Prevalence and Correlates of Mental Disorders Among Native American Women in Primary Care

Prevalence and correlates of mental disordersin Israeli adolescents: results from a national

mental health survey

Ilana Farbstein,2 Ivonne Mansbach-Kleinfeld,1 Daphna Levinson,1

Robert Goodman,3 Itzhak Levav,1 Itzik Vograft,2 Rasim Kanaaneh,2

Alexander M. Ponizovsky,1 David A. Brent,4 and Alan Apter51Mental Health Services, Ministry of Health, Jerusalem, Israel; 2Department of Child and Adolescent Psychiatry, ZivHospital, Safed, Israel; 3King’s College London Institute of Psychiatry, London, UK; 4University of Pittsburgh School

of Medicine, Pittsburgh, USA; 5Feinberg Child Study Center, Schneider Children’s Medical Center of Israel

Background: The development of epidemiological instruments has enabled the assessment of mentaldisorders in youth in countries that plan policy according to evidence-based principles. The Israel SurveyofMentalHealth amongAdolescents (ISMEHA)was conducted in2004–2005 in a representative sample of957 adolescents aged 14–17 and their mothers. Methods: The aims of this study were to estimateprevalence rates of internalizing and externalizing mental disorders and their socio-demographic andhealth correlates. Disorders were ascertained with the Development and Well-Being Assessment inven-tory and verifiedby childpsychiatrists. Results: Theprevalence rateswere11.7%,8.1%and4.8% for anydisorder, internalizing disorders and externalizing disorders, respectively. Distinct risk factors wereassociated with the different types of disorders: internalizing disorders were associated with femalegender, chronic medical conditions and being cared for by a welfare agency. Risk factors for externalizingdisorders were male gender, having divorced or single parents, being an only child or having only onesibling. Learning disability was associated with both types of disorders. Conclusions: The risk andprotective factors related to internalizing and externalizing disorders are interpreted within theframework of family composition in this multicultural society. Keywords: Prevalence, risk factors,mental disorders, adolescents, Israel.

Epidemiological studies of mental disorders inchildhood and adolescence have been conductedworldwide with prevalence rates varying between 7%and 16.4% (Canino et al., 2004; Costello, Farmer,Angold, Burns, & Erkanli, 1997; Heiervang et al.,2007; Meltzer, Gatward, Goodman, & Ford, 2003). InIsrael, however, only selected mental health prob-lems and population groups have been studied(Apter et al., 1993; Auerbach, Goldstein, & Elbedour,2000; Molcho, Harel, & Dina, 2004; Naon, Morgin-stin, Schimmel, & Rivlis, 2000; Ponizovsky, Ritsner,& Modai, 1999) and their limited scope has notprovided the needed information on prevalence ratesand risk factors for mental disorders. Therefore,there is an urgent need to assess whether some ofthe risk and protective factors that affect mentaldisorders in other societies produce the same effecton the Israeli population. Selected risk factors, suchas living with a divorced parent (Verhulst & van derEnde, 1997), ethnic minority status (Sagatun, Lien,Søgaard, Bjertness, & Heyerdahl, 2008), as well aslarge family size usually associated with povertyand low parental education, have been linked toincreased rates of mental disorders (Burns et al.,1995; Ford, Goodman, & Meltzer, 2004; Heiervang

et al., 2007). Chronic disease has also been associ-ated with increased rates of emotional disorders(McLoyd, Jayaratne, Ceballo, & Borquez, 1994) andexposure to the stress of war and terrorism isa risk factor for posttraumatic stress disorder(Pat-Horenczyk et al., 2007). The case of Israel as amulti-ethnic society in a state of ongoing stress dueto regional conflict presents a unique opportunity tolearn how different socio-cultural experiences mayaffect the prevalence of mental disorders.

The first nation-wide Israel Survey of MentalHealth among Adolescents (ISMEHA) was conductedby the Mental Health Services of the Ministry ofHealth, the Ministry of Education, Ziv Hospital, andthe Schneider Children’s Medical Center of Israel in2004–2005 and provided data on prevalence ofmental disorders and use of mental health servicesin distinct subpopulations. This paper presentsestimates of prevalence rates of internalizing andexternalizing psychiatric disorders and their rela-tion to selected demographic, health and socialrisks and protective factors. We hypothesized that:1) adolescents of minority population groups woulddisplay higher rates of mental disorders than thegeneral population; and 2) adolescents from largefamilies would be at increased risk for any mentaldisorders.Conflict of interest statement: No conflicts declared.

Journal of Child Psychology and Psychiatry 51:5 (2010), pp 630–639 doi:10.1111/j.1469-7610.2009.02188.x

� 2009 The AuthorsJournal compilation � 2009 Association for Child and Adolescent Mental Health.Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA

Methods

A summary of the ISMEHA’s methods is presented here,while a detailed description of the sample, data collec-tion, procedures and instruments has been publishedelsewhere (Mansbach-Kleinfeld et al., in press).

Sample and procedures

The sample included 957 adolescents aged 14–17 andtheir mothers. The sampling frame used was theNational Population Register (NPR), which included thenames of all legal residents of Israel born between July2, 1987 and June 30, 1990, whether or not in school(N = 317,604). We excluded from our sample adoles-cents living in settlements with less than 2,000 inhab-itants, mainly rural settlements, and therefore coveragefor the target population was nearly 90%. Additionalinformation provided by the NPR was gender, popula-tion group, date and country of birth and homeaddress. Only one child from each family was includedin the sample.

The sample included 24 clusters and sampling wasdone in two steps.

Sampling of settlements. All Israeli urban settle-ments with more than 2,000 inhabitants were includedin the sampling frame (N = 229 settlements). The 11largest cities were included and the remaining 218settlements were stratified according to type of locality(Jewish and mixed cities or mainly Arab cities) andsampled with a probability proportional to size so that23 Jewish or mixed cities and 10 Arab cities wereselected.

Sampling of individuals within settlements. Thiswas done through the NPR. Adolescents from the largestcities were chosen, proportionately to city size, througha systematic random sampling. From each of thesmaller cities, 30 adolescents were selected through asystematic random sampling procedure. There were noreplacements.

Out of the total sample 14.8% could not be located,whereas 17% refused to participate. Thus, responserate was 80% in the located sample (N = 1,195) and68.2% in the total sample. Non-response was higheramong Jews (24.1%) than among Arabs (7%), whereasno differences by gender or immigrant status werenoted. The results were weighted back to the totalpopulation to compensate for clustering effects andnon-responses.

Mothers and adolescents were interviewed sepa-rately, face to face, at their homes, by two trainedlay interviewers. The interviews took between 45and 90 minutes, and were conducted in Arabic,Hebrew, or Russian. The interviewers recordedverbatim the respondents’ comments. Twenty-twomothers refused to be interviewed but consented totheir offspring’s participation, while 51 adolescentsrefused to answer, despite their mothers’ participa-tion. We included these cases because it is commonpractice to determine DAWBA diagnoses based ona single informant, as is also the case for allother psychiatric assessments (Goodman, personalcommunication).

Informed consent. Parents provided writteninformed consent for their own and their child’s par-ticipation in the study, as approved by the HumanSubjects Committee of the Schneider Children’s Med-ical Center. Adolescents were told the objectives andmethods of the survey and that they could abstainfrom answering questions or parts of them. Confiden-tiality was assured.

Study variables

Diagnostic assessment. Mental disorders wereassessed using the Development and Well-BeingAssessment Inventory (DAWBA; Goodman, Ford,Richards, Gatward, & Meltzer, 2000). The DAWBA, amulti-informant interview, combines structured withopen-ended questions about psychiatric symptoms andtheir impact on the adolescent’s life and/or his/herfamily. Responses to the structured questions were usedto generate a computerized diagnosis according to DSM-IV (American Psychiatric Association, 1994) criteria.Senior child psychiatrists (IF, AA & RK) relied on the re-corded comments to verify the computerized diagnoses.

The specific disorders were categorized into inter-nalizing disorders: separation anxiety, specific phobia,social phobia, panic disorder, post-traumatic stressdisorder (PTSD), obsessive-compulsive disorder (OCD),generalized anxiety disorder (GAD) and major depres-sive disorder (MDD); or externalizing disorders: atten-tion deficit and hyperactivity disorder (ADHD),oppositional defiant disorder (ODD) and conductdisorder (CD).

The DAWBAwas translated into Hebrew especially forthis study. The Hebrew translation was culturallysensitive and the back-translation was compared to theoriginal English version by the developer (RG). TheArabic, Russian and Hebrew versions of the DAWBAare available at the DAWBA website (http://www.dawba.com).

Test–retest reliability and validity data (yet to bepublished) will provide information on DAWBA’s com-parability with other major diagnostic instruments(Goodman, personal communication).

Socio-demographic information. This includedgender, population group (Israel-born Jews and immi-grants; or Muslim and Christian Arabs and Druze), typeof locality of residence (Jewish or mixed Jewish/Arablocality; or Arab locality), birthplace, maternal educa-tion (low = below 12 years of schooling; intermediate =12 years of schooling with matriculation exams; high =some post-secondary or university education), parentalmarital status, family size, paternal employment statusand welfare status. Data regarding gender, populationgroup, type of locality of residence and birthplace wereobtained from the NPR. Information about maternaleducation, marital status, family size, paternalemployment and welfare status was obtained from therespondents and therefore is subject to known self-report biases. However, the averages of the socio-demographic variables such as marital status, familysize and employment conform to known populationtotals taken from reliable Central Bureau of Statistics(CBS) sources.

Mental disorders in Israeli adolescents 631

� 2009 The AuthorsJournal compilation � 2009 Association for Child and Adolescent Mental Health.

Health and learning risks. These were based onmothers’ reports of diagnosed learning disability; sen-sory impairment (hearing or speech); congenital disor-der (heart, limbs or nervous system); chronic medicalcondition (frequent headaches, asthma, allergies, epi-lepsy, diabetes, etc.); and involvement in a seriousaccident.

Protective factors. Participation in youth movementsand/or sports activities was grouped into two catego-ries: ‘never or almost never’ and ‘at least once a week’.Social support was evaluated by affirmative responsesto the questions: ‘Is there at least one adult that youtrust especially?’ and ‘Is there anyone to whom you cantell important personal things?’

Statistical analysis

Statistical analyses were conducted using an SPSS-14complex sample analysis module (SPSS Inc, Chicago,IL). Prevalence rates for mental disorders according tothe socio-demographic factors are presented as per-centages with standard errors. Rao-Scott chi-squareswere calculated to correct for complex sample designand weighting. The adjusted F is as variant of the sec-ond-order Rao-Scott adjusted chi-square statistics andsignificance tests are based on the adjusted F and itsdegrees of freedom. Logistic regression coefficients weretransformed into odds ratios (OR) with 95% confidenceintervals (CI).

Results

Sociodemographic characteristics

About 77% of the adolescents were Jewish and 23%were Moslem or Christian Arabs or Druze. Themajority of respondents (80%) lived in Jewish ormixed Jewish-Arab cities and20% in exclusively Arabcities; 18.5% of the adolescentswere born abroad and14% lived with their divorced, widowed or singleparent, usually the mother. The majority of respon-dents (77%) lived in families with three or morechildren. Approximately 40% of the respondents’mothers had 13 years or more of schooling. Nearly23%of the fatherswerenot currently in theworkforce,as they were retired, disabled, students or home-makers. Only about 8%were actually looking forworkand could be defined as unemployed (Table 1).

The socio-demographic characteristics of the twomain population groups differ. Arab youth, comparedto Jewish youth, were more likely to come from two-parent families (p <.001), with 4 or more children(p < .0001), to have mothers with less than 12 yearsof education (p < .0001), fathers not in the workforce(p < .0001), and receive welfare care (p < .05).

Prevalence of mental disorders

Overall, the most common disorders were majordepression (3.3%), ADHD (3%) and specific phobia(2.5%). Oppositional defiant disorder (1.8%), GAD

(1.4%) and OCD (1.2%) followed and for theremaining specific disorders the rates were below1% (Table 2). Higher rates for girls than boys werefound for separation anxiety (1.3% vs. .2%), specificphobias (3.7% vs. 1.4%), PTSD (1.5 vs. 0), anddepression (4.7% vs. 1.8%). There were interethnicdifferences, with more Arab- than Jewish-Israeliadolescents having separation anxiety (2.4% vs..3%) and panic attacks (1.6% vs. 0), and more Jewsthan Arabs recognized with depression (3.9% vs.1.1%).

The prevalence rates for any mental disorder andfor internalizing and externalizing disorders were11.7%, 8.1% and 4.8%, respectively.

Univariate analyses

Risk factors. We found that internalizing disorderswere associated with female gender (p < .01); livingwith a divorced/single parent (p < .01); having afather not in the workforce (p < .01) and receivingwelfare support (p < .01); and with having an expert-diagnosed learning disabilities (LD) (p < .0001),a sensory impairment (p < .0001) and a chronicmedical condition (p < .01).

Externalizing disorders were significantly associ-ated with male gender (p < .05); being Jewish (p <.05); living with a divorced/single parent (p < .001);

Table 1 Socio-demographic characteristics of the ISMEHAsample (raw numbers and weighted proportions)

Characteristic N %

GenderBoys 497 51.2Girls 460 48.8

Population groupJewish 658 77.1Muslim and Christian Arab, Druze 299 22.9

Type of localityJewish or mixed city 689 80.1Arab city 268 19.9

Country of birthIsrael 826 81.5Abroad 131 18.5

Maternal years of schooling0–11 299 27.312 277 32.813 and over 325 39.9

Marital status of parentsMarried 813 85.6Single/divorced/widowed 122 14.4

Employment status of fatherEmployed 661 77.0Unemployed* 214 23.0

Welfare services carePresent 136 14.1Absent 793 85.9

Number of children in family1 23 3.02 151 19.73 230 25.94–6 401 40.17–16 132 11.3

*Includes looking for work and not in workforce such asretired, disabled, students or homemakers.

632 Ilana Farbstein et al.


and having only one or no siblings (p < .01); and alsowith LD (p < .001) and involvement in a seriousaccident (p < .05). The prevalence of both internal-izing and externalizing disorders increased with thenumber of health problems (Table 3).

Separate analyses of the two major populationgroups showed that 25% of Arab but only 10% ofJewish adolescents were presented with comorbidityof internalizing disorders with a chronic medicalcondition.

Likewise, we found a strong association betweenfamily size and externalizing disorders for Jewishadolescents, whereas we were not able to assess theassociation among Arab adolescents due to lack ofvariance (90% of Arab families had four or morechildren).

Protective factors. While neither youth movementparticipation nor family supports were significantlyassociated with mental disorders, there was an in-verse association between participation in sportsand externalizing disorders (p < .05) (Table 4).

Multivariate analyses

Logistic regression analyses were performed to pre-dict internalizing and externalizing disorders fromthe variables found to be significantly associated atthe bivariate level (gender, population group,parental marital status, number of siblings, welfarestatus, learning disability, chronic illness) (Table 5).Overall, these analyses confirmed that having aninternalizing disorder was significantly associatedwith: female gender (OR = 3.0, 95% CI 1.6–5.5);having a poor or dysfunctional family in need ofwelfare services (OR = 2.6, 95% CI 1.2–5.6); an LD(OR = 3.0, 95% CI 1.7–5.2) and a chronic medicalcondition (OR = 1.7, 95% CI 1.1–2.9).

The risk of an externalizing disorder was signifi-cantly associated with: male gender (OR = 2.4, 95%CI 1.1–4.9); living with a divorced/single parent (OR= 3.3, 95% CI 1.3–8.2); LD (OR = 8.7, 95% CI 3.9–19.1), and having only one or no siblings (OR = 3.5,95% CI 1.5–8.3). Although in the bivariate compari-son Jews had higher rates of externalizing disordersthan Arab adolescents, this association disappearedafter adjusting for other variables in the model.

Discussion

The ISMEHA’s findings show that the prevalence forany mental disorder, internalizing and externalizingdisorders were 11.7%, 8.1% and 4.8%, respectively.The specific risk factors were different for the twotypes of disorders and somewhat inconsistent withother reports. Thus, for internalizing disorders thesewere being female, living in a family on welfare andhaving a diagnosed chronic health problem, whereasfor externalizing disorders they were being male,living with a divorced parent and having only one orno siblings. The presence of a learning disability wasassociated with both types of disorders.

Our hypotheses were not supported by our data aswe found that: 1) rates of mental disorders weresimilar for adolescents from minority and majoritypopulations; and 2) adolescents living with a largenumber of siblings had lower rates of mental disor-ders than those living with only 1 sibling.

Prevalence of mental disorders

Approximately one in eight adolescents were diag-nosed as having a mental disorder potentiallyrequiring clinical intervention. A review of Europeanand American studies (Mansbach-Kleinfeld et al., in

Table 2 Prevalence of specific mental disorders by gender and population group (percentages and SE)

Specific disorder

Gender Population group

Total sample (n = 954)% SE

Boys (n = 497)% SE

Girls (n = 460)% SE

Jewish (n = 657)% SE

Arab (n = 300)% SE

Any anxiety 3.1 1.0 9.2 1.6 5.3 .9 9.3 2.9 6.1 .9Separation anxiety .4 .3 1.3 .5 .3 .2 3.1 1.4 .8 .9Specific phobia 1.4 .7 3.7 .9 2.1 .5 4.3 1.6 2.5 .5Social phobia .1 .1 1.8 1.0 1.0 .6 .6 .4 .9 .5Panic .4 .3 .3 .2 – 1.8 .8 .4 .2PTSD .2 .1 1.5 .6 .6 .3 1.6 1.0 .8 .3OCD .6 .3 1.9 .9 .9 .4 2.6 1.8 1.2 .5GAD 1.0 .4 2.1 .8 1.6 .5 1.1 .7 1.5 .4Depression 1.9 .8 4.7 1.0 3.8 .8 1.3 .7 3.3 .6ADHD 3.9 1.0 2.0 .8 3.4 .8 1.2 .9 3.0 .6ODD 2.2 .9 1.3 .6 2.1 .7 .5 .5 1.8 .6Conduct disorder 1.4 .5 .4 .3 .8 .3 1.4 .7 .9 .3Any internalizing disorder 4.8 1.2 11.6 1.8 7.9 1.3 9.1 2.8 8.1 1.1Any externalizing disorder 6.6 1.3 3.0 .9 5.7 1.0 1.9 .9 4.8 .8

PTSD, post traumatic stress disorder; OCD, obsessive compulsive disorder; GAD, general anxiety disorder; ADHD, attention deficithyperactivity disorder; ODD, oppositional defiant disorder.



Table 3 Prevalence of mental disorders by risk factors (socio-demographic variables and health problems)

Variable n

Type of mental disorder

Any disorder Internalizing Externalizing

% SE % SE % SE

Total 954 11.7 1.3 8.1 1.1 4.8 0.8GenderBoy 496 9.7 1.7 4.8 1.2 6.6 1.3Girl 458 13.9 1.9 11.6 1.8 3.0 0.9

NS F = 9.9; p=.002 F = 5.4; p=.02Population groupJewish 654 12.5 1.5 7.9 1.3 5.7 1.0Arab & Druze 300 9.3 2.7 9.1 2.8 1.9 0.9

NS NS F = 5.8; p=.02Type of localityJewish/mixed 686 12.1 1.5 7.7 1.2 5.5 1.0Arab 268 10.2 3.2 9.9 3.2 2.2 1.0

NS NS F = 3.9; p=.05Country of Birth (for Jews)Israel 528 11.9 1.5 8.5 1.2 4.9 0.9Abroad 129 11.2 3.3 6.6 2.8 4.5 2.1

NS NS NSMaternal education (yr.)0-12 299 13.5 2.6 9.7 2.1 5.0 1.512 with diploma 277 11.0 2.4 6.6 1.7 4.8 1.513 and more 323 10.6 1.8 7.8 1.7 4.4 1.2

NS NS NSParental marital statusDivorced/single 121 22.9 4.0 13.4 2.8 12.2 3.8Married 811 10.1 1.3 7.3 1.2 3.7 0.7

F = 15.1; p=.000 F = 7.2; p=.008 F = 10.8;p=.001Paternal employment statusUnemployed 213 13.2 2.6 12.3 2.7 3.5 1.2Employed 659 10.9 1.5 6.8 1.2 4.5 0.9

NS F = 5.5; p=.02 NSWelfare services carePresent 135 23.4 4.5 17.3 4.2 8.9 2.9Absent 791 10.1 1.3 6.8 1.1 4.4 0.8

F = 13.9; p=.000 F = 9.9; p=.005 NSNumber of children1-2 171 15.3 2.8 9.7 2.2 8.8 2.23 230 11.4 2.3 6.0 1.7 5.9 1.74 and more 533 10.7 1.8 8.6 1.6 2.8 0.8

NS NS F = 4.9;p=.008Learning DisabilityPresent 129 31.4 4.5 17.4 3.7 19.4 4.0Absent 782 9.1 1.4 6.9 1.1 2.8 0.8

F = 36.0; p=.000 F = 13.2; p=.000 F = 36.3; p=.000Sensory impairment*Present 58 33.8 6.9 17.3 4.4 22.4 6.8Absent 854 10.4 1.4 7.6 1.2 3.8 0.7

F = 21.6; p=.001 F = 8.3; p=.000 F = 26.6; p=.000Chronic disease**Present 254 17.3 2.3 12.4 2.2 6.7 1.6Absent 681 9.9 1.4 6.6 1.1 4.3 1.0

F = 10.6; p=.001 F = 9.7; p=.002 NSSerious Accident***Present 267 14.5 2.4 9.3 1.9 8.0 1.9Absent 668 10.9 1.5 7.8 1.3 3.8 0.8

NS NS F = 5.8; p=.02Number of health problemsNone 382 7.2 1.8 5.3 1.6 2.1 1.01 328 13.0 2.1 8.6 1.5 5.4 1.62 and more 225 18.5 2.7 12.5 2.4 9.2 2.0

F = 6.7; p=.002 F = 4.0; p=.02 F = 4.8; p=.009

NS = not significant* The category ‘‘sensory impairments’’ includes hearing disability and speech problems.** The category Chronic diseases includes congenital disorders of the heart, limbs or nervous system; asthma,headaches/migraine and allergies; epilepsy and Crohn’s disease.***The category Serious Accident includes road accident or other serious accident, burn, poisoning, broken bones andinjury that required hospitalization



press) shows that prevalence rates of mental disor-ders in children and adolescents may vary greatly,depending on the instruments used and the inclu-sion of the impact criterion for determining adiagnosis. Salient studies using the DAWBA repor-ted figures similar to our estimates: the British Childand Adolescent Mental Health Services surveysfound prevalence of mental disorders of 11.2%among 11–15-year-olds in 1999 (Ford, Goodman, &Meltzer, 2003) and of 11.7% in an independentsample studied in 2004 (Green, Mcginnity, Meltzer,Ford, & Goodman, 2005). The Smoky MountainStudy (Costello et al., 1997) reported rates between12% and 15%. Studies using instruments with lessrestricted criteria for functional impairment havefound higher rates (Canino et al., 2004; Shafferet al., 1996).

Although rates for any mental disorder are similarin Israel and Great Britain, internalizing disordersprevail in the former whereas externalizing disordersprevail in the latter (Meltzer et al., 2003). The lowerprevalence of externalizing disorders in Israel couldbe explained by the traditional, collectivistic familyvalues and communitarian orientation of its sub-populations that favor more control over theirchildren’s behaviors than in less traditional societies(Sagy, Orr, Bar-On, & Awwad, 2001). These conser-vative values, however, do not seem to exert a pro-tective effect against internalizing disorders, whichare often a product of social and familial pressures.Higher rates of emotional than behavioral problemswere also found in Norway (Heiervang et al., 2007),Italy (Frigerio et al., 2009) and Yemen (Alyahri &Goodman, 2008).

We did not find increased rates of PTSD comparedto other countries. This finding is surprising given

ongoing regional conflict. Since we cannot explainthis finding at present, further in-depth investigationis required.

Risk and protective factors

The results show gender-specific associations bet-ween type of disorder and personal and family

Table 4 Prevalence of mental disorders by protective factors (involvement in social and sports activities and social support)

Protective factors n

Type of mental disorder

Any disorder Internalizing Externalizing

% SE % SE % SE

Participation in youth movementNever/almost never 760 12.3 1.6 8.6 1.4 4.9 .9At least 1 day/week 138 7.6 2.2 5.5 2.0 2.6 1.1

NS NS NSParticipation in sportsNever/almost never 201 16.3 2.9 10.5 2.4 7.8 2.3At least 1 day/week 698 10.2 1.5 7.4 1.3 3.5 .8

F = 4.6; p = .03 NS F = 4.8; p = .03Social supportIs there an adult you trust particularly?Yes 763 11.3 1.5 8.1 1.3 4.1 .9No 133 13.7 3.3 8.5 2.5 7.0 2.9

NS NS NSIs there anyone whom you can tell important personal (intimate) things?Yes 775 11.6 1.4 8.1 1.2 4.4 .9No 124 11.9 3.5 8.7 2.9 5.0 2.4

NS NS NS

NS, non-significant.

Table 5 Risk factors for internalizing and externalizing disor-ders: summary of logistic regression analyses (odds ratios and95% confidence intervals)

Internalizing Externalizing

OR (95% CI) OR (95% CI)

GenderBoys 1.00 [Reference] 2.43 (1.14–5.16)*Girls 3.01 (1.65–5.46)*** 1.00 [Reference]

Population groupJewish .74 (.34–1.61) 2.15 (.89–5.21)Arabs and Druze 1.00 [Reference] 1.00 [Reference]

Marital status of parentsMarried 1.00 [Reference] 1.00 [Reference]Single/divorced 1.64 (.92–2.92) 3.24 (1.31–8.02)**

Number of siblings0 or 1 1.26 (.59–2.68) 2.80 (1.14–6.91)*2 .85 (.41–1.78) 2.04 (.83–5.00)3 or more 1.00 [Reference] 1.00 [Reference]

Care of welfare agenciesPresent 2.61 (1.22–5.58) * 1.82 (.73–4.52)Absent 1.00 [Reference] 1.00 [Reference]

Diagnosed learning disabilityPresent 2.96 (1.70–5.15)*** 8.77 (3.95–19.51)***Absent 1.00 [Reference] 1.00 [Reference]

Diagnosed chronic medical problemPresent 1.78 (1.08–2.96)* 1.14 (.54–2.44)Absent 1.00 [Reference] 1.00 [Reference]

*p < .05; **p < .01; ***p < .001.



characteristics. These patterns suggest that girlsmaysee their emotional health more affected by physicaldisease and family dysfunction, while boys may bemore vulnerable to the effects of loneliness, as a resultof being an only child, and to lack of attention andcontroloftheirbehaviorduetohavingdivorcedparentswho have less time for them.

The relation we found between chronic disease andadolescents’ emotional life may be mediated by theirconcerns with survival and their future or by theirdiminished participation in pleasurable activitiesand subsequent isolation (Lewinsohn, Seeley, Hib-bard, Rohde, & Sack, 1996). In addition, economicstress and living in a dysfunctional, non-effectivefamily may indirectly impact the emotional health ofgirls, via its effects on the mothers’ psychologicalfunctioning and parenting behaviors (McLoyd et al.,1994). Internalizing disorders may occur as a resultof the combined effect of these direct and mediatedstresses on a vulnerable individual. This vulnerabilityis more pronounced in girls, probably in the contextof greater emotional self-disclosure to their mothers(Papini, Farmer, Clark, Micka, & Barnett, 1990). Thisinterpretation is consistent with studies reportingthat lower family income and maternal depressionuniquely predict an increase in girls’ internalizingdisorders (Leve, Kim, & Pears, 2005), as adolescentswho perceive their families as experiencing severehardship report higher anxiety, more cognitive dis-tress and lower self-esteem (McLoyd et al., 1994).Lewinsohn et al. (1996) also found associationsbetween physical morbidity, reduction in activities,functional impairment and depression. Alternativeexplanations, such as genetic vulnerability, cannotbe ruled out because family environmental risk fac-tors are often related to heritable risk factors(Paracchini et al., 2008). Reverse causality, withinternalizing disorders causing somatic symptoms,could also be considered.

In contrast with studies showing that mental dis-orders increase with family size, usually associatedwith poverty and low parental education (Ford et al.,2004), in our population we found the opposite trend:externalizing disorders were more common amongboys living with a single parent and those having fewor no siblings. A possible explanation may be thattraditional Jewish and Muslim subpopulations inIsrael, which usually have large families and strongfamily values and a community orientation, favorcontrol and surveillance over children’s behaviors sothat they conform to group norms (Sagy et al., 2001).A study of Palestinian-Arab adolescents in Israelreported that an authoritative parenting style wasassociated with better mental health, whereas apermissive parenting style was associated with neg-ative attitudes towards parents, lower self-esteemand increased identity, anxiety, phobia, depressiveand conduct disorders (Dwairy, 2004).

In addition, in families where senior siblings func-tion as surrogate parents and are involved in the

upbringing of junior siblings, children rarely reportfeeling lonely or neglected (Hay, Payne, & Chadwick,2004; Newcomb, Bukowski, & Pattee, 1993),whereas, in single-child families, children oftenreport feelings of loneliness, boredom and inferiority,even in the presence of both parents (Qualter &Munn, 2002). Consequently, these feelings may bemore pronounced in single children of one-parentfamilies, compared to children living in extendedfamilies, and externalizing disorders in these casesmay be interpreted as an attempt to compensate forthese internal negative experiences.

Overall, our study confirms the well-documentedassociations between gender and type of disorder(Costello et al., 1997; Meltzer et al., 2003), betweenbehavioral problems and living in a single-parenthome (Costello, Compton, Keeler, & Angold, 2003;Lipman, Boyle, Dooley, & Offord, 2002), andbetween mental disorders and living in a familyrequiring welfare services (Costello et al., 2003).Likewise, our findings confirm the associationbetween LD and both internalizing and externaliz-ing disorders (Meltzer et al., 2003; Willcutt &Pennington, 2000), and between health and emo-tional problems in particular (Lewinsohn et al.,1996). They also support the Great Smoky Moun-tains Study’s findings that somatic complaints(mainly pains) are strongly associated with anxietydisorders and female gender (Egger, Costello, Erk-anli, & Angold, 1999).

The lack of association between mental disordersand the risk factors presented here, namely minoritystatus, immigration and maternal education, alsodeserves attention. Unlike studies showing thatindigenous minorities have higher rates of mentaldisorders, we found that the population group vari-able became a non-significant predictor in theregression model, after adjusting for interveningvariables such as family size and marital status ofparents.

Immigration status – 18.5% of adolescents immi-grated to Israel – was not associated with mentaldisorders, probably because 54.4% of these adoles-cents immigrated before age 5 and an additional32.4% between age 6 and 10 and, therefore, wereeffectively acculturated. Maternal education, con-trary to other studies (Meltzer et al., 2003; Goodman,Fleitlich-Bilyk, Patel, & Goodman, 2007), was notassociated with mental disorder, probably due to theprotective effect of large, conservative, two-parentfamilies in our population.

The buffering effect of social support networks onpsychiatric disorders has been extensively studied(Brugha, 1995; Rae-Grant, Thomas, Offord, & Boyle,1989). Although we found a negative associationbetween participation in sports activities and exter-nalizing disorders, our cross-sectional design pre-cludes the inference of causal relationships.Involvement in sports may have had a beneficialeffect, but a process of self- or group-selection that



excludes those with a mental disorder from sports orother group or pleasurable activities cannot be ruledout (Lewinsohn et al., 1996). Unlike other studies(Sanders, Field, Diego, & Kaplan, 2000), we did notfind an association between internalizing disordersand involvement in sports or other protective factorssuch as participation in youth movement, trusting aparticular adult or having a confidant. The lack ofassociation between the other protective factors andmental disorders may be an artifact due to the lack ofstatistical power owing to the small subgroups size.Further efforts should be directed to identifyinginfluential protective factors in our different sub-population.

Limitations

The relatively high non-response rate was mainlydue to failure to locate many recent immigrants whohave no fixed address. Excluding those not located,youth living in Jewish or mixed localities had aresponse rate of 76% and those living in Arab cities93.4%. The possibility must be considered thatthose who were not found have higher rates ofmental disorders than those who were found andthat the prevalence of mental disorders in this agegroup is underestimated, though we cannot ascer-tain this.

Another potential limitation is the assumption ofuniversality regarding expression of psychiatricsymptoms across cultures. Although our instru-ments were appropriately translated to Hebrew,Arabic and Russian and parents were interviewed intheir preferred language by culturally sensitiveinterviewers, cross-cultural comparability and equi-valences remain in question (Canino & Alegria,2008; Fabrega, 1990). For example, the cross-cul-tural variability of certain diagnostic concepts andtheir measurement could be responsible for thehigher rates of separation anxiety disorders in theArab population.

Our set of risk factors was restricted to selectedsocio-demographic variables because, due to timeand resource constraints, we were concerned that wewould not obtain reliable assessment of maternaldepression and that asking mothers about familyconflict could significantly decrease response rates.It is possible that the findings related to higher ratesof mental disorder among small families or amongchildren living with divorced parents could beexplained by maternal depression as an interveningvariable but this is something that has to be exam-ined in future studies.

Although this study examined a representativesample of Israeli youth we were not able to includetwo subpopulations: the Jewish Ultra-Orthodox andPalestinian adolescent residents of East Jerusalem,who comprise 17.8% and 2.8%, respectively, of theadolescents in this age group (Mansbach-Kleinfeld

et al., in press). The former refused to participatebecause they reject the worldview that the ISMEHA’squestions imply, whereas the latter do not trust oridentify with the national institutions requestingtheir participation.

Conclusion

This study provides, for the first time, a clear esti-mate of the size of the population aged 14–17needing professional mental health care in Israel. Itprovides important information regarding preva-lence of internalizing and externalizing disordersand identifies the distinct risk and protective fac-tors affecting this population. It emphasizes thecounterintuitive finding that small family size isassociated with higher rates of externalizing disor-ders, and provides an interpretation within theframework of family composition in this multicul-tural society.

These data focus attention on adolescents inneed of mental health services, namely, children ofdivorced parents, suffering from chronic diseasesand diagnosed with a learning disability, as they arethe groups at risk that need more detailed planningof prevention and intervention programs.

Acknowledgements

This survey was supported by the Israel NationalInstitute for Health Policy and Health ServicesResearch, Israel, the Association for Planning andDevelopment of Services for Children and Youth atRisk and their Families (ASHALIM), the EnglanderCenter for Children and Youth of the BrookdaleInstitute and the Rotter Foundation of the MaccabiHealth Services, Israel. Dr. A.M. Ponizovsky wassupported in part by the Ministry of ImmigrantAbsorption. We also acknowledge the importantcontribution of Jane Costello in the planning of thisproject and of Anneke Ifrah and Anat Shemesh in thepreparation of this paper.

Preliminary findings of this studywere presented atthe 6th Annual Conference on Health Policy, Decem-ber12, 2007,Tel Aviv, Israel, andat the IACAPAP18thWorld Congress, April 30, 2008, Istanbul, Turkey.

Ivonne Mansbach-Kleinfeld had full access to allthe data in the study and takes responsibility for theintegrity of the data and the accuracy of the dataanalysis.

Correspondence to

Ivonne Mansbach-Kleinfeld, Mental Health Services,Ministry of Health, 2 Ben Tabai, Jerusalem, Israel;Tel: +972 2 565 7796; Mobile +972 54 531 9369;Fax: +972 2 565 7798; Email: [email protected]



Key points

• Epidemiological studies of mental disorders in adolescents show prevalence rates of psychiatric disordersbetween 11% and 15%.

• Distinct risk factors are associated with internalizing and externalizing disorders.• No association was found between mental disorders and minority status or maternal education.• Adolescents growing in small families had higher rates of externalizing disorders than those growing up inlarger families, over and beyond the effect of parental divorce.

• Prevalence rates of mental disorders in Israeli adolescents are comparable to rates in countries usingsimilar impact assessment criteria.

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Manuscript accepted 7 September 2009



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