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Research Article                                                                                                                                        Open Access

## Psychological Difficulties among Children and Adolescents with Ethnic Danish, Immigrant, and Refugee Backgrounds

Ingrid Leth 1* , Janni Niclasen 1 , Else Ryding 2 , Yasmine Baroud 3 , Barbara H. Esbjørn 1

1 Department of Psychology, University of Copenhagen, Denmark 2 OASIS Rehabilitation- and Treatment Centre for Traumatized Refugees, Denmark 3 Danish Refugee Council, Denmark

## *Corresponding author: Ingrid.leth@psy.ku.dk

## Abstract

Objective: This study investigated and compared the prevalence of psychological difficulties among Danish, immigrant, and refugee children.

Methods: We enrolled 332 children between the ages of 8 and 18 years (148 Danish children, 81 immigrant children, and 67 children with refugee backgrounds), all from low-income areas of residence. The Health Behaviour in School-aged Children Symptoms Checklist, the Strengths and Difficulties Questionnaire, and the Revised Children's Anxiety and Depression Scale were applied.

Results: We  found  significant  differences  among  the  groups,  with  Danish  children  reporting  lower  levels  of  conduct problems than both immigrant children (P < .01) and refugee children (P < .05). Refugee children also reported more peer problems (P < .05), more symptoms of obsessive-compulsive disorder (P < .01), and more separation anxiety symptoms (P < .05) than the Danish children. No significant differences with regard to age or gender were found among the groups.

Conclusions: Our  data  suggest  that,  although  immigrant  children  had  higher  levels  of  conduct  problems  than  ethnic Danish children, they did not suffer from higher levels of internalizing psychological difficulties. However, refugee children were at higher risk for psychological difficulties associated with both externalizing and internalizing.

Keywords: Mental health, refugee children, immigrant children, school children

## Introduction

Children  and  adolescents  with  immigrant  parents will,  in  some cultures, represent an ethnic minority group. Some will be descendants of parents who are labor immigrants, whereas other parents have refugee backgrounds and may have been traumatized by their previous experiences.  The effects of being a member of an ethnic minority and of having traumatized parents on the mental health of  children  have  been  examined  in  several  studies (1;2).  However,  these  studies  were  not  conclusive. Instead,  they  provided  a  mixed  picture,  with  some studies reporting an increased risk of mental health problems  among  displaced  and  refugee  children who  had  been  resettled  in  high-income  countries and others not suggesting such issues (3). Living in countries  that  are  characterized  as  being  ethnically homogeneous,  like  the  Nordic  countries,  can  be particularly challenging for youth from ethnic minority populations. The  prevalence of ethnic minorities  in  Denmark  is  approximately  10%,  and refugees constitute 20% of that group. In 2011, the refugee  population  in  Denmark  included  approximately 107,000 adults and children total (4).

## Mental health among children of immigrant parents

A large-scale study that enrolled more than 2000 11year-old  immigrant  and  ethnic  Dutch  children  was conducted  in  Holland  (5),  a  country  with  approximately the same percentage of immigrants as Denmark. The  study  included  measures  of  mental health  from  multiple  sources,  such  as  the  Youth Self-Report and the Child Behavior Checklist (6;7). The authors found discrepancies in reported difficulties  between  the  two  groups.  The  young respondents themselves did not report any differences  in  difficulty  levels,  whereas  immigrant parents  reported  that  their  daughters  had  more mental-health-related  internalizing  problems  than the  daughters  reported  themselves.  Furthermore, teachers reported higher levels of externalizing problems in both boys and girls among the immigrant  groups  than  among  the  ethnic  Dutch children.  This latter finding is  corroborated  by another study that found Turkish immigrant adolescents to have a significantly higher total rate of problems than Dutch adolescents (8).

Similar  tendencies  have  been  observed  among youth  samples  from  other  countries.  In  a  Turkish study that compared migrant children (having temporary  residence  in  Turkey)  with  non-migrant children,  Diler  and  colleagues  (9)  found  that  the migrant children had significantly lower self-esteem and  higher  levels  of  depression  and  anxiety.  By contrast, externalizing behavior was not significantly elevated in the migrant group. In a review of mental health among migrant children, Stevens and Vollebergh  (10)  stated  in  their  review  that  it  was difficult to draw any sound conclusions with respect to  these  children's  risk  of  mental  health  problems. Many confounding factors that may affect the risk of  children's  mental  health  are  mentioned  in  these studies, including the family's socioeconomic status and the parents' employment status and educational level.  In  addition, family stress often resulted from the fact that immigrant adolescents generally acculturate  to  the  values  of  the  new  society  faster than their parents do.

## Subjective health among children of immigrant parents

How children inform others about their well-being is often expressed in complaints about their subjective  health.  In  a  large  study  of  adolescents living  in  five  Nordic  countries,  subjective  health complaints, which may be conceived as a proxy for psychological and physical well-being, were applied to assess the young persons' subjective health (11). The  study  showed  that  adolescents  with  foreign backgrounds reported  significantly  higher  levels  of subjective  health  complaints  (e.g.,  headache,  back pain, stomach pain, loss of appetite, lower feeling of well-being)  as  compared  with  children  from  the majority  of  the  population.  Several  similar  studies have  also  been  conducted  in  Denmark.  A  recent study  found  immigrant  children  to  suffer  from more  health-related  problems  as  compared  with ethnic  Danish  children  (12).  This  study  included 7,056 students (age groups: 11 years, 37%; 13 years, 34%;  15  years,  29%)  and  addressed  both  physical and  mental-health-related  problems,  which  were referred  to  in  the  article  as  'nervous  symptoms.'

The youth were divided into three groups: immigrant (4%), descendants (7%), and ethnic Danes (89%). The outcomes demonstrated no significant differences in self-reported somatic health  complaints  among  the  three  groups  with regard to headache, stomachache,  or backache. However, 32% of the immigrant girls and 28% of the  immigrant  boys  reported  experiencing  nervous symptoms; these were a significantly higher prevalence  than  those  found  among  the  ethnic Danish girls and boys at 23% and 18%, respectively. These findings were supported by a Swedish study that  reported  higher  levels  of  subjective  healthrelated complaints among girls with foreign backgrounds, who from the seventh grade onward showed  an  increased risk for subjective health complaints  as  compared  with  girls  with  Swedish backgrounds (13).

## Mental health among children of refugees

Children  of  refugee  parents  may  be  perceived  as immigrants,  and  they  are  often  included  in  the groups  of  immigrants  in  studies  such  as  those described previously. However, it is highly possible that  parents  who  are  refugees  may  differ  from parents  who  have  immigrated  as  a  result  of  their own  choice  with  regard  to  mental-health-related problems (e.g.,  post-traumatic  stress,  lack  of  social network) and other important parameters that affect the upbringing of a child. Therefore, it is important to distinguish between the impact of being a member of an ethnic minority and that of having a refugee background on mental health; studies have been undertaken to address this distinction. According  to  a  review  conducted  by  Reed  and colleagues regarding the mental health of displaced and refugee children, protective effects include confounding  factors such as stable family life, education, and support received during the process of integration into local communities (14).

Although  the  literature  is  limited,  the  existing findings  indicate  that  being  a  refugee  or  being  the child of a refugee parent may increase an individual's risk of experiencing mental health problems  (15).  Leavey  and  colleagues  examined psychological disorders among refugee and migrant children  in  London  with  the  use  of  the  Strengths and  Difficulties  Questionnaire  (SDQ)  as  a  selfreport  measure  and  found  that  both  migrant  and refugee children expressed greater psychological distress on a number of the questionnaire's subscales (16). A British study of the mental health of  refugee  children  included  a  classmate  control group  that  consisted  of  both  ethnic  minority  and indigenous white children (17). The study applied a teacher-rated SDQ. Teachers rated refugee children as having higher levels of emotional difficulties than both of the control group populations.

## Gender  differences  with  regard  to  reported  mental  health among refugee children

In a review of 44 studies of refugee youth by Fazel and  colleagues,  boys  were  reported  to  experience higher levels of post-traumatic stress disorder symptoms as compared with girls (3). In half of the studies that enrolled both accompanied and unaccompanied refugee children, the prevalence of depression  and  internalizing  difficulties  was  higher among  girls  than  boys.  However,  the  remaining studies showed no gender-related effects. The overall conclusion presented by the review was that results  involving  gender  differences  in  relation  to mental health were inconsistent. Other studies also found depression and internalizing difficulties to be higher  among  girls  than  boys  (14).  Overall,  the differences  between  genders  follow  the  patterns found in the general population: emotional disorders  are  more  prevalent  among  females  than males and males are more susceptible to externalizing disorders than females (18). One explanation for the lack of firm conclusions within this topic may also be found in the heterogeneity of study  samples  and  the  applied  measurements  of mental health issues.

## Purpose of the study

Motivated by the lack of clarity in the literature with regard  to  the  effect  of  immigration  or  having  a refugee  background on mental health in the youth population, we examined mental health problems in three groups of youth between the ages of 8 and 18 years.  We  looked  at  three  groups:  1)  an  ethnic Danish group; 2) a group of children with a background as secondor third-generation immigrants;  and  3)  a  group  of  children  whose parents  were  refugees.  On  the  basis  of  previous findings,  we  hypothesized  that  immigrant  children and refugee children would have more somatic and psychological difficulties (both internalizing and externalizing) than children of Danish origin. Furthermore,  we  expected  refugee  children  to  be more  burdened  by  internalizing  mental  problems than immigrant children were.

## Methods

Sample

The total sample consisted of 332 children between 8  and  18  years  old.  Data  were  collected  from different  sources.  The  first  source  was  the  OASIS Treatment  and  Counselling  for  Refugees,  Copenhagen, Denmark. OASIS  contacted 51 refugee families with permanent residence in Denmark who had  been  referred  for  trauma  treatment  at  the center.  The  contact  was  established  by  mailing permission  forms  to  the  families  in  their  native language. The families were selected on the basis of their geographic  placement  (i.e., living within  a radius  of  approximately  50  km  from  Copenhagen) and on whether they had children between the ages of 11 and 16 years. The parents were asked to give written consent that allowed their children to fill out a  few  questionnaires  in  the  classrooms  at  their schools. Parents of 15 children allowed their children to participate. We included these children's classmates in the sample group that included immigrant, Danish, and other refugee children. The next  step  was  to  contact  the  children's  respective schools and obtain permission to perform the data collection in their classrooms. In addition to the 15 children  previously  described,  we  included  another group  of  refugee  children  from  identified  refugee countries in accordance with a formal list obtained from  the Danish  Foreign Ministry. Finally,  we compiled  data  from  children  who  attended  the 'homework cafés' run by the Red Cross in Denmark, which are exclusively frequented by immigrant  and  refugee  children.  These  children received  consent  forms  to  be  filled  out  by  their parents.  The  data  collection  was  carried  out  in Danish. In the classrooms, a teacher was present; in the  homework  cafés,  the  supervising  teacher  was present together with the researchers. The research project was described to the children, and they were free to ask questions about the questionnaires. The questionnaires  were  read  aloud  to  the  children  to secure their understanding. Children who had difficulty understanding the text could ask the researchers for assistance.

Outcome measures Strengths and Difficulties Questionnaire (19;20) :

The  youth  self-report  version  of  the  SDQ  was applied in the present study. This questionnaire has been found to have sound psychometric properties in both Westernized and non-Westernized countries (21-24).  It consists of 25 items that can be scored as  'Not  true,'  'Somewhat  true,'  and  'Certainly true.' The  items  are  scored  on  five  scales: 1) hyperactivity/inattention;  2)  conduct  disorder;  3) emotional problems; 4) peer problems; and 5) prosocial. Each of these scales contains five items; the hyperactivity/inattention and conduct disorder scales are combined into an externalizing scale, and the emotional and peer problems scales are combined  into an internalizing scale (25).  The children filled out the two-page version of the SDQ, but  it  turned  out  that  they  had  difficulty  reporting the impact of their symptoms (e.g., making conclusions  about  a  generalized  impact  from  the types and numbers of symptoms present). Therefore  only  the  answers  from  the  first  page  of the questionnaire have been analyzed.

## Revised Children's Anxiety and Depression Scale (26):

The  Revised  Children's  Anxiety  and  Depression Scale  (RCADS) consists of 47 items and measures (DSM-IV) symptoms of anxiety disorders and depression in children and adolescents. It is scored on a four-point scale (i.e., 0 = Never, 1 = Sometimes, 2 = Often, 3 = Always). It has satisfactory psychometric properties, with good internal consistency  and  adequate  reliability  and validity, and it has been tested in a Danish population (27). In the present study, the self-report child version of the RCADS was applied.

## Health Behavior in School-Aged Children Symptom Checklist (28-30):

The Health Behavior in School-Aged Children Symptom Checklist is an eight-item symptom checklist that assesses how often the young person has  suffered  from  different  physical  and  nervous symptoms within the past 6 months. Good psychometric properties have been found for both one- and two-factor solutions. The one-dimensional scoring  adds  up  to  a  total  health  complaint  score that  excludes  sleep  problems  (28).  The  two-factor solution  also  includes  a  three-item  psychological health complaint scale as well as a five-item somatic health  complaint  scale  (30).  Both  of  these  models have  been  included  as  outcome  measures  in  the present study.

## Statistical analyses

All analyses were carried out with the use of SPSS Statistics  software  (version  20.0).  The  total  sample consisted of 332 children. On the basis of information about their parents' migrant status, the children  were  classified  into  three  broad  groups. The  Danish  sample  included  children  with  two Danish  parents  (N  =  148);  the  immigrant  sample consisted  of  children  with  two  immigrant  parents (N = 81), whereas the refugee sample was comprised of children with two refugee parents (N = 67). Half of the immigrant group was made up of children  with  two  Turkish  parents  (N  =  41),  with other large ethnic groups including Pakistani children  (N  =  13)  and  Filipino  children  (N  =  7). Children of immigrants from Western countries (N = 7) and children of parents with different statuses (e.g., one immigrant parent and one refugee parent, one immigrant parent and one Danish parent) were excluded from all analyses (N = 24). Five children with  missing  values  for  their  countries  of  origin were also excluded from the analyses.

With  regard  to  the  refugee  children,  the  largest ethnic groups consisted of Iraqi children (N = 19), Afghan  children  (N  =  11),  and  children  from Palestine  (N  =  7).  The  remaining  groups  were composed  of  less  than  five  children  from  each nationality.

Because the distribution of SDQ scores has been found  to  be  skewed  (25),  the  internalizing  and externalizing scale scores were log transformed before they were used as continuous variables in the analysis  of  variance  probability  testing.  The  four problem scales (i.e., hyperactivity/inattention, conduct  disorder,  emotional  problems,  and  peer problems)  were  used  in  logistic  regressions,  with appropriate cutoffs used to identify the 20% of the sample with the highest problem scores.

## Results

## Demographic data

A  total of 296 children and adolescents were included in the study. They had a mean age of 13.2 years  (range,  8  to  16  years),  and  158  (53.3%)  were boys.  With  regard  to  language  use,  54.2%  of  the children  reported  speaking  Danish  only  at  home, whereas 19.4% reported that no Danish was spoken at  home.  Overall,  significant  age  differences  were observed among the three groups (Table 1); however, Bonferroni post hoc testing revealed that none of the intergroup comparisons were significant. No significant differences were observed among  the  groups  with  regard  to  gender,  but, expectedly,  large  differences  were  observed  with regard  to  language  use  among  the  groups.  The refugee group had the highest frequency of speaking non-Danish languages only (48.5%).

TABLE 1. Distribution of demographic variables for the total sample and for the Danish, immigrant, and refugee groups

|                                        | Total sample   | Danish     | Immigrant   | Refugee     | P value   |
|----------------------------------------|----------------|------------|-------------|-------------|-----------|
| N                                      | 296            | 148        | 81          | 67          |           |
| Age (mean and standard deviation)      | 13.1 (2.2)     | 13.5 (2.1) | 12.8 (2.3)  | 13.0 (2.3)  | .04       |
| Gender (male)                          | 53.5%          | 57.1%      | 53.1%       | 44.8%       | .25       |
| Language at home (%) Danish only       | 52.2% 26.4%    | 98.0% 2.0% | 17.3% 53.1% | 10.6% 40.9% | < .000    |
| Danish and another language Non-Danish | 19.4%          | 0.0%       | 29.6%       | 48.5%       |           |

Analysis  of  variance  for  the  mean  scores  and  chi-squared  probability  testing  for  the percentages were used

No significant differences were observed for any of  the  health  complaint  scale  scores  among  the three groups (Table 2). However, borderline significance  was  observed  for  the  somatic  health complaint scale. However, this observation was the opposite of what was expected (i.e., fewer somatic health  complaints  were  reported  by  the  refugee group,  whereas  it  was  believed  that  this  group would have more such complaints).

TABLE 2. Mean scores and standard deviations of the Health Behavior in School-Aged Children Symptom Checklist scale scores for the total sample and for the Danish, immigrant, and refugee group

|                                 | Total sample   | Danish     | Immigrant   | Refugee    |   P value |
|---------------------------------|----------------|------------|-------------|------------|-----------|
| N                               | 296            | 148        | 81          | 67         |           |
| Somatic health complaints       | 14.9 (5.5)     | 15.3 (5.3) | 15.5 (5.2)  | 13.6 (6.0) |       .07 |
| Psychological health complaints | 8.9 (3.4)      | 8.8 (3.3)  | 9.1 (3.4)   | 8.6 (3.7)  |       .65 |
| Total health complaints         | 21.2 (7.5)     | 21.4 7.4)  | 21.7 (7.3)  | 19.8 (8.0) |       .26 |

Analysis of variance probability testing was used to compare the three ethnic groups

As  shown  in  Table  3,  no  significant  differences were  observed  for  the  continuous  SDQ  externalizing and internalizing scale scores.

TABLE 3. Means and standard deviations for the Strengths and Difficulties Questionnaire internalizing and externalizing scale scores for the total sample and for the Danish, immigrant, and refugee groups

|               | Total sample   | Danish    | Immigrant   | Refugee   |   P value |
|---------------|----------------|-----------|-------------|-----------|-----------|
| N             | 296            | 148       | 81          | 67        |           |
| Internalizing | 4.5 (3.3)      | 4.2 (3.4) | 4.7 (3.1)   | 5.0 (3.2) |       .12 |
| Externalizing | 5.0 (3.3)      | 4.7 (3.2) | 5.6 (3.4)   | 5.0 (3.5) |       .08 |

Analysis of variance probability testing was used for the log transformed internalizing and externalizing scores

Furthermore,  Table  4  shows  that  no  significant differences were observed for the above and below cutoffs  for  the  SDQ  emotional  and  hyperactivity scales.

TABLE 4. Observed number of cases and percentages of cases rated on the peer problems, emotional problems, hyperactivity/inattention, and conduct disorders scales of the Strengths and Difficulties Questionnaire for the total sample and for the Danish, immigrant, and refugee groups

|                           | Total sample   | Danish     | Immigrant   | Refugee    |   P value |
|---------------------------|----------------|------------|-------------|------------|-----------|
| N                         | 296            | 148        | 81          | 67         |           |
| Peer problems             | 120 (40.5 %)   | 53 (35.8%) | 31 (38.3%)  | 36 (53.7%) |       .04 |
| Emotional problems        | 90 (30.4%)     | 42 (28.4%) | 26 (32.1%)  | 22 (32.8%) |       .75 |
| Hyperactivity/inattention | 93 (31.5%)     | 46 (31.3%) | 25 (30.9%)  | 22 (32.8%) |       .96 |
| Conduct disorder          | 112 (38.0%)    | 43 (29.3%) | 39 (48.1%)  | 30 (44.8%) |      .008 |

The P values obtained via two-tailed Pearson chi-squared probability testing are shown

Alternatively, significant differences were observed  for  the  SDQ  conduct  disorder  and  peer problems scales, with the most favorable outcomes seen  among  the  Danish  children.  Post  hoc  testing revealed  significant  differences  with  regard  to  the conduct scale scores of the Danish children and the immigrant  children  ( P =  .004)  and  the  Danish children and the refugee children ( P =  .026). Significant differences were also found for the peer problem  scores  between  the  Danish  children  and the refugee children ( P = .013).

Overall,  significant  differences  among  the  three groups  were  observed  for  the  separation  anxiety disorder scale and the obsessive-compulsive disorder (OCD) scale of the RCADS (Table 5).

TABLE 5. Mean scores and standard deviations of the Revised Children's Anxiety and Depression Scale scores for the total sample and for the Danish, immigrant, and refugee groups

|                                                             | Total sample   | Danish      | Immigrant   | Refugee     |   P value |
|-------------------------------------------------------------|----------------|-------------|-------------|-------------|-----------|
| N                                                           | 296            | 148         | 81          | 67          |           |
| Generalized anxiety disorder                                | 4.7 (2.9)      | 4.5 (3.0)   | 4.6 (3.0)   | 5.0 (2.9)   |       .53 |
| Separation anxiety disorder                                 | 1.9 (2.4)      | 1.6 (2.2)   | 1.8 (2.0)   | 2.6 (3.1)   |       .02 |
| Social phobia                                               | 8.3 (4.7)      | 8.7 (4.7)   | 7.7 (4.7)   | 8.2 (4.7)   |       .33 |
| Panic disorder                                              | 3.4 (3.5)      | 3.2 (3.2)   | 3.2 (3.4)   | 4.3 (4.2)   |       .09 |
| Obsessive- compulsive disorder                              | 3.4 (3.0)      | 2.9 (2.9)   | 3.7 (2.9)   | 4.3 (3.2)   |      .007 |
| Major depressive disorder                                   | 5.4 (4.1)      | 5.3 (4.3)   | 5.5 (3.5)   | 5.6 (4.2)   |       .85 |
| Total anxiety score                                         | 21.7 (13.1)    | 20.9 (12.7) | 21.0 (12.9) | 24.3 (13.9) |       .18 |
| Total Revised Children's Anxiety and Depression Scale score | 27.1 (16.0)    | 26.2 (15.7) | 26.5 (15.2) | 29.8 (17.3) |       .28 |

Analysis of variance probability testing was used to compare the three ethnic groups. The total anxiety score includes the five anxiety scales, and the total Revised Children's Anxiety and Depression Scale score includes all six scales

The  most  favorable  outcomes  were  observed among the Danish children, and the least favorable outcomes  were  seen  among  the  refugee  children. Bonferroni  post  hoc  testing  revealed significant differences between the Danish and refugee groups with  regard  to  their  OCD  scale  scores  ( P =  .007) and their separation anxiety disorder scale scores ( P = .017).

## Discussion

Subjective  health  complaints  among  immigrant  and  refugee children

Our first hypothesis was that immigrant and refugee children would experience more somatic and psychological  complaints  than  children  of  Danish origin. We tested this hypothesis with the use of the Health Behavior in School-Aged Children Symptom Checklist to assess somatic, psychological, and overall complaints. Much to our surprise, we found fewer differences than expected. In fact, we found no  statistically  significant  differences  among  the groups. This finding is partly supported by the work of Nordahl Jensen and Holstein (12), who reported no differences between immigrants and ethnic Danish youth on the somatic complaints subscales or  the  total  scale.  They  did,  however,  report  that immigrant  boys  and  girls  in  general  experienced  a higher  degree  of  nervous  symptoms  as  compared with ethnic Danish youth. One explanation for the lack  of  differences  among  the  groups  in  our  study may  be  found  in  the  use  of  a  self-report.  It  is plausible  that,  had  we  applied  a  multi-informant approach,  our  results  would  have  been  different. Another reason for these small differences may be the limited size of the sample, or it may be found in the applied measure. The Health Behavior in School-Aged Children Symptom Checklist consists of  only  eight  items.  Despite  the  fact  that  this  tool demonstrated  adequate  psychometric  qualities,  it may not pick up on mental-health-related complaints to the same degree that a more specialized assessment tool would.

## Mental  health  complaints  among  immigrant  and  refugee children

To further explore our hypothesis, we assessed the mental health of our sample by applying the SDQ. By  applying  this  more  refined  measure  to  assess psychological difficulties, we found significant differences among immigrant children, refugee children, and Danish children. The immigrant children reported higher levels of conduct problems and  the  refugee  group  had  higher  levels  of  both conduct and peer problems  as  compared  with Danish children. The significant conduct problems among the immigrant and refugee children may be reinforced  by  the  fact  that  both  immigrant  and refugee families prefer to use their native languages at home, which gives rise to a lack of mastery of the Danish  language.  Among  the  immigrant  children, 29.6% used no Danish at home; among the refugee families, 48.5% used no Danish at home. The lack of Danish language skills in these groups may cause misunderstandings and perhaps conflicts when these children are in contact with others (e.g., peers, teachers), thereby  contributing to their elevated levels of conduct symptoms. In a study performed in London,  Leavey  and  colleagues  (16)  already reported that not having English as a first language appears to be a significant risk factor for psychological  stress  for  both  refugee  and  migrant children.

We further explored differences in mental health status as measured by the SDQ scores. For all three groups,  we  found  a  minimum  of  30%  of  youth scoring above the clinical cutoff. Although 27% of refugee children had previously been shown to meet case  criteria  (17),  our  numbers  were  surprisingly high for all three groups. This may in part be due to the samples being recruited from low-income areas of residence; such areas have previously been associated with higher levels of mental health problems among youth (31). However, the SDQ is not based on the DSM-IV and therefore does not tap  directly  into  anxiety  and  depression  symptoms at a pathological level.

We  then assessed internalizing mental health issues with the use of self-report measures that were based  on  the  DSM-IV  criteria  via  the  use  of  the RCADS.  Significant  differences  were  observed  in the refugee group with regard to separation anxiety disorder  and  OCD.  Despite  the  face  value  of  the symptom  level indicating that refugee children experienced more anxiety than immigrant children, who in turn experienced more anxiety than Danish children, no significant differences emerged between the immigrant children and Danish children. The finding that refugee children experienced  higher  levels  of  anxiety  supports  the previous literature,  which reported higher  levels  of emotional difficulties (32). A study by Montgomery and  Foldspang  (33)  suggested  that  exposure  to discrimination in Denmark is associated with internalizing behavior among refugee adolescents.

To  the  best  of  our  knowledge,  no  other  studies have assessed OCD symptoms in refugee children. However,  studies  of  OCD  symptoms  in  different ethnic groups may inform our understanding of the findings. For example, Williams and colleagues (34) reported that non-clinical black and Hispanic groups  reported  contamination  symptoms  at  the same  mean  level  as  whites  with  clinical  levels  of OCD. It is thus likely that culture and ethnicity may play  a  role  in  the  expression  of  OCD  and  related disorders; however, at present, little is known about these  mechanisms  (35).  In  the  present  study,  the high level of OCD in the immigrant group - and, in particular,  in  the  group  of  refugee  children  -  may also  be  caused  by  ethnicity  or  unknown  factors rather than a product of a true difference in anxiety level.  Therefore,  further  studies  are  required  to address this question.

Overall, our study has confirmed that children of refugee parents, as a group, have specific vulnerabilities when  it comes  to  mental health issues. This is particularly striking because the majority of the refugee group in this study may be considered quite resourceful: these children actively sought  assistance  at  homework  cafés  and  were willing  to  participate  in  the  study.  However,  the vulnerabilities may be caused by the fact that part of the sample of refugee children was recruited from a treatment center for traumatized refugees and therefore  may  have  parents  with  mental  health problems. It is not possible from the result of this study to reveal aggravating or improving factors that may affect the family conditions of these children, because the refugee children were not examined in relation  to  whether their  parents  were  or  were  not traumatized.  This  issue  was  discussed  in  an  article by Daud and colleagues (36) that addressed resilience  and  vulnerability  among  refugee  children of traumatized and non-traumatized parents. In that study,  children  without  traumatized  parents  had more favorable values on the SDQ and other tests as  compared  with  the  group  of  children  whose parents had been traumatized. The fact that children of  refugees  presented  with  more  mental  problems than  the  immigrant  and  Danish  groups  should encourage educational staff to be more aware of the backgrounds of ethnic minority children.

## Limitations of the study

The  largest  limitation  of  this  study  is  that  our sample was a convenience sample. It was difficult to establish  contact  with  the  refugee  group,  which resulted in a very low response rate: only 15 parents (out of 51 invitations to participate) agreed to their children's participation. These parents were rewarded by means of a modest gift token (i.e., 20 Euros). The children from this part of the refugee sample (i.e., those recruited from OASIS) comprised what was likely the  most  burdened group,  with  parents  who  may  still  suffer  from trauma. To expand the group, we included children of refugees who attended homework cafés and who were  not  in  contact  with  the  OASIS  treatment centre,  thereby  adding  a  group  of  refugee  children with unknown backgrounds.

The  information  in  this  study  is  based  on  the students'  self-reported  data.  This  gives  rise  to  the question  of  whether  these  children  were  able  to provide  reliable  data,  particularly  with  regard  to their  background  data.  In  a  study  undertaken  by Nordahl  and  colleagues  (37),  the  percentage  of student-parent agreement about the language usually spoken at home  was  high. The  proxy measure for ethnic background should therefore be considered robust. With regard to the self-reported data about possible psychological problems, we did not  include  the  parents  in  the  study,  which  is  a limitation regarding the ability to obtain  more detailed  multi-informant  data.  However,  even  if  a screening  instrument  such  as  the  SDQ  had  been translated into many  languages, there is scarce evidence to support its validity among cross-cultural populations.  In  addition,  the  refugee  parents  were very hard to enroll in the study. Other studies, such as the one by Daud and colleagues (36), have found that refugee parents felt the interview situation to be stressful.  Including  only  a  few  parents  would  have compromised the generalizability of the study, which  is  why  we  opted  for  the  use  of  self-report data. We may have found more significant differences if we had used a group of ethnic Danish children from more advantaged backgrounds. Alternatively, our less advantaged sample should be considered  a  strength  of  the  design,  because  it provides a community control sample that compares  peers  of  different  ethnicities  who,  in some  respects,  share  the  same  living  conditions. Other  studies  have  shown  that  agreement  among informants is low for children, parents, and teachers with  regard  to  internalizing  difficulties  (38).  This suggests  that  it  is  important  to  explore  youth  selfreports of subjective experience in further detail at it relates to internalizing symptoms.

Only a few children were less than 11 years old. The  SDQ  self-report  is  validated  for  children  11 years old and older; RCADS has been validated for the  entire  span  of  ages  included  in  the  study.  To compensate  for  the  possible  influence  of  reading difficulty  as  it  related  to  the  understanding  of  the questionnaires, the questions were read aloud to the children during test administration, and administrators were circulating in the classrooms to allow  the  children  to  ask  questions  if  they  were  in doubt.

## Conclusions

Our study found some differences (but fewer than expected)  among  ethnic  Danish,  immigrant,  and refugee children. There were more similarities than differences  in  these  groups  with  regard  to  somatic complaints  and  mental  health  issues.  To  obtain  a more  in-depth  understanding  of  the  mental  health differences  involving  conduct  disorders,  separation anxiety disorders, and OCD, further investigation is required.

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## Acknowledgements

Thank you to the refugee families and their children for helping us to carry out the screening necessary for this study. We would like to thank the headmasters and teachers at the participating schools  as  well  as  the  volunteers  from  the  Red Cross and the staff of Lejerbo (settlement assistance)  for  kindly  allowing  us  to  collect  data  in schools  and  homework  cafés.  Thank  you  to  all  of the children who provided us with the relevant data.

The Danish Data Protection Agency (http://www.datatilsynet.dk/) provided us with permission for the relevant data collection.

This project was made possible by the Rockwool Foundation, Aase and Ejnar Danielsen's Foundation, and Susi and Peter Robinsohn's Foundation.

In  addition,  we  thank  psychologist  Jon  Maaløv Holm for his assistance and the psychology students who assisted us with the data collection.