Depression and Suicidal Ideation Among Mexican ...

Research

and Theory for Nursing Practice: An Internationa/]ournal, Vol. 19, No.1,

2005

Depression and Suicidal Ideation Among Mexican American School..Aged Children Julia Muennich Cowell, PhD, RN, FAAN Deborah Gross, DNSc, RN, FAAN Diane McNaughton, PhD, RN Sarah Ailey, PhD, RN Louis Fogg, PhD

Ii Ii,I: I ~ , f; ::: 1: 'I' [ ',I ! I, rl II,' II" " [ ~' ~ II

Rush University Chicago, IL

The purpose of this study was to describe depression and suicidal ideation rates in a community sample of 182 urban fourth and fifth grade Mexican American children using the Children's Depression Inventory (CD!).We used a descriptive secondary data analysis design. The mean CD!score was 9.55 (SD= 5.8). Thirty-one percent fell in the depressed range using a clinical cut point of 12 and 7% fell into the depressed range using the non-clinical cut point of 19. Thirty-eight percent (n = 69) reported suicidal ideation. The depression rate was consistent with national rates. A non-clinical cut point of 19 showed that 87% of children reporting suicidal ideation were not identified as depressed. Many of these children do not report the most typical symptoms of depression. The results of this study provide school nurses with vital information to support efforts addressing the mental health needs of Mexican American children.

i "I

Keywords: child depression; suicide ideation; Mexican American

S

uicide is the third leading cause of death among adolescents ages 13-19 during adolescence and it is strongly associated with depression (Andrews & Lewinsohn, 1992; Lewinsohn, Rohde, & Seeley, 1993; Roberts & Chen, 1995; Shaffer, Gould, et a!., 1996;Sourander, Helstela, Haavisto, & Bergroth, 2001). Research shows that 90% of youth who commit suicide have an emotional disorder (Shaffer & Craft, 1999). the most common being a mood disorder (Shaffer; Gould, et a!., 1996).

Literature addressing psychiatric and mental health needs of children usu-

ally focuses on infancy and adolescence and refers to the grade school-aged period as latency (Silberg & Rutter, 2002). Therefore, there is a significant need to address mental health needs of children before adolescence. There is evidence that symptoms of depression evident during adolescence begin during the younger school-age years (Domenech, Canals, & Femandez-Ballert, 1992; Sourander et a!., 2001). However, there is relatively little data on the prevalence @ 2005 Springer Publishing Company

--

77

~ I' t rR i~ ~; iii Ii! H u; t: i"" II',"

" 78

Cowell et al.

of depression and suicidal ideation in children before adolescence separate from rates reported for adolescents. For example, the Surgeon General (U.S. Department of Health and Human Services [USDHHSj, 1999) estimates a 6.2% prevalence rate for mood disorders among children ages 9-17. The suicide rates reported by the National Center for Health Statistics (2002) refer to children ages 13-19. Even less is known about childhood depression and suicidal ideation among Hispanic populations. There are several reasons for this problem. First, most epidemiplogic samples include an inadequate representation of Hispanics (Flores et aI., 2002). Even when Hispanic youth are included in prevalence studies, the research tends to aggregate children from different Hispanic ethnicities, making it difficult to determine to which Hispanic populations the data can be generalized. The data that are available on Hispanic children usually center on children 12 years and older (Roberts, Attkisson, & Rosenblatt, 1998). The nature and rates of depression during adolescence are likely to differ with those during the school-aged years given the vast differences between these two developmental stages. Finally, investigators assessing the prevalence of childhood depression have employed a range of assessment methods and analytic approaches, each yielding different rates of depression (Roberts et aI., 1998). Data from the 2000 Census show that one in eight people in the United States is of Hispanic origin, and Hispanic youth represent 16% of the population under the age of 18 years. People of Mexican origin constitute the largest majority of Hispanics, with 66.1% of 32.8 million Hispanics in the United States of Mexican descent (U.s. Census Bureau, 2000). There are nearly 1.4 million immigrants living in the metropolitan Chicago area and that number continues to rise (Avila & Mastony, 2003). Because of the growth of the Mexican immigrant population and the challenges faced in estimating and meeting the mental health needs of Mexican American children, additional research is essential. The purpose of this study is to report the prevalence of suicidal ideation and depressive symptoms in a convenience sample of Mexican American children in fourth and fifth grade living in Chicago.

ASSESSING DEPRESSION AND SUICIDAL IDEATION Numerous measures are available for assessing depressive symptoms and many of them have been used in research with Hispanic youth. While clinicians have increased flexibility with a variety of measures, it is a challenge for researchers to make comparisons in studies using different measures. Measures used. in assessment of depression among youth, authors, and years of published reports are listed in Table 1. Different cut points for defining mental health problems are often recommended for clinical populations with mental health problems and for community populations. Kovacs (1992) recommends using a score of 12-13 on the Children's Depression Inventory to identify depression in clinical populations and a score of 19-20 to identify depression in community populations. However, investigators using the CD!have also employed other cut scores for identifying children at risk for depression (Charman,

79

Depression and Suicidal Ideation

TABLE 1. Depression Years

Assessment

Measures

Utilized With Youth Over 30

Measure

Author

Year

Beck Depression Inventory Center for Epidemiological Studies Depression Scale Diagnostic Interview Schedule for Children

Guiao & Esparza Roberts & Chen

1995 1995

Bergeron, Valla, & Breton Jensen et al. Kashani et al. Shaffer, Fisher, et al. Velez & Cohen Bird et al. Costello et al. Gomez-Beneyto et al. Jensen et al. Offord et al. Sawyer, Sarris, Baghurst, Cornish, & Kalucy Verhulst, Berden, & Sanders-Woudstra Connell, Irvine, & Rodney Ekblad Esser, Schmidt, & Woerner Matsuura et al. McGee, Silva, & Williams Minde Morita, Suzuki, Suzuki, & Kamoshita Rutter, Cox, Tupling, Berger, & Yule Rutter, Tizard, & Whitmore Earls Earls Earls & Richman Richman, Stevenson, & Graham

1992 1995 1987 1996 1988 1988 1988 1989 1995 1987 1990

Internalizing Dimension of the Child Behavior Checklist

Rutter Scale

Behavior Screening Questionnaire

1985 1982 1990 1990 1989 1984 1975 1993 1975 1970 1980a 1980b 1980 1975

1994; Donnelly & Wilson, 1994). The result of using different measures and different cut points for identifying depressed youth is that prevalence rates for depressive symptoms in the Hispanic population remain unclear. Based on the literature, rates of depression in Hispanic adolescents have ranged from 7.4% using DSM-IIIcriteria (Roberts & Chen, 1995; Roberts, Chen, & Solovitz, 1995) to 47.5% using the Center for Epidemiologic Studies Depression Scale (Roberts & Chen). Although a strong association between suicidal ideation and depression in adolescents has been demonstrated (Shaffer & Craft, 1999), little is known about the prevalence of suicidal ideation among younger Hispanic school children. For example, many studies report depression rates without identifying the rate of suicidal ideation (Charman & Pervova, 2001; Donnelly & Wilson, 1994; Smucker, Craighead, Craighead, & Green, 1986; Weisz, Sweeney, Proffitt, & Carr, 1993). Children who

l

III!!!! r

Cowell et al.

80

meet criteria for depression may not report suicidal ideation. Conversely, some children may experience suicidal ideation but still not meet criteria for depression. Kovacs (1992) has suggested that in community populations (not diagnosed with mental health problems) the use of the suicide item might be inappropriate iffollowup is not provided. Consequently, some investigators studying childhood depression in community samples have purposely excluded the item on suicidal ideation because follow-up is not provided (Kataoka et aI., 2003; Smucker et aI., 1986). Kovacs (1992) has further suggested that in clinical populations, the inclusion of the suicide item can be useful in intervention. Thus, it is unclear whether depression measures are sensitive to a critical symptom that can place children at risk for premature death. It is also not clear if children at high risk for depression including poverty, violence exposure, or other risk factors should be considered clinical or non-clinical in studies designed to improve mental health. MEASURING DEPRESSION USING THE CHILDREN'S DEPRESSION INVENTORY

Although many of the screening tools reported in the research literature are based on parent-reports, there is growing evidence that child self-report is reliable and valid (Romano & Nelson, 1988). The Children's Depression Inventory (CDI)(Kovacs, 1985) is the most widely used child self-report tool for measuring depression. Two European studies report depression rates of approximately 13% in adolescent samples using the cm. Specifically, in a sample of 211 Caucasian, Afro-Caribbean, and Asian 12 to 13-year-old children in London, mean cm scores ranged from 6.8 (SD = 6.2) to 7.9 (SD = 3.8). Using a cut score of 15, depression rates ranged from 12.7% to 13.5% (Charman, 1994). In a study conducted in Northern Ireland with 887 children ages 11-15, researchers found that 12%of children had scores higher than 17 on the CDI (Donnelly & Wilson, 1994). Unfortunately, making cross-cultural comparisons across these studies is hampered by the fact that neither used the standard CDI cut point of 12 or 19 as defined by Kovacs (Kovacs, 1992) for identifying cases of depression. A third study conducted longitudinally in the United States with 150 adolescents in Georgia found stable mean CDI scores that ranged from 7.61 (SD = 7.1) at baseline to 7.5 (SD = 6.1) one year later (Jones, Beach, & Forehand, 2001). While younger children were not examined in any of these studies, the scores of adolescents provide a comparison of scores in younger children. Two other studies conducted in the United States have assessed depression in young school-aged children using the cm. In neither study were ethnic distributions of the samples reported, although it can be speculated that neither included a significant portion of Hispanic children. In a sample of 273 fourth and fifth grade Utah children (Crowley & Emerson, 1996), the mean CDI score was 6.8 (SD = 7.1). An earlier study of 1,252 third through eighth grade children (Smucker et aI., 1986) in eight Pennsylvania

public schools found an overall mean

cm score

of9.09 (SD =

7.04). However, mean cm scores for the fourth and fifth graders were slightly lower at 8.61 (SD = 6.99) and 8.67 (SD = 6.94), respectively. Approximately 10% of the children in this sample scored above the non-clinical cut-off of 19.

...

Depression and Suicidal Ideation

81

Worchel, Nolan, and Willson (1987) examined the incidence of depression in 304 Texas school-aged (6-11 years old) and adolescent children to identify differences in cm scores by age, gender, and race/ethnicity. In this sample, 28% of the children scored in the depressed range, with 21 % scoring between 12 and 19 on the cm, and 7% receiving cm scores greater than 19. More children in the 6-11 year

age range (13%)had scores exceeding 19 than did younger adolescents (6%) or older adolescents (5%).In addition, more girls (12%)reported high cm scores than boys (2%). The authors reported no differences in cm scores by race/ethnicity. However, only 11% (n = 33) of the sample was Hispanic and there may not have been sufficient power to detect differences for racial/ethnic group. Jaycox and colleagues (2002) reported cm scores among immigrant third through eighth grade children, aged 8-15, in Los Angeles who were Hispanic (mostly Mexican), Korean, Western Armenian, or Russian. They examined the unique contribution of violence exposure to post-traumatic stress disorder (PTSD) symptoms and depression as assessed by the CD!. The researchers elected to omit item 9, suicidal ideation. They utilized a cut score of 18 and found that 16% of all children were in the clinical range or in need of further diagnostic examination. The reliability for this heterogeneous sample of immigrant children was high with a Cronbach's Alpha of .82. In a follow-up article (Kataoka et aI., 2003), the baseline measures of only the Hispanic children were reported. Among the Hispanic children, 57% were from Mexico, 19% from EI Salvador, 11% from Guatemala, and 13% were from other Latin American countries. The mean cm score was 16.3 (SD = 6.9). In this sub-sample, the reliability was even higher with a Cronbach Alpha coefficient of .89. In general, there is very little research on the prevalence of depression among grade school children using the cm and even less research on depression in Hispanic children. Given the increasing numbers of Hispanic children living in the United States and the likelihood that depression originates sometime during the years preceding adolescence, research on the prevalence of depression among Hispanic children prior to 12 years of age is needed.

ESTIMATING SUICIDAL IDEATION The CDI includes one item asking the child the extent to which he or she has considered suicide in the past 2 weeks. Respondents have the option to indicate whether they "never think about killing myself' (scored as 0), "think about killing myself, but wouldn't do it" (scored as 1), or "would want to kill myself' (scored as 2). A score of 1 or 2 is considered endorsement of suicidal ideation (Kovacs, 1992). Donnelly and Wilson (1994) found that adolescent boys and girls in Northern Ireland endorsed this item 4% of the time. In a study of Spanish 11- and 12-year-old children, 18%of ll-year-old girls and 21% of 12-year-old boys endorsed this item (Domenech et aI., 1992). Four cm studies in the United States among samples of school-aged children did not report suicide ideation rates (Crowley & Emerson, 1996; Jones et aI., 2001; Kataoka et aI., 2003; Smucker et aI., 1986).

III

..

Cowell et al.

82

Roberts, Chen, and Roberts (1997) utilized items developed in the Oregon Adolescent Depression Project (Hops, Lewinsohn, Andrews, & Roberts, 1990) to measure suicidal ideation in the previous 2 weeks and over the child's lifetime, and used the items to examine ethnic differences in a non-clinical sample of adolescents. This multi-ethnic sample (n = 4,186) included African Americans, Anglo Americans, Central Americans, Chinese Americans, Indian Americans, Mexican Americans, Pakistani Americans, Vietnamese Americans, and children of mixed ancestry. Among these adolescents, 7.3% felt hopeless, 9.1%had thoughts of death, 5.4%.wished they were dead, and 4.3% had thoughts about suicide. These rates were similar for males and females with the exception of hopelessness; females were more likely to report feelings of hopelessness (8.2%) than were males (6.3%). Among all respondents, 10.5% reported a lifetime history of suicide attempts, and 3.5% reported an attempt in the 2 weeks preceding the survey. Overall, 15.1% of respondents had a lifetime prevalence of suicide plans and 5.7% had suicidal plans in the last 2 weeks. Females reported higher rates of lifetime plans for suicidal thinking (18.2%)than males (12%).In this large sample, Mexican American adolescents demonstrated the highest rates of suicidal thinking with 23.6% reporting thoughts about suicide in the prior 2 weeks. Only Pakistani teens had higher rates of suicide attempts over the past 2 weeks (7.4%) compared to Mexican American teens (5.5%). A recent study by Tortolero and Roberts (2001) compared suicidal ideation among Mexican and European American sixth through eighth graders in New Mexico and Texas (n = 3,442). This study showed significantly higher rates of suicide ideation among Mexican American children and higher rates among females than males. Mexican American males and females reported suicide ideation rates of 19% and 27.5%, respectively, compared to 13% and 16% for male and female European American children. In another community study of sixth to eighth graders (n = 924 Anglo; 1,354 Mexican origin) the correlation of depression and suicidal thinking was high for both groups, r = .68 for Anglo children and r = .71 for children of Mexican origin (Roberts & Chen, 1995). These data demonstrate that Mexican American adolescent youth are experiencing suicidal thinking and a significant number have made plans to commit suicide. The data also show the strong relationship between depression and suicidal ideation. However, the lack of studies with younger Mexican American children leaves open the question of how prevalent these feelings and experiences are during the school-aged years before adolescence.

METHOD This study is a secondary data analysis of baseline data from a larger clinical trial with Mexican American immigrant mothers and their school-aged children in Chicago called Rush Mexican American Problem Solving Program or Rush MAPS (Cowell, Ailey, McNaughton, & Gross, 2002). Rush MAPS is a home visiting intervention that is designed to promote mental health and family functioning and improve

II

----

rDepression

and Suicidal

Ideation

83

school behaviors of Mexican American immigrant mothers and their fourth and fifth grade children. The Institutional Review Board of the Office of Research Affairsat the Rush UniversityMedicalCenter approved the study. SAMPLE All children and their mothers were recruited through schools in three Chicago neighborhoods during the fall and spring semesters of the 2001-2003 academic years. Two of the neighborhoods are characterized as international with over 30 languages other than English identified as the primary language in study schools. The third neighborhood is characterized as mostly Hispanic with residents selfidentifying as Mexican. Eligibility criteria for participants included a mother born in Mexico, with a fourth or fifth grader enrolled in study schools. Further, children were eligible if their mother was born in Mexico, if they were enrolled in a regular education class, and if they were the only child in the family enrolled in the study. In the parent study, data ,were collected from 182 mothers and children in the first three recruitment waves. Recruitment was conducted in several steps. First, a notification was sent home to all fourth and fifth grade children of Mexican origin with brief information about the study and a form indicating their interest in participation to be signed and returned if the mother was interested in the study. If a mother was interested in participating, a home visit was conducted to obtain informed consent, assent from the child and to complete the study questionnaires. These 182 mothers and children constituted the sample of this secondary analysis. Study children were on average 10.2 years old (SD = .82), and the mean age for their mothers was 36 years (SD = 7.0). The average length of time the families had lived in the United States was 12.2 years (SD = 7.4). Most (82.9%) of the mothers were married or living with a partner and most families (78.6%)reported total household incomes of less than $500/week. All but two children met federal criteria for free lunch. Almost half (48.9%) of the mothers reported having no formal education or only a primary school education. Table 2 illustrates selected demographic characteristics of the sample. MEASURES

AND PROCEDURES

After informed consent was signed, data were collected in the home or at a private location of the mother's choice, such as a school or local library. To assure an understanding of the survey, data collectors read the surveys with mothers and children. Mothers completed a demographic background form, family measures, and a stress assessment. Children completed the CD!, self-esteem and self-concept measures, and a stress index. The survey took from 60 to 90 minutes to complete with both mother and child. Only the demographic and CDI data are presented in this report to describe the rates of depression and suicide ideation. Child Depression Inventory. The Child Depression Inventory (Kovacs, 1992) is a 27 -item self-rated depression scale intended for use with children 3-13 years old. Each item is rated on a scale of 0 (indicating no evidence of this symptom) to 2 (a clear manifestation of the symptom). Items are summed to yield a score of 0-54,

I

Ii I;: Ii

r 84

Cowell et al.

TABLE 2. Demographic Children

Characteristics

Variable Maternal age (in years) Maternal length of time in US (inyears) Marital status Married or partnered Single Education < 6th grade ;?: 6th grade Annual household income :5

$500/week

> $500/week Child age (in years) Gender Boys Girls

of Participating Mean

Mothers and or %

36.0 12.2

SD or n (7.0) (7.4)

82.9% 17.1%

(151) (31)

48.9% 51.1%

(89) (93)

78.6% 21.4% 10.2

(143) (39) (0.8)

46.2% 53.8%

(84) (98)

Note. n = 182 mothers and 182 children.

with higher scores indicating more depressive symptoms. Kovacs (1992) recommended using a cut score of 12-13 for identifying depression in clinical populations and a cut score of 19-20 for identifying depression in community populations. The CDIwas originally normed on a sample of 2,532 children (age 2-16 years) enrolled in Florida public schools. Kovacs (1992) described this normative sample as predominantly middle-class. Although race/ethnicity data were not collected, the author estimated that 77%of the children were White and 23% were African American, American Indian, or Hispanic. No further information about the racial! ethnic distribution of this normative sample was provided. Kovacs (1992) reported mean CDI scores for school-aged children (7-12 years old) in the normative sample as 10.8for boys, 9.0 for girls, and 9.8 for the total group. Validityhas been supported in studies demonstrating significant positive associations between CDIscores and children's more negative perceptions and cognitive distortions (Kendall, Stark, & Adam, 1990; Worchel, Little, & Alcala, 1990). A bilingual data collector administered the CD! in English to the children. The CD! is not commercially available in Spanish. However, in the event that children had questions about the meaning of CD! items, all data collectors were trained to use standard Spanish language responses to children's questions. To arrive at these standard responses, the English language version of the CD! was translated and then back-translated using two bilingual Spanish-speaking nurses during both steps. At the completion of both steps, Spanish-speaking researchers reviewed the translations and worked with the first author to refine wording to assure conceptual equivalence followingthe de-centering approach recommended byVarrichio (2003). Separate focus groups with Mexican American immigrant mothers and 9- to

""

i':

85

Depression and Suicidal Ideation

TABLE 3. Means, Standard Deviations, and Subscale Reliabilities for the Children's Depression Inventory (CD!) cor (Sub)scale

Mean

SD

Minimum

Maximum

Alpha

Total CDI Negative mood Ineffectiveness Interpersonal problems Anhedonia Negative self-esteem

9.55 2.10 1.77 0.71

5.76 1.56 1.60 0.93

0.00 0.00 0.00 0.00

25.00 6.00 6.00 4.00

0.79 0.33 0.44 0.33

2.97 1.58

2.06 1.42

0.00 0.00

7.88 6.00

0.55 0.48

Note. n = 182. 12-year-old children were conducted to assess the conceptual equivalence of Spanish language explanations for the CDI items. Finally, the Spanish language explanations of each CDI item used to train the data collectors were then reviewed by a committee of native Spanish speakers from Mexico to assure their conceptual accuracy for Mexican-Americans (Cowell, McNaughton, & Ailey, 2000). The CDI includes five subscales measuring negative mood (n = six items), ineffectiveness (n = four items), interpersonal problems (n = four items), negative selfesteem (n = five items), and anhedonia (n = eight items). Alpha reliability of the cor for this sample of Mexican American fourth and fifth grade children was .79. This reliability estimate is consistent with that reported by others (see cor manual) (Kovacs, 1992). However, the alpha reliabilities for each of the subscales were low, ranging from .33-.55 (see Table 3). Given these low sub scale reliabilities, only total cor means are reported. Since we expected improvements in the experimental group, test-retest reliability was assessed on a subsample of 45 children from the control group over 20 weeks from baseline. The correlation coefficient was .66. These data indicate adequate reliability of the cor with this Mexican American sample. Suicidal Ideation. Suicidal ideation was defined as thinking about killing oneself, regardless of whether the child has a plan for suicide. In this study, suicidal ideation is measured by the child's response to item 9 on the cor. Children who endorse this item with a score of I ("1think about killing myself but I would not do it") or 2 ("1want to kill myself') are considered to be experiencing suicidal ideation.

RESULTS DEPRESSION RATES AMONG MEXICAN AMERICAN SCHOOL,AGED CHILDREN

The mean CDI score in this sample was 9.55 (SD = 5.8). There were no differences in mean cor total scores by gender; mean cor scores for girls and boys were 9.55 (SD = 6.0) and 9.52 (SD = 5.6), respectively. Although the children in this study were recruited from the community, they represent a relatively high-risk group of

F"" 86

Cowell et al.

children. Most of their families are poor and live in low-income communities characterized by limited resources and heightened crime rates. Therefore, prevalence rates for depression using the clinical and non-clinical cut points are presented. Using the CD! clinical cut point of 12, 31% (n = 56) of the children fell into the depressed range. Using the non-clinical cut point of 19, 7.8% (n = 13) of the children were in the depressed range on the CO!. SUICIDALIDEATIONAMONG MEXICANAMERICAN SCHOOL~ AGED CHILDREN Thirty-eight percent (n = 69) of the children endorsed item 9, indicating suicidal ideation. All of these children met criteria for suicidal ideation by endorsing this

item with a score of 1 ("I think about killingmyself but 1would not do it");none of the children scored themselves with a 2 on this item ("rwant to kill myself"). Followup was provided for all children endorsing item 9. Because of the strong association between depressive symptoms and suicide, a depression cut point that is sensitive to suicidal ideation is crucial. To explore the sensitivity and specificity of clinical and non-clinical cut points, two analyses were conducted. First, we examined the number of children who were experiencing suicidal ideation who also scored in the depressed range on the cor (i.e., the sensitivity of the CD! to suicidal ideation). Second, we examined the number of children who were experiencing suicidal ideation who did not score in the depressed range on the cor (i.e., the specificity of the CD! to suicidal ideation). These analyses were conducted twice, first using the CD! clinical cut point and then using the non-clinical cut point. Children who were identified as depressed with a clinical cut point of 12 were 1.54 (odds ratio [OR])times more likely to endorse suicidal ideation. Using this CD! clinical cut point, 48% (n = 27) of depressed children had suicidal thoughts. However, 33.3% (n = 42) of the children who did not meet clinical criteria for depression (CD! score", 12) also endorsed item 9. Thus, almost half of the children who fell into the depressed range were also experiencing suicidal ideation. However, one-third of the children who were having suicidal ideation were not identified as depressed using the clinical cut point 12 on the CD!. Using the non-clinical CD! cut point of 19, 7% (n = 13) of the children met the depression criteria. Among the 13 depressed children, 69% (n = 9) reported suicidal ideation (OR 1.95). However, 87% of the children (n = 60) who endorsed suicidal ideation did not meet this criterion for depression. That is, using the cor cut point score for community samples, 87% of the children who were experiencing suicidal ideation were not identified as depressed. Frequencies and percentages of children reporting suicidal ideation by clinical and non-clinical CD! cut point scores are presented in Table 4. A strong relationship between the depression total score and item 9, the suicide ideation item, was identified as anticipated, r = 0.24 (p = .001). Further, the relationship between the total depression score and the sub scale that includes item 9, negative self-esteem, was even stronger at r = 0.70 (p = 000).

87

Depression and Suicidal Ideation

TABLE 4. Number of Depressed and Nondepressed Children Endorsing Suicidal Ideation on the Children's Depression Inventory (Cm) Based on Community and Clinical Cutoff Scores Suicidal Ideation No suicidal ideation Suicidal ideation Total

cm < 12

cm", 12

CDI < 19

cm", 19

84 (66.7%) 42 (33.3%) 126 (69.2%)

29 (51.8%) 27 (48.2%) 56 (30.8%)

109 (64.5%) 60 (35.5%) 169 (92.6%)

4 (30.8%) 9 (69.2%) 13 ( 7.1%)

Note. Recommended CDI cutoff score for identifying depression in community samples is 19; recommended CDI cutoff score for identifying depression in clinical samples is 12. n = 182.

CDIITEM RESPONSES Numerous studies have shown gender differences in depression as well as differences in presentation of depression symptoms (Domenech et a!., 1992; Donnelly & Wilson, 1994; Smucker et a!., 1986). Although total cm scores did not differ by gender, we examined whether there were gender differences on individual item responses to ascertain whether symptoms presented differently in boys and girls. Using a p-value of .01 (to correct for multiple t-tests), two items were significantly different by gender. Boys scored higher than girls on self-deprecation (item 3, "I do most things OK," "I do many things wrong," or "I do everything wrong") (M = .33, SD .57 versusM = .14, SD = .43, t=2.57, dJ= 180,p = .01). Girls scored higher than boys on fatigue (item 17, "I am tired once in a while," "I am tired many days," or "I am tired all the time") (M = .42, SD = .72 versus M = .19, SD = .48, t = -2.48, dJ = 180, P = .01). There were no significant differences between boys and girls on mean item response to suicide ideation (item 9). Percentages of children endorsing each of the items on the cm by score of "0," "1" or "2" are presented in Table 5. The items were further examined to identify those on which over 50% of the children endorsed some degree of depressive symptomatology. Three items on the CDI received scores of 1 or 2 by over half of the children. Approximately 60% of the children in this sample were experiencing pessimistic worry (item 6), with 51.6% scoring 1 ("things bother me many times") and 8.8% scoring 2 ("things bother me all of the time"). Approximately 52%of the children had self-deprecating thoughts (item 3), with 40.3% feeling they do "many things wrong" and 2.2% feeling they do "everything wrong." Finally, 50.5% of the children reported somatic concerns (item 19) with 34.1 % of the children worrying about aches and pains "many times" and 16.5% worrying about aches and pains "all of the time." Finally, the item responses displayed in Table 5 show most children did not report feeling sad or experiencing self-hate. That is, although 7.8-31 %ofthe children were scoring in the depressed range (depending on whether a clinical or non-clinical cut point score is used), 89% of the children reported feeling sad only "once in awhile" and 92.8% reported that "I like myself."

r I I

II

Cowell et al.

88 TABLE 5. Item Responses Percent Responses CDI Item

on the Children's

1. Sadness 2. Pessimism 3. Self-deprecationa 4. Anhedonia 5. Misbehavior 6. Pessimistic worry 7. Self-hate 8. Self-blame 9. Suicidal ideation 10. Crying spells 11. Irritability 12. Reduced social interest 13. Indecisiveness 14. Negative body image 15. Schoolwork difficulty 16. Sleep disturbance 17. Fatigueb 18. Reduced appetite 19. Somatic concerns 20. Loneliness 21. School dislike 22. Lack of friends 23. School performance decrement 24. Self-deprecation via peer comparison 25. Feeling unloved 26. Disobedience 27. Fighting

Depression

Inventory

0 89.0 47.5 80.7 53.3 92.3 39.9 92.8 64.3 62. I 92.3 86.3 85.2 53.3 61.5 54.9 71.4 77.2 71.3 49.5 71.3 63.2 59.7 73.1 57.1 80.8 68.7 87.2

(CD!) by 2

8.2 40.3 15.5 46.1 6.1 51.6 5.0 30.8 37.9 6.1 9.9 13.7 34.6 31.9 26.4 22.0 13.9 11.6 34.1 26.0 34. 1 38.7 14.3 35.7 18.1 30.8 12.2

2.7 2.2 3.9 0.6 1.7 8.8 2.2 4.9 0.0 1.7 3.8 1.1 12.1 6.6 18.7 6.6 8.9 17.1 16.5 2.8 2.7 1.7 12.6 7.1 1.1 0.5 0.6

Note. aBoys endorsed item #3 at a higher rate than girls, p < .01. bGirls endorsed item # 17 at a higher rate than boys, p < .0 I. CDI scores: 0 = no manifestation of the symptom, 1 = mild manifestation of the symptom, 2 = more severe manifestation of the symptom. n = 182.

DISCUSSION There are several important findings from this study. The mean CD!score obtained in this sample of Mexican American school-aged children (9.55) is comparable to the mean CDI score reported by Kovacs (1992) for the normative sample (9.8). In addition, the number of Mexican American children falling into the depressed range on the CD! is somewhat comparable to the rates reported in other studies. Using the non-clinical cut score recommended for community samples, 7.8% of the children were classified as depressed. This rate is consistent with that reported by Worchel and colleagues (1987) who found that 7% of the children in their sample

....

Depression and Suicidal Ideation

89

received total CDI scores greater than 19. These results suggest that the depression scores of the Mexican American school-aged children in this sample are consistent with those obtained for non-Hispanic normative samples. However, cross-sample and cross-cultural comparisons cannot be made because those studies that have examined CDI scores in school-aged children have lacked either sufficient information about the ethnic distributions of their samples or included too few Hispanic children to obtain valid estimates of depressive symptoms in that population. Although 7.8% of the children scored in the depressed range when cases were identified using the non-clinical cut point recommended for community samples, 3 I% of the children scored in the depressed range when the CDI clinical cut point score of 12was used. Deciding which criterion to use for identifying depression cases is important for obtaining meaningful estimates of depression risk in youth. The families were under-educated, lived in low-income communities with limited culturallyappropriate resources, and nearly 75% of them were extremely poor. Therefore, depression rates were estimated using both criterion scores. Under these circumstances, we speculate that few of the children who might need mental health services are likely to receive them even if income levels would permit (Echeverry, 1997; USDHHS, 2001). We suggest that low-income Mexican American children in the community represent a high-risk population and that using the more conservative cm score criterion of 12 for identifying cases of depression may be warranted. More research with larger populations of Mexican American children is needed to obtain valid estimates of depressive symptoms and to compare those distributions with those from normative samples originally used to create cm cut point scores. Thirty-eight percent of the children endorsed the suicide ideation item 9. Although none of the children indicated that they wanted to kill themselves (i.e., none endorsed a score of 2 on this item), the findings indicate that well over one-third of the Mexican American children thought about killing themselves. This rate represents a higher endorsement rate than has been previously reported in community studies of adolescents, which have ranged from 4% for Irish youths (Donnelly & Wilson, 1994) to 27.5% for Mexican American middle-school girls (Tortolero & Roberts, 2001). Also perplexing, the correlation between the suicide ideation item and total score was .24 compared to a correlation of. 71 for Mexican American children in sixth to eighth grade in previous research (Roberts & Chen, 1995). Since previous research with young children before adolescence has not reported suicidal ideation, it is unclear whether the rate obtained for the Mexican American children in this study is an aberration. However, the data highlight the importance of further study to determine whether Mexican American school-aged children are at increased risk for suicidal behavior. Of even greater interest is that many of the children endorsing suicidal ideation would not have been classified as depressed based on CDI criteria, thus suggesting they may endorse the item for other reasons. Using the non-clinical cut point of 19, 87% of the children who endorsed suicidal ideation were not identified as depressed on the CD!. Although using the more conservative clinical cut point of 12 increased the chance of identifying children with suicidal ideation, 33.3% would still have not met the screening criterion for depression. This suggests that even

r'"'

90

Cowell et al.

when using a clinical cut point for identifying depression, many Mexican American children would still risk "falling through the cracks" if endorsing item 9 were to represent suicidal ideation. Although over 50% ofthe children reported pessimism, self-deprecating thoughts, and somatic concerns, 92.8% reported that they liked themselves and 89%indicated that they felt sad only "once in awhile." Such inconsistencies in the pattern of symptoms the children endorsed may partly account for the poor subscale reliability coefficients obtained in this sample, which ranged from .33-.55. These data suggest that the CD! symptoms may have different meanings for Mexican American children than for children of other ethnicities (Knight & Hill, 1998). More research using larger samples of Mexican American children is needed to determine whether items on the CD! function differently across different racial and ethnic groups of children. Mexican American adolescents have demonstrated higher fatalism and pessimism rates than their non-Hispanic peers. Furthermore, pessimism has been a predictor of increased depression Goiner, Perez, Wagner, Berenson, & Marquina, 2001). The unanticipated relationship between the total depression score and endorsement of suicidal ideation may be related to fatalistic or pessimistic thinking in a young school-aged population of Mexican American children. Future research should include measures that would help to delineate this relationship. Several methodological limitations of this study warrant discussion. The sample studied is a relatively small, nonrandom sample of Mexican American children in Chicago. That these families were recruited as part of a larger intervention study designed to support Mexican American immigrant families may have led to the selection of families experiencing more emotional turmoil. As a result, the sample may have been biased toward children with higher rates of depressive symptoms and suicidal thought. However, it is equally plausible that the sample was biased toward healthier families who understood the importance of health promotion and prevention interventions for their children and were able to access needed services made available through this clinical trial. Participation rates among eligible participants across schools range from 18.6% to 46.9%. Unfortunately, because of the relative lack of epidemiological data on depression among young Mexican American school-aged children, it is difficult to discern how this sample compares with the Hispanic child population means and distributions. More research is needed to estimate the reliability and validity of the cm for Mexican American children. Although we took numerous steps to train data collectors on providing accurate Spanish language explanations for the cm items, more research is needed on understanding the validity of the cm for Mexican Americans. This need is highlighted by the finding that although 38% endorsed suicidal ideation, few children disliked themselves or felt sad, two common symptoms of depression. The mental health needs of Mexican American children are of national concern. The call to address the needs is reflected in official publications (USDHHS,2001). The beginning research base, showing the high rates and presentation of symptoms among Mexican American children, clarifies the call to action. Researchers and clinicians are now alerted to the call and need to expand research efforts to address the mental health needs of Mexican American children.

--.

Depression and Suicidal Ideation

91

REFERENCES Andrews, ]. A., & Lewinsohn, P. M. (1992). Suicidal attempts among older adolescents: Prevalence and co-occurrence with psychiatric disorders.journal of the American Academy of Child &Adolescent psychiatIy, 31,655-662. Avila, 0., & Mastony, C. (2003, June 6). Immigrants here in record numbers. The Chicago Tribune, p. 1,4. Bergeron, L., Valla, J. P., & Breton,].]. (1992). Pilot study for the Quebec Child Mental Health Survey: Part I. Measurement of prevalence estimates among six to 14 year olds. Canadian Journal of Psychiatry-Revue Canadienne de Psychiatrie, 37, 374-380. Bird, H. R, Canino, G., Rubio-Stipec, M., Gould, M. S., Ribera, J., Sesman, M., et a!. (1988). Estimates of the prevalence of childhood maladjustment in a community survey in Puerto Rico. The use of combined measures [erratum appears in Archives of General Psychjatry, 1994,51,429]. Archives of General Psychjatry, 45, 1120-1126. Charman, T. (1994). The stability of depressed mood in young adolescents: A school-based survey. Journal of Affecuve Disorders, 30, 109-1 16. Charman, T., & Pervova, I. (2001). The internal structure of the Child Depression Inventory in Russian and UK schoolchildren. Journal of Youth & Adolescence, 30, 4 I-51. Connell, H. M., Irvine, L., & Rodney, ]. (1982). psychiatric disorder in Queensland primary schoolchildren. AustraJjan Paediatlic Journal, 18, 177-180. Costello, E.]., Costello, A.]., Edelbrock, c., Burns, B.]., Dulcan, M. K., Brent, D., et a!. (1988). Psychiatric disorders in pediatric primary care. Prevalence and risk factors [comment]. Archives of General PsychiatIy, 45, 1107-1 I 16. Cowell,]. M., Ailey, S. H., McNaughton, D. B., & Gross, D. A. (2002). Fears, experiences and mental health of Mexjcan American chMren. Paper presented at the State of the Science Congress, Washington, DC. Cowell, J. M., MCNaughton, D. B., & Ailey, S. (2000). Development and evaluation of a Mexican immigrant family support program. Journal of school Nursing, 16, 32-39. Crowley, S. L., & Emerson, E. N. (1996). Discriminant validity of self-reported anxiety and depression in children: Negative affectivity 0f independent constructs. Journal of CJjnical Child Psychology, 25, 139-146. Domenech, E., Canals, ]., & Fernandez-Ballert,]. (1992). Suicidal ideation among Spanish schoolchildren: A three-year follow-up study of a pubertal population. PersonaJjty & IndMdual Differences, 13, 1055-1057. Donnelly, M., & Wilson, R (1994).The dimensions of depression in early adolescence. Persona]jty & IndMdual Differences, 17,425-430. Earls, F. (I980a). The prevalence of behavior problems in 3-year-old children. Journal of the American Academy of ChM psychiatry, 19, 439-452. Earls, F. (1980b). Prevalence of behavior problems in 3-year-old children. A cross-national replication. Archjves of General psychiatIy, 37, 1153-1157. Earls, F., & Richman, N. (1980). The prevalence of behavior problems in three-year-old children of West Indian-born parents.journal ofCMd Psychology&psychiatIy &Amed Disdp]jnes, 21,99-106. Echeverry, J. (1997). Treatment barriers: Accessing and accepting professional help. In]. Garcia & M. Zea (Eds.), Psychological interventions and research with Latino populauons (pp. 94-107). Boston: Allyn & Bacon. Ekblad, S. (1990). The children's behaviour questionnaire for completion by parents and teachers in a Chinese sample. Journal of Child Psychology & PsychiatIy &Al]jed Disdplines, 31, 775-791.

92

Cowell et al.

Esser, G., Schmidt, M. H., & Woerner, W. (1990). Epidemiology and course of psychiatric disorders in school-age children-results of a longitudinal study. journal of Child Psychology & psychiatry &Allied Disciplines, 31, 243-263. Flores, G., Fuentes-Afflick, E., Barbot, 0., Carter-Pokras, 0., Claudio, L., Lara, M., et a!. (2002). The health of Latino children: Urgent priorities, unanswered questions, and a research agenda [comment]. journal of the American Medical Association, 288, 82-90. Gomez-Beneyto, M., Bonet, A., Catala, M., Puche, E., & Vila, V. (1989). Prevalence of mental disorders among children in Valencia, Spain. Acta psychiatricaScandinavica, Supplementum, 89,352-357. Guiao, !. Z., & Esparza, D. (1995). Suicidality correlates in Mexican American teens. Issues in Mental Health Nursing, 16,461-479. Hops, H., Lewinsohn, P. M., Andrews, J. A, & Roberts, R. E. (1990). Psychosocial correlates of depressive symptomatology among high school students. journal of Clinical Child Psychology, 19,211-220. Jaycox, L.H., Stein, B. D., Kataoka, S. H., Wong, M., Fink, A, Escudero, P., eta!. (2002). Violence exposure, posttraumatic stress disorder, and depressive symptoms among recent immigrant schoolchildren. journal of the American Academy of Child & Adolescent Psychiatry, 41,1104-1110. Jensen, P. S., Watanabe, H. K., Richters, ]. E., Cortes, R., Roper, M., & Liu, S. (1995). Prevalence of mental disorder in military children and adolescents: Findings from a two-stage community survey [comment]. journal of the American Academy of Child & Adolescent Psychiatry, 34,1514-1524. Joiner, T. E., Perez, M., Wagner, K. D., Berenson, A., & Marquina, G. S. (2001). On fatalism, pessimism, and depressive symptoms among Mexican-American and other adolescents attending an obstetrics-gynecology clinic. Behaviour Research & Therapy, 39, 887-896. Jones, D. J., Beach, S. R., & Forehand, R. (2001). Stress generation in intact community families: Depressive symptoms, perceived family relationship stress, and implications for adolescent adjustment. journal of Social & Personal Relationships, 18, 443-462. Kashani, J. H., Beck, N. c., Hoeper, E. W., Fallahi, c., Corcoran, C. M., McAllister, ]. A, et a!. (1987). Psychiatric disorders in a community sample of adolescents [erratum appears in American journal of Psychiatry, 1987, 144, 1114].American journal of Psychiatry,144, 584-589. Kataoka, S. H., Stein, B. D.,Jaycox, L.H., Wong, M., Escudero, P., Tu, W., et a!. (2003). A schoolbased mental health program for traumatized Latino immigrant children. journal of the American Academy of Child & Adolescent Psychiatry, 42,311-318. Kendall, P. c., Stark, K. D., & Adam, T. (1990). Cognitive deficit or cognitive distortion of childhood depression. journal of Abnormal Child Psychology, 18,255-270. Knight, G. P., & Hill, N. E. (1998). Measurement equivalence in research involving minority adolescents. In V.C.McLoyd & L.Steinberg (Eds.),Studying minority adolescents:Conceptual, methodological, and theoretical issues (pp. 183-210). Mahwah, NJ: Lawrence Erlbaum. Kovacs, M. (1985). The Children's Depression Inventory (CDI).Psychopharmacology Bulletin, 21,995-998. Kovacs, M. (1992). Children's Depression Inventory Manual. North Tonawanda, NY:Multi-Health Systems. Kovacs, M., Goldston, D., & Gatsonis, C. (1993). Suicidal behaviors and childhood-onset depressive disorders: A longitudinal investigation. journal of the American Academy of Child & Adolescent Psychiatry, 32, 8-20. Lewinsohn, P. M., Rohde, P., & Seeley, J. R. (1993). Psychosocial characteristics of adolescents with a history of suicide attempt. journal of the American Academy of Child&Adolescent Psychiatry, 32, 60-68.

l1li

Depression and Suicidal Ideation

93

Matsuura, M., Okubo, Y., Kato, M., Kojima, T., Takahashi, R., Asai, K., et al. (1989). An epidemiological investigation of emotional and behavioral problems in primary school children in Japan. The report of the first phase of a WHOcollaborative study in Western Pacific Region. Sodal PsycNauy & Psychiatric Epidemiology, 24, 17-22. McGee, R., Silva, P. A., & Williams, S. M. (J984). Behaviour problems in a population of seven-year-old children: Prevalence, stability and types of disorder-A research report. journal of Child Psychology & Psychiatly &Allied Disdplines, 25, 251-259. Minde, K. K. (1975). Psychological problems in Ugandan school children: A controlled evaluation. journal of Child Psychology & Psychiauy &Allied Disdplines, 16, 49-59. Morita, H., Suzuki, M., Suzuki, S., & Kamoshita, S. (J993). Psychiatric disorders in Japanese secondary school children. journal of Child Psychology & Psychiatly & Allied Disdplines, 34,317-332. National Center for Health Statistics. (2002). Unpublished data. Offord, D. R., Boyle, M. H., Szatmari, P., Rae-Grant, N. I., Links, P. S., Cadman, D. T., et al. (1987). Ontario Child Health Study. II.Six-month prevalence of disorder and rates of service utilization. Archives of General Psychiatry, 44, 832-836. Richman, N., Stevenson, J. E., & Graham, P. J. (1975). Prevalence of behaviour problems in 3year-old children: An epidemiological study in a London borough.journal ofChM Psychology & Psychiauy &Allied Disdplines, 16,277-287. Roberts, R.E., Attkisson, C. c., & Rosenblatt, A. (1998). Prevalence of psychopathology among children and adolescents. American journal of Psychiauy, 155, 715-725. Roberts, R. E., Chen, Y. R., & Roberts, C. R. (1997). Ethnocultural differences in prevalence of adolescent suicidal behaviors. Suidde & Life-Threatening Behavior, 27, 208-217. Roberts, R. E., & Chen, Y. W. (1995). Depressive symptoms and suicidal ideation among Mexican-origin and Anglo adolescents.journal of theAmerican Academy of Child&Adolescent Psychiauy, 34, 81-90. Roberts, R. E., Chen, Y. W., & Solovitz, B. L. (1995). Symptoms of DSM-lII-Rmajor depression among Anglo, African and Mexican American adolescents. journal of Affective Disorders, 36,1-9. Romano, B. A., & Nelson, R. o. (1988). Discriminant and concurrent validity of measures of children's depression. journal of Clinical Child Psychology, 17,255-259. Rutter, M., Cox, A., Tupling, c., Berger, M., & Yule, W. (1975). Attainment and adjustment in two geographical areas. I-The prevalence of psychiatric disorder. British journal of Psychiatry, 126,493-509. Rutter, M., Tizard,J., & Whitmore, K. (J970). EducaUon, health and behavior: psychological and medical study of childhood development. London: Longman Group. Sawyer, M. G., Sarris, A., Baghurst, P. A., Cornish, C. A., & Kalucy, R. S. (1990). The prevalence of emotional and behaviour disorders and patterns of service utilization in children and adolescents. Australian & New Zealand journal ofpsychiauy, 24, 323-330. Shaffer, D., & Craft, L. (1999). Methods of adolescent suicide prevention. journal of Clinical Psychiatry, 60, 70-74, discussion 75-76,113-116. Shaffer, D., Fisher, P., Dulcan, M. K., Davies, M., Piacentini, J., Schwab-Stone, M. E., et al. (J996). The NIMHDiagnostic 1nterviewSchedule for Children Version 2.3 (DISC-2.3): Description, acceptability, prevalence rates, and performance in the MECAStudy. Methods for the Epidemiology of Child and Adolescent Mental Disorders Study. journal of the American Academy of Child & Adolescent Psychiauy, 35, 865-877. Shaffer, D., Gould, M. S., Fisher, P., Trautman, P., Moreau, D., Kleinman, M., et al. (J996). Psychiatric diagnosis in child and adolescent suicide. Archives of General Psychiauy, 53, 339-348.

.

.

,

".,.

94

Cowell et al.

Silberg,]., & Rutter, M. (2002). Nature-nurture interplay in the risks associated with parental depression. In S. H. Goodman & I. H.GotIib (Eds.),Childrenof depressed parents: Mechanjsms ofrjsk and jmpJjcaUonsfor treatment (pp. 13-36). Washington, DC:American Psychological Association. . Smucker, M. R, Craighead, W., Craighead, L. W., & Green, B. J. (1986). Normativeand reliability data for the Children's Depression Inventory. journal of Abnormal Child Psychology, 14,25-39. Sourander, A., Helstela, L., Haavisto, A., & Bergroth, L. (2001). Suicidal thoughts and attempts among adolescents: A longitudinal 8-year follow-up study. journal of AlfecUve Djsorders, 63, 59-66. Tortolero, S. R, & Roberts, R E. (2001). Differences in nonfatal suicide behaviors among Mexican and European American middle school children. Sujcjde & Life-Threatenjng Behavjor, 31, 214-223. U.S. Census Bureau. (2000). Current populaUon survey: PopulaUon by sex, age, mspanjc oTigjn and race. Retrieved March 10,2003, from http://www.census.gov/population/socdemo/hispanic/p20-535/pdf u.s. Department of Health and Human Services. (1999). Mental health: A report of the Surgeon General-ExecuUve Summa!)'. Rockville, MD: Author. u.S. Department of Health and Human Services. (2001). Mental health: Culture, race, and ethnjcHy. A supplement to Mental health: A report of the Surgeon General. Washington, DC: Author. Varrichio, C. (2003). Measurement issues concerning linguistic translations. In M. FrankStromborg & j. Olsen (Eds.), Instruments for cJjnjcal health-care research (pp. 56-64). Sudbury, MA:Jones & Bartlett. Velez, C. N., & Cohen, P. (1988). Suicidal behavior and ideation in a community sample of children: Maternal and youth reports.journal of the AmeTican Academy ofChM &Adolescent Psychjatry, 27, 349-356. Verhulst, F. c., Berden, G. F., & Sanders-Woudstra, j. A. (1985). Mental health in Dutch children: (II).The prevalence of psychiatric disorder and relationship between measures. Acta PsycNatrjca Scandjnavjca Supplementum, 324, 1-45. Weisz,}. R., Sweeney, L., Proffitt, V., & Carr, T. (1993). Control-related beliefs and self-reported depressive symptoms in late childhood. journal of Abnormal Psychology, 102, 4 11-4 I8. Worchel, F., Little, V., & Alcala, J. (1990). Self-perceptions of depressed children on tasks of cognitive abilities. journal of School Psychology, 28, 97-104. Worchel, F., Nolan, B., & Willson, V. (1987). New perspectives on child and adolescent depression.journal of School Psychology, 25, 411-414. Acknowledgments.

This study is funded by NINR,ROI NR05008-0 IAI.

OffPrints. Requests for offprints should be directed to Julia Muennich Cowell, PhD, RN, FAAN, Communityand MentalHealthNursing,RushCollegeof Nursing, 1028AAC,600SouthPaulina, Chicago, IL 606 I2. E-mail: [email protected]

III