.7 (39.5) Female 89.8 (56.4)
Attends religious activities 0.620
Seldom 71.6 (54.5) Frequently 75.3 (50.2) Age 0.055 Family characteristics Disruptive parenting −1.244 Yes 79.8 (55.3) No 71.8 (50.3)
Low socioeconomic status 1.031
Yes 82.9 (56.5) No 73.0 (51.2) Father’s education 0.710 > 9 yr 77.7 (49.7) ≤ 9 yr 72.9 (52.4) Mother’s education 0.078 > 9 yr 72.6 (50.6) ≤ 9 yr 73.9 (51.9)
Parents drink alcohol regularly −0.571
Yes 77.5 (56.5)
No 73.2 (50.8)
Number of siblings 0.097
Family conflict 0.301†
Family support 0.256†
Affinity for peer group 0.111*
Affinity for school 0.082
Meanwhile, females (β = –0.281, t = –5.687, p < 0.001) and adolescents who perceived higher family conflict (β=0.239, t=4.857, p < 0.001) and lower family support (β = 0.209, t = 4.263, p < 0.001) were more likely to suf-fer more severe psychopathology. These four variables accounted for 22.2% of the variance. Affinity toward peer group did not prove to be any more significantly associated with adolescents’ psychopathology.
The scores on the SCL-90-R subscales were further compared between aboriginal and non-aboriginal ado-lescents (Table 2). Except for the “hostility” subscale, aboriginal adolescents had more severe psychopathol-ogy on all the SCL-90-R subscales than non-aboriginal ones. The association between psychopathology and demographic and family characteristics, and affinity for peer group and school were further examined regarding ethnicity (Table 3). Both aboriginal and non-aboriginal adolescents who were female, who per-ceived a greater level of family conflict, and who reported that they experienced a lower level of family support were more likely to feature a more severe level of psychopathology.
D
ISCUSSIONIn this study, we examined the association between ethnicity and psychopathology among the adolescent population living in a mountainous region character-ized by deficiencies in economic and educational opportunities, a scenario that has previously been suggested to increase adolescents’ distress and com-promise their mental health. The results of this study
indicated that, by controlling for specific individual and environmental factors, aboriginal adolescents do feature a more severe level of psychopathology than their non-aboriginal peers. This discrepancy may be partially accounted for by the suggestion that as a minority ethnic group in Taiwan, aboriginal people may be likely to encounter more disadvantages in their daily lives than non-aboriginal people. For exam-ple, their various native languages are losing ground, which may result in some difficulties as regards the preservation of their traditional values and also result in making communication between elders and youths even more difficult. Meanwhile, there have been some stereotyped, even prejudiced, opinions relating to Taiwanese aborigines that have spread, and continue to circulate, within the general Taiwanese population. For example, some people believe that aborigines demonstrate a greater proclivity toward alcoholism and are generally less industrious than their non-aboriginal analogs [24]. These rather unjust opini-ons may discourage aboriginal adolescents and negatively impact their morale. Because adolescent psychopathology is suggested to be predictive of poor adjustment in adulthood [25], the results of this study further support the notion that the mental health of aboriginal adolescents is an important issue for clinicians, mental health workers, and public health experts.
In line with the results of previous studies of Asian [10,26] and Western adolescent populations [27], this study also found that female adolescents experience more severe psychopathology than age-matched males. Hankin and Abramson proposed Table 2.Comparison of scores on the SCL-90-R subscales between aboriginal and non-aboriginal adolescents
Aboriginal Non-aboriginal Mean (SD) Mean (SD) Z* Somatization 0.734 (0.631) 0.588 (0.593) −2.192† Obsession–compulsion 1.054 (0.683) 0.863 (0.778) −2.758‡ Interpersonal sensitivity 0.988 (0.636) 0.831 (0.750) −2.598‡ Depression 0.841 (0.631) 0.617 (0.667) −3.623§ Anxiety 0.867 (0.676) 0.664 (0.741) −2.965‡ Hostility 0.924 (0.795) 0.884 (0.903) −1.060 Phobic anxiety 0.726 (0.711) 0.592 (0.742) −2.526† Paranoid ideation 0.823 (0.662) 0.665 (0.719) −2.466† Psychoticism 0.830 (0.636) 0.681 (0.752) −2.755‡ Others 0.841 (0.646) 0.673 (0.713) −2.785‡ *Mann–Whitney U test; †p< 0.05; ‡p< 0.01; §p< 0.001.
a developmentally sensitive, elaborate cognitive vulnerability–transactional stress model of depression to attempt to explain the emergence of a gender dif-ference in depression [28]. McCauley et al also sug-gested that self-competence is partially responsible for the emergence of gender differences in depression and anxiety during early adolescence [9]. In Taiwan, it would appear to be fair to say that female adoles-cents are often suppressed by the stereotyped opin-ions toward traditional gender roles. For example, females may be asked to do more housework than their male siblings and to conduct their lives in a way commensurate with traditional beliefs as to “what
girls should do”. Meanwhile, they may also suffer from the stress of attempting to match public values/ expectations as regards feminine “beauty”, such that all these factors may contribute to a gender difference in mental health. Except for the gender role social-ization, biologic changes associated with puberty, cognitive coping styles, family support, and parent-ing style may also explain the gender differences in psychopathology [29].
Adolescent development is reported to be the result of multisystematic interaction [30]. Our study found that high family conflict and low family support were associated with a more severe level of psychopathology Table 3.Association between psychopathology and ethnicity, demographic and family characteristics, and affinity for peer group and school in aboriginal and non-aboriginal adolescents
Psychopathology Aborigines Non-aborigines Mean (SD) t r Mean (SD) t r Gender 5.746* 3.046† Male 60.7 (38.5) 41.8 (40.6) Female 94.2 (52.8) 77.9 (64.6)
Attends religious activities 0.148 −0.405
Seldom 78.4 (49.5) 61.5 (53.7) Frequently 77.3 (49.5) 70.3 (53.6) Age 0.118 −0.161 Family characteristics Disruptive parenting −0.707 −1.139 Yes 81.1 (52.8) 75.6 (64.4) No 76.2 (47.7) 58.5 (56.1)
Low socioeconomic status 0.671 0.712
Yes 76.7 (48.0) 62.8 (58.4) No 82.9 (56.5) 64.3 (55.4) Father’s education 0.510 −0.288 > 9 yr 80.1 (50.4) 57.1 (40.5) ≤ 9 yr 76.5 (48.7) 63.4 (60.2) Mother’s education 0.469 −0.547 > 9 yr 82.0 (55.9) 57.0 (30.3) ≤ 9 yr 77.0 (48.4) 63.6 (61.5)
Parents drink alcohol regularly 0.300 −1.539
Yes 75.4 (52.8) 83.5 (67.5)
No 77.9 (48.4) 57.9 (55.5)
Number of siblings 0.066 0.097
Family conflict 0.280* 0.364†
Family support 0.268* 0.226‡
Affinity for peer group 0.095 0.196
Affinity for school 0.082 0.155
among Taiwanese adolescents. From the view of adolescent development, for an individual to construct an emancipated identity is a major task during the period of adolescence [31]. Moderate conflict between parents and adolescents is viewed as a process that fosters adaptive forms of change within parent– adolescent relationships, and conflict encourages par-ents and adolescpar-ents to revise their expectations and renegotiate autonomy, without fundamentally chang-ing their feelchang-ings of bechang-ing connected to each other [32]. However, conflict requires intuitive or intentional forms of management to keep the frequency and sever-ity of this process at moderate levels. Escalating con-flict in terms of frequency and severity often becomes a central feature of troubled parent–youth relation-ships that leads to poor mental health and greater involvement in deviant behavior by the youth [33]. Families maintain a strong influence on adolescents, and adolescents turn to their families in times of need and ask parents for advice. Family closeness and attach-ment are major factors in predicting adolescents’ adjustment and service as a buffer against engaging in unhealthy behaviors [34]. High family conflict and low family support may decrease an adolescent’s will to look for support for their life difficulties from their parents and, thus, increase the difficulties in such individuals’ daily lives, a problem which may further impair their mental health. Although this study found significant correlations between psychopathology and family conflict and support in adolescents, the r values for these associations were small, which indicates weak correlations between variables. This might have been due to the small sample size in this study.
Older age [10], a lower level of religious commit-ment [11], disrupted parenting [35], low socioeco-nomic status [36], parents’ substance use [36], and low connectedness to school [12] have previously been reported to be associated with more severe psycho-pathology or problem-behaviour patterns among ado-lescents. Such variables, however, were not found to be associated with severity of psychopathology in this study, which suggests that the individual and environmental correlates of psychopathology may vary widely among different adolescent populations. Research has indicated that adolescents are at greatest risk for divorce-related problems both during the di-vorce crisis and for a time after their parents separate, with significant recovery occurring for the majority of youth by 1–2 years after the separation [37]. In this
study, the adolescents’ mean age at the time of their parents’ divorce was 8.4±4.1 years, which may par-tially explain why no association was found between disrupted parenting and psychopathology in this study. Meanwhile, external support outside the fam-ily may function as role models and sources of guid-ance. For example, some ethnic minority families (e.g. African American families) have long-standing tradi-tions of providing external support for single-parent families, and external family relatives may become important sources of support and guidance for the youth [38]. In Taiwan, children whose parents are divorced often grow up in the care of their grandpar-ents, together with other family members such as aunts or uncles. It may be that the fundamental mod-ification in family structure resulting from divorce may result in similar family caring for adolescents as was the case prior to parental separation, and thus reduce the negative impact of disruptive parenting on adolescents’ mental health.
Some potential limitations of this study should be considered. First, the cross-sectional nature of this study limited our ability to draw meaningful conclu-sions relating to the causal relationship between psy-chopathology and family factors, including family conflict and support. Second, we examined only ado-lescents’ psychopathology on the SCL-90-R in the preceding week, but did not examine their psychi-atric disorders by structured diagnostic interviews. Third, this study did not examine the psychopathol-ogy of adolescents who lived in the same mountain-ous region as that which was investigated who dropped out of school, although this proportion appeared to have been fairly small according to the available school records. Fourth, despite examination of various individual and environmental factors, some factors that may affect aboriginal adolescents’ mental health, for example, acculturation, were not examined in this study. Finally, further studies are needed to examine whether or not the results of this study can be generalized to other adolescent popula-tions living in other mountainous areas in Taiwan.
R
EFERENCES1. Beals J, Piasecki J, Nelson S, et al. Psychiatric disorder among American Indian adolescents: prevalence in Northern Plains youth. J Am Acad Child Adolesc
2. Duclos CW, Beals J, Novins DK, et al. Prevalence of common psychiatric disorders among American Indian adolescent detainees. J Am Acad Child Adolesc Psychiatry 1998;37:866–73.
3. May PA. Suicide and self-destruction among American Indian youths. Am Indian Alsk Native Ment Health Res 1987;1:52–69.
4. Blum RW, Harmon B, Harris L, et al. American Indian— Alaska Native youth health. JAMA 1992;267:1637–44. 5. Beauvais F, Jumper-Thurman P, Helm H, et al.
Sur-veillance of drug use among American Indian adoles-cents: patterns over 25 years. J Adolesc Health 2004;34: 493–500.
6. Goebert D, Nahulu L, Hishinuma E, et al. Cumulative effect of family environment on psychiatric symptoma-tology among multiethnic adolescents. J Adolesc Health 2000;27:34–42.
7. Collins RL. Issues of ethnicity in research on preven-tion of substance abuse. In: Botvin GJ, Schinke S, Orlandi MA, eds. Drug and Alcohol Use Prevention
with Multiethnic Youth. Thousand Oaks, CA: Sage, 1995:
28–54.
8. Brofenbrenner U. Ecology of the family as a context for human development: research perspectives. Dev Psychol 1986;22:723–42.
9. McCauley Ohannessian C, Lerner RM, Lerner JV, et al. Does self-competence predict gender differences in adolescent depression and anxiety? J Adolesc 1999;22: 397–411.
10. Kim YH. Correlation of mental health problems with psychological constructs in adolescence: final results from a 2-year study. Int J Nurs Stud 2003;40:115–24. 11. Jessor R. Problem behavior theory, psychosocial
devel-opment, and adolescent problem drinking. Br J Addict 1987;82:331–42.
12. Cummins JR, Ireland M, Resnick MD, et al. Correlates of physical and emotional health among Native American adolescents. J Adoles Health 1999;24:38–44. 13. Borowsky IW, Resnick MD, Ireland M, et al. Suicide
attempts among American Indian and Alaska Native youth: risk and protective factors. Arch Pediatr Adolesc
Med 1999;153:573–80.
14. Ministry of the Interior. Monthly Bulletin of Interior
Statistics, Republic of China. Taipei, Executive Yuan,
Taiwan, 2005. [In Chinese]
15. Council of Indigenous People. Employment in Taiwanese
Indigenous People in 2004. Taipei, Executive Yuan, Taiwan,
2004. [In Chinese]
16. Directorate-General of Budget, Accounting and Statis-tics. Quarterly National Economic Trends, Taiwan Area,
Republic of China. Taipei: Executive Yuan, Taiwan, 2005.
[In Chinese]
17. Ko YC, Liu BH, Hsieh SF. Issues on aboriginal health in Taiwan. Kaohsiung J Med Sci 1994;10:337–51.
18. Council of Indigenous People. Statistics of Health in
Taiwanese Indigenous People. Taipei: Executive Yuan,
Taiwan, 2004. [In Chinese]
19. Derogatis LR, Lipman RS, Covi L. SCL-90: an outpa-tient psychiatric rating scale-preliminary report.
Psycho-pharmacol Bull 1973;9:13–28.
20. Tsai MT, Wen JK, Lin HN, et al. Application of self-rating symptom scales to psychiatric outpatients.
Bull Chin Soc Neurol Psychiatry 1978;4:13–22. [In
Chinese]
21. Hsu CC, Chong MY, Yang PC, et al. Earthquake and posttraumatic stress disorder among adolescent victims. J Am Acad Child Adolesc Psychiatry 2002;41: 875–81.
22. Yen CF, Shieh BL. Suicidal ideation and correlates in Taiwanese adolescent methamphetamine users. J Nerv
Ment Dis 2005;193:444–9.
23. Rin H, Schooler C, Caudill WA. Symptomatology and hospitalization. Culture, social structure and psycho-pathology in Taiwan and Japan. J Nerv Ment Dis 1973; 157:296–312.
24. Yeh MY. Exploring the effects of psychosocial and acculturation factors on drinking behavior among abo-riginal adolescents in Taiwan. Psychiatry Clin Neurosci 2004;58:453–9.
25. Hofstra MB, van der Ende J, Verhulst FC. Child and adolescent problems predict DSM-IV disorders in adulthood: a 14-year follow-up of a Dutch epidemio-logical sample. J Am Acad Child Adolesc Psychiatry 2002; 41:182–9.
26. Gau SSF, Chong MY, Chen THH, et al. A 3-year panel study of mental disorders among adolescents in Taiwan.
Am J Psychiatry 2005;162:1344–50.
27. Light H. Sex differences in indicators of well-being in adolescents. Psychol Rep 2000;87:531–3.
28. Hankin BL, Abramson LY. Development of gender differences in depression: an elaborated cognitive vulnerability–transactional stress theory. Psychol Bull 2001;127:773–96.
29. Roberts C, Bishop B. Depression, adolescents. In: Gullotta T, Bloom M, eds. Encyclopedia of Primary
Prevention and Health Promotion. New York: Kluwer
Academic/Plenum Press, 2003:403–10.
30. Lerner RM, Castellino DR. Contemporary develop-mental theory and adolescence: developdevelop-mental systems and applied developmental science. J Adoles Health 2002;31:122–35.
31. Gemelli R. Normal Child and Adolescent Development. Washington, DC: American Psychiatric Press, 1996. 32. Collins WA, Laursen B, Mortenson N, et al. Conflict
process and transitions in parent and peer relationships: implications for autonomy and regulation. J Adolec Res 1997;12:178–98.
33. Patterson GR, Capaldi DM. Antisocial parents: unskilled and vulnerable. In: Cowan PA, Hetherington EM, eds.
Family Transitions. Hillsdale, NJ: Lawrence Erlbaum
Associates, 1991:195–218.
34. Adams GR. Adolescent development. In: Gullotta TP, Adams GR, eds. Handbook of Adolescent Behavioral
35. Stoker A, Swadi H. Perceived family relationships in drug abusing adolescents. Drug Alcohol Depend 1990; 25:293–7.
36. Costello EJ, Farmer EM, Angold A, et al. Psychiatric disorders among American Indian and white youth in Appalachia: the Great Smoky Mountains Study. Am J
Public Health 1997;87:827–32.
37. Hetherington EM, Stanley-Hagan M. Parenting in divorced in remarried families. In: Bornstein MH, ed.
Handbook of Parenting, Volume 3: Being and Becoming a Parent, 2nd edition. Mahwah, NJ: Erlbaum, 2002:
287–315.
38. Hetherington EM, Kelly J. For Better or Worse: Divorce
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