Differences in Anxiety and Depression Among Migrant and Non-Migrant Primary School Children in The Netherlands

Abstract

This is the first Dutch study investigating symptoms of five DSM-IV-classified anxiety disorders and depression in a large sample of pre-adolescent children with and without a migration background, adjusting for socioeconomic position (SEP) and social preference. Both are potential explanatory factors for differences in mental health among migrant children. We measured anxiety and depression scores with the self-report Revised Child Anxiety and Depression Scale (RCADS) in 2063 children (aged 8–13 years, 55% girls) in the Netherlands. Surinamese/Antillean, Turkish, and Moroccan children reported significantly higher anxiety scores than Dutch children. SEP and peer rejection partly explained higher anxiety scores. Surinamese/Antillean and Turkish children reported comparable depression scores to Dutch children, but Moroccan children reported lower depression scores after adjusting for SEP and peer rejection. Girls reported higher anxiety and depression levels across all four subgroups. Although differences between children with or without a migration background were small, these may increase in later life as the prevalence of anxiety and depression increases with age.

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ORIGINAL ARTICLE
Child Psychiatry & Human Development (2024) 55:588–598
https://doi.org/10.1007/s10578-022-01454-0
Introduction
In European countries, the population of migrant youth –
rst generation foreign-born or second generation native-
born with foreign-born parents – is expanding [1]. Various
European cities have become or are close to becoming
majority-minority cities, i.e. cities in which the majority
of the population consists of people from ethnic minorities
[2]. This is also the case for Amsterdam, the Netherlands. In
Amsterdam elementary schools, the share of children from
migrant groups (henceforward migrant children) has been
about 60% of the total elementary school population over
the last decade [3, 4].
In general, the literature states that belonging to a migrant
minority increases the risk for internalizing problems [5, 6].
This is worrisome, as these problems are already highly
prevalent among youth. Anxiety and depression, both inter-
nalizing disorders, are globally among the leading causes
of mental illness and disability in children and youth [7, 8].
There are, however, also studies reporting no dierences in
internalizing problems or even less internalizing problems
in migrant children compared to children without a migrant
background [5, 9]. These inconsistencies may be explained
by study dierences in age groups, informants and measures.
The original online version of this article was revised due to unmask
the blinded contents.
Hans M. Koot
j.m.koot@vu.nl
1 Healthy Living Department, Public Health Service of
Amsterdam, Amsterdam, The Netherlands
2 Amsterdam UMC location Vrije Universiteit Amsterdam,
dept Public and Occupational Health, Amsterdam, The
Netherlands
3 Amsterdam Public Health Research Institute, Amsterdam,
The Netherlands
4 Dutch Knowledge Centre for Child and Adolescent
Psychiatry, Utrecht, The Netherlands
5 Department of Clinical, Neuro- and Developmental
Psychology, Amsterdam Public Health Research Institute,
Amsterdam, The Netherlands
6 Department of Clinical, Neuro- and Developmental
Psychology, Vrije Universiteit Amsterdam, Van der
Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
Abstract
This is the rst Dutch study investigating symptoms of ve DSM-IV-classied anxiety disorders and depression in a large
sample of pre-adolescent children with and without a migration background, adjusting for socioeconomic position (SEP)
and social preference. Both are potential explanatory factors for dierences in mental health among migrant children. We
measured anxiety and depression scores with the self-report Revised Child Anxiety and Depression Scale (RCADS) in
2063 children (aged 8–13 years, 55% girls) in the Netherlands. Surinamese/Antillean, Turkish, and Moroccan children
reported signicantly higher anxiety scores than Dutch children. SEP and peer rejection partly explained higher anxiety
scores. Surinamese/Antillean and Turkish children reported comparable depression scores to Dutch children, but Moroc-
can children reported lower depression scores after adjusting for SEP and peer rejection. Girls reported higher anxiety
and depression levels across all four subgroups. Although dierences between children with or without a migration
background were small, these may increase in later life as the prevalence of anxiety and depression increases with age.
Keywords Anxiety · Depression · Child · Migrant background
Accepted: 28 September 2022 / Published online: 2 November 2022
© The Author(s) 2022, corrected publication 2022
Dierences in Anxiety and Depression Among Migrant and Non-
Migrant Primary School Children in The Netherlands
Mia PKösters1· Mai JMChinapaw2· MariekeZwaanswijk4· Marcel Fvan derWal1· Hans M.Koot3,5,6
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Child Psychiatry & Human Development (2024) 55:588–598
First, studies dier regarding the age range of the sample
and a substantial part of the studies on dierences between
migrant and non-migrant children in internalizing problems
include samples that cover a broad range of ages, including
both children and adolescents [9–11]. Prevalence of anxiety
and depression may dier across age [12], with increasing
prevalence during adolescence [13, 14]. In addition, during
adolescence, gender dierences become more pronounced
for anxiety and become visible for depression [13, 14].
Therefore it is dicult to compare the prevalence of anxiety
and depression symptoms across studies covering dierent
age ranges.
Secondly, studies dier regarding informants. Low
agreement between child-reported and parent- or teacher-
reported anxiety and depression has been shown [15, 16].
In addition, the ethnic background of parents or teachers
has been shown to inuence the identication of childhood
anxiety and depression symptoms [17–19]. As anxiety and
depression have a strong experiential component and self-
report reects children’s own feelings, self-report is the
preferred method when studying these problems. Children’s
self-reports are considered to be reliable from age 8 years
onwards [20].
Thirdly, questionnaires used in previous studies are not
always t for assessing specic emotional problems. For
example, the Child Behavior Checklist [CBCL; 21], the
Youth Self Report [YSR; 22], and the Strengths and Dif-
culties Questionnaire [SDQ; 23] are measures to assess
emotional problems in general. The Revised Child Anxi-
ety and Depression Scale [RCADS; 24] was developed to
measure symptoms of anxiety and depression exclusively.
A disorder-specic questionnaire is able to dierentiate
between dierent types of anxiety. This is important, as the
study of Austin and Chorpita [25], in which the RCADS
was used, showed ethnic dierences between various anxi-
ety disorders. Therefore, studies using non-disorder-spe-
cic questionnaires may not nd dierences on a general
anxiety/mood scale, while there may have been dierences
between migrant and non-migrant children for specic anxi-
ety disorders.
Apart from these methodological factors, apparent dif-
ferences in anxiety and depression scores in migrant and
non-migrant children may reect dierential risk exposure.
Dierential exposure to discrimination and peer rejection
may be among the factors underlying any apparent dier-
ences. European migrant youth and young adults report
feeling discriminated [1], and compared to non-migrant
children, migrant children are more often rejected by their
native peers [26]. Peer rejection is linked to the develop-
ment of internalizing problems [27, 28]. Further, migrant
youth report more peer and social problems, and are more
often involved in bullying, whether as victim or bully or
both [29–31].
Another factor that may explain dierences in internal-
izing problems between migrants and non-migrants, is fam-
ily socioeconomic position (SEP). An important indicator
of SEP is nancial auency. Migrant families, specically
from non-western descent, are more often less auent than
families without a migration background [32], and poverty
is a risk factor for anxiety and depression in children [33,
34]. In addition, a low SEP is also a risk factor for peer
rejection [35].
Lastly, no ‘one size ts all’ approach applies to migrant
groups. For instance, their (general) migration history may
vary, as may their cultural/language background, level
of education and SEP. In the Netherlands, the three larg-
est migrant groups are from Surinam/Netherlands Antilles
(South America/Caribbean), Turkey (Middle East), and
Morocco (North Africa) [36]. Surinam and the Nether-
lands Antilles are former colonies of the Netherlands. As
schools in Surinam and the Antilles followed the Dutch
curriculum, children were not only taught Dutch as rst
language, but also Dutch history and geography lessons.
Turks and Moroccans came to the Netherlands as laborers
in the 1960’s and 1970’s, mostly being men from rural areas
and often with low education level. They were originally
expected to work temporarily in the Netherlands and then
return to their country of origin; they were called ‘guest-
laborers’. As a result, little eort was made oering services
that would help their societal integration, such as language
courses. In practice, many of these laborers stayed in the
Netherlands and had their families come over or started a
family in the Netherlands. Most Dutch migrant children are
the second generation, and thus born in the Netherlands.
However, on population level, remnants of these dier-
ences between groups still exist. For example, in Amster-
dam, the Netherlands, Surinamese/Antillean children more
often have lower educated parents than Dutch children, and
Turkish and Moroccan children more often have lower edu-
cated parents than Surinamese/Antillean children [37]. Also
in Amsterdam, Surinamese/Antillean households are often
more auent than Turkish and Moroccan households, but
less auent than Dutch households [32]. These dierences
in SEP may constitute dierent levels of risk for child inter-
nalizing problems. As for peer rejection, in a small sample
of young Dutch children, it was found that children with a
Dutch background preferred Middle Eastern/North African
children less than Black (in the Netherlands mostly Suri-
namese/Antillean) children [26].
In the present paper, we examine dierences in symp-
toms of anxiety and depression between Dutch migrant and
non-migrant children, in school-aged children from Dutch,
Surinamese/Antillean, Turkish, and Moroccan background
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Child Psychiatry & Human Development (2024) 55:588–598
using a disorder specic, anxiety and depression self-
report questionnaire, while also taking into account peer
acceptance and family SEP. We hypothesized that migrant
children would report more symptoms of anxiety and
depression than children with a non-migration background,
and that Turkish and Moroccan children would report more
symptoms than Surinamese/Antillean children. Further, we
expected that these dierences would decrease after adjust-
ing for peer acceptance or family SEP. Lastly, we expected
to nd gender dierences, as many studies reported gender
dierences for internalizing problems among youth [5]. We
examined whether this expected dierence was the same
across the various groups.
Methods
Sample
We used baseline data from a controlled trial evaluating
a preventive intervention aimed at reducing symptoms of
anxiety and depression [63]. Participants were primary
school children from grades 4 to 6 (generally 9–12 years
old) in the Amsterdam area, the Netherlands. Data were col-
lected in school years 2010–2011 and 2011–2012.
Measures
Revised Child Anxiety and Depression Questionnaire
(RCADS). The RCADS is a 47-item questionnaire that mea-
sures symptoms of anxiety and depression in children [24].
The RCADS consists of six scales, based on the DSM-IV
classication of childhood anxiety and depression (Ameri-
can Psychiatric Association, 1994): generalized anxiety
disorder (GAD), social phobia (SP), separation anxiety dis-
order (SAD), panic disorder (PD), obsessive compulsive
disorder (OCD), and major depressive disorder (MDD).
The ve anxiety scales can be combined into a total anxiety
scale, all six scales can be combined into a total internaliz-
ing scale. Examples of items are: “I worry about things”, “I
feel sad or empty”, and “I feel scared when I have to take a
test”. Children indicate how often each item applies to them
on a 4-point Likert scale (never, sometimes, often, always).
Conrmatory factor analysis with six factors showed an
acceptable t (RMSEA 0.048, TLI 0.86) and good inter-
nal consistency (alphas ranged from 0.75 to 0.95 for the
total sample and from 0.70 to 0.96 for the dierent migrant
and non-migrant subgroups) in sample including the sam-
ple used in the present study [64]. Results from discrete
multiple-group conrmatory factor analyses showed that
in the present sample the RCADS scores could be mean-
ingfully compared between boys and girls. The scores of
GAD, OCD, and MDD scales could also be meaningfully
compared between Dutch and Surinamese/Antillean, Turk-
ish, and Moroccan children. For the SP (all three migrant
groups compared to Dutch children), SAD (only for Turkish
children compared to Dutch), and PD (only for Moroccan
children compared to Dutch) scales, some minor violations
of measurement invariance were found, which impacted the
mean factor scores minimally [62].
Sociodemographic information. Children were asked to
ll in their birth date and their own and parents’ country of
birth, and the four digits of their postal code.
Migration status was based on the mother’s country of
birth, or, if the mother was born in the Netherlands, the
father’s country of birth [cf. 38]. Classication was based
on the most common migrant groups in the Netherlands:
Dutch, Turkish, Moroccan, Surinamese and Antillean. Type
of immigration was classied as rst (child was born out-
side the Netherlands) or second generation (child was born
in the Netherlands).
A SEP score could be retrieved from the family’s 4-digit
postal code. This score was based on mean household
income, percentage of low household income, percentage
of unemployment, percentage of households with a low
education level on average. Negative numbers indicate a
lower SEP and positive numbers indicate a higher SEP [39].
The composite score on the 4-digit postal code level validly
reects SEP in Dutch neighborhoods [40, 41].
Social preference scores. We used classroom social
preference scores as a measure of peer rejection [cf. 28].
Children were asked to unlimitedly nominate classmates
they liked (rejection) and did not like (popularity). Both
scores were summed and divided by the number of class-
mates minus one, as self-nomination was not allowed. By
subtracting the rejection score from the popularity score a
social preference score was computed. Low social prefer-
ence scores indicate poor acceptance by classmates and
have been widely accepted as a valid measure of peer status
[42].
Procedures
All 265 primary schools in the Amsterdam area were
invited for participation in an intervention study evaluat-
ing the eectiveness of a school-based, indicated preven-
tion program targeting anxiety and depression [63]. The 45
participating schools were not dierent from the remaining
schools regarding migrant background and SEP composi-
tion. Children and parents received an information letter
about the study and a passive informed consent form. If
children or parents did not wish to take part in the trial, they
could decline to participate.
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Child Psychiatry & Human Development (2024) 55:588–598
of background in the present sample was 53% Dutch,
15% Surinamese/Dutch Antillean, 11% Turkish, and 21%
Moroccan. The majority (94%) of the children were born
in the Netherlands. Table 1 reports the characteristics of our
sample per group.
Dierences Between Migrant and Non-Migrant
Groups
Table 1 presents the raw means and standard deviations of
the RCADS scales per group. Item means were added to
enhance comparison of scale scores. All migrant groups had
signicantly lower family SEP scores than the Dutch group.
Turkish and Moroccan children had signicantly lower
social preference scores than Dutch and Surinamese/Antil-
lean children.
Multilevel analyses adjusted for gender and age showed
that migrant children reported signicantly higher anxi-
ety scores, specically PD and OCD, than Dutch children
without a migrant background (Model 1, Table 2). Moroc-
can children also reported higher total anxiety and GAD
scores. When further adjusting for SEP, all migrant groups
reported higher OCD scores than Dutch children (Model
2). In addition, Moroccan children reported more GAD
and PD scores compared to Dutch children, and Surinam-
ese children reported higher PD scores than Dutch chil-
dren. Adjusting for social preference scores inuenced the
dierences in anxiety scores less than adjusting for SEP
(Model 3). In these analyses, all migrant groups reported
more OCD symptoms than Dutch children. Surinamese/
Antillean children also reported higher PD scores compared
to Dutch children. Moroccan children also reported higher
total anxiety, GAD, and PD scores, and lower depression
scores compared to Dutch children. The nal model (Model
4), adjusting for age, gender, SEP, and social preference,
showed that higher OCD scores were reported in all ethnic
minority groups than in Dutch children, and that higher PD
scores were more often reported in Surinamese/Antillean
and Moroccan children than in Dutch children. Moroccan
children reported lower depression scores than Dutch chil-
dren. As a sensitivity analysis to examine the inuence of
rst generation migrant children, we reran the model with-
out these children (Model 5). Although the general picture
is that anxiety scores were lower without this group, only
PD symptoms in Surinamese/Antillean children were no
longer signicantly higher compared to Dutch children,
and depression scores in Moroccan children became signi-
cantly lower than in Turkish children.
Children completed questionnaires in the classroom dur-
ing school time. Researchers or research assistants explained
the questionnaires and were available for additional clari-
cation during completion of the questionnaires.
Ethical permission for the study was granted by the Med-
ical Ethics Committee of the VU University Medical Center
Amsterdam, the Netherlands.
Analyses
Descriptive statistics were performed using SPSS Statis-
tics version 19 (IBM SPSS Statistics, 2010). Dierences
between children with and without information on SEP
were assessed using chi-square tests and a t-test.
Dierences in SEP, social preference scores, anxiety, and
depression were assessed using linear multilevel regression
analyses, as children were nested within classes and classes
within schools (Stata version 15.1 Intercooled; StataCorp
LLC). The rst series of models assessed associations
between RCADS scales and migrant group, adjusting for
gender and age. The next series of models were addition-
ally adjusted for SEP or social preference score. Gender
dierences were derived from the rst model. Moderating
eects of gender were investigated by adding a migrant x
gender interaction term to Model 4. We used a cut-o value
of p < 0.10 for testing the signicance of moderating eects
[cf. 43].
Results
Sample
Of the 3890 invited children from grades 4, 5 and 6, 115 (3%)
declined. Another 139 children (4%) dropped out before or
during data collection because of leaving school, illness or
unknown reasons. Children with another background than
Dutch, Surinamese/Dutch Antillean, Turkish, or Moroccan
(n = 826; 24%) or missing background (n = 124; 3%) were
excluded. Children for whom no information on gender
(n = 3; 0.1%) and/or SEP (n = 621; 23%) was available were
excluded from the present analyses. Children without infor-
mation on SEP were signicantly more often boys (28%
boys versus 18% girls with missing SEP; χ2 < 0.01) and were
younger (mean age: 10.3 versus 10.7 years; p < 0.01). Miss-
ing information on SEP was not selective for background
(χ2 = 0.45).
The distribution in the original sample – which also
included children from other descent than the four largest
migration groups – was 40% Dutch, 12% Surinamese/Antil-
lean, 9% Turkish, 16% Moroccan, and 24% other back-
ground (total 101% due to rounding) [64]. The distribution
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Child Psychiatry & Human Development (2024) 55:588–598
scores than their Turkish and Moroccan peers. Also unex-
pectedly, for MDD we did not nd dierences in scores
between Surinamese/Antillean, Turkish and Dutch children.
When taking peer rejection and family SEP into account,
Moroccan children’s MDD scores were even lower than
those of Dutch. Gender dierences were as expected. Girls
reported more symptoms of anxiety and depression than
boys, and this nding was consistent across all groups.
Dierences between migrant and non-migrant groups
were mainly found on specic disorder scales. This could
explain why studies using broad anxiety or internalizing
instruments or scales did not pick up dierences in specic
areas in the internalizing spectrum, specically in samples
including preadolescents. As anxiety prevalence increases
with age and anxiety symptoms at a young age are related
to anxiety in later life [13], dierences between groups with
a dierent background may get more pronounced with age
and only then become detectable using broad-band scales.
Two anxiety types were more prevalent in children from all
three migrant groups: PD and OCD. This nding is partly
in line with a previous study by Austin and Chorpita using
the RCADS in children and adolescents [25]. Both types
Gender Dierences
Girls reported more symptoms of anxiety and depression
than boys (Table 1). We found no signicant moderating
eects of gender, indicating that gender dierences were
comparable for each group.
Discussion
The present study examined dierences in symptoms of
self-reported anxiety and depression in migrant and non-
migrant preadolescent children. We found that migrant
children reported higher anxiety scores than Dutch children
without a migrant background, in particular higher PD and
OCD symptoms. Dierences were small, but signicant.
Peer rejection and family SEP partly explained dierences
between migrant and non-migrant groups; but most dier-
ences in PD and OCD remained statistically signicant after
controlling for these factors. In contrast to our hypothesis,
Surinamese/Antillean children did not report lower anxiety
Table 1 Demographic characteristics, means (standard deviations) and item means of the RCADS scales in the study sample of children aged 8–13
years, per migration group
Dutch
n = 1086
M (SD)
Surinamese/
Antillean
n = 310
M (SD)
Turkish
n = 235
M (SD)
Moroccan
n = 432
M (SD)
Age 10.7 (0.9) 10.9 (0.8) 10.8 (0.8) 10.6 (0.8)
Gender n girls (%) 608 (56%) 182 (59%) 116 (49%) 235 (54%)
Generation n 2nd (%) NA 263 (85%) 213 (91%) 375 (87%)
SEPa0.41 (1.26) -1.65 (1.25) -1.71 (1.35) -1.66
(1.18)
Social preferenceb0.15 (0.25) 0.21 (0.27) 0.13 (0.25) 0.10 (0.27)
Scale (range)
Item means
Boys GirlscBoys GirlscBoys GirlscBoys Girlsc
Total anxiety (0-111) 17.0 (13.0) 23.8 (16.4) 20.2 (15.3) 26.3 (17.6) 22.6 (14.5) 26.3 (17.1) 21.1 (18.1) 28.7 (21.8)
0.46 0.64 0.54 0.71 0.61 0.71 0.60 0.77
GAD (0–18) 3.4 (2.9) 4.4 (3.3) 4.0 (3.6) 4.8 (3.7) 4.1 (3.1) 5.0 (3.9) 4.3 (4.0) 5.3 (4.5)
0.57 0.74 0.67 0.80 0.69 0.84 0.72 0.88
SP (0–27) 5.9 (4.1) 8.5 (5.1) 6.4 (4.8) 8.6 (5.7) 7.1 (4.7) 8.9 (5.3) 6.6 (5.6) 9.0 (6.0)
0.66 0.95 0.71 0.95 0.79 0.99 0.74 0.99
SAD (0–21) 1.8 (2.5) 3.3 (3.3) 1.7 (2.5) 2.8 (3.2) 2.2 (2.4) 3.3 (3.5) 2.4 (3.3) 3.8 (4.1)
0.26 0.47 0.25 0.40 0.31 0.47 0.34 0.54
PD (0–27) 3.0 (3.2) 4.3 (4.2) 3.8 (3.5) 5.3 (4.8) 4.5 (4.2) 5.0 (4.1) 4.0 (4.5) 5.8 (5.5)
0.33 0.48 0.43 0.59 0.51 0.56 0.45 0.64
OCD (0–18) 2.9 (2.7) 3.3 (3.2) 4.2 (3.6) 4.8 (3.6) 4.6 (3.5) 4.2 (3.4) 4.0 (3.7) 4.6 (4.1)
0.48 0.55 0.70 0.80 0.77 0.70 0.67 0.77
MDD (0–30) 5.1 (3.6) 5.8 (4.0) 4.8 (3.6) 5.9 (4.1) 5.9 (4.1) 5.7 (4.3) 4.8 (4.3) 5.6 (4.3)
0.51 0.58 0.48 0.59 0.57 0.56 0.48 0.56
Note: SEP = socioeconomic position. RCADS = Revised Child Anxiety and Depression Scale. GAD = Generalized A nxiety Disorder.
SP = Social Phobia. SAD = Separation An xiety Disorder. PD = Panic Disorder. OCD = Obsessive Compulsive Disorder. MDD = M aj or De pre s-
sive Disorder. n var ies slightly per scale due to missing values. a =all ethnic minority groups had lower SEP scores (p < 0. 05 ). b = Turkish and
Moroccan children had lower social preference scores than Dutch and Surinamese children (p < 0. 05) . c = All girls had signicantly higher
scores than boys (p < 0. 05 )
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Child Psychiatry & Human Development (2024) 55:588–598
anxiety related to religious rituals and beliefs, to which OCD
symptoms are linked [47]. The migrant groups included in
our study are reported to be more religious than the Dutch
without a migration background [48–50]. The appearance
of OCD symptoms seems not related to a specic religion
[47]. That could hold in the present study: where Turks
and Moroccans are mainly Muslim, Surinamese are mostly
Christian, Hindu or Muslim, and Antilleans mainly Chris-
tian [48].
of anxiety disorder seem to reect the indirect expression
of anxiety rather than presenting feelings of anxiety as
such. As often discussed [e.g., 44], in non-Western cultures
expression of anxiety and fears through somatic complaints
as seen in PD or through ritualistic behavior as seen in OCD
seem more common and acceptable forms than right-out
statements of negative feelings or social inhibition. For
OCD, other studies also found a higher prevalence in non-
White samples [45, 46]. It may be that dierences between
migrant and non-migrant groups in OCD are a reection of
Scale Dutch Surinamese/
Antillean
B [95% CI]
Turkish
B [95% CI]
Moroccan
B [95% CI]
Model 1: Adjusted for age and gender
Total anxiety (0-111) ref 1.87 [-0.66, 4.39] 2.34 [-0.45, 5.13] 2.81 [0.49, 5.13] a
GAD (0–18) ref 0.42 [ -0.10, 0.93] 0.50 [-0.06, 1.07] 0.66 [0.20, 1.12] a
SP (0–27) ref -0.01 [-0.78, 0.76] 0.45 [-0.40, 1.30] 0.22 [-0.48, 0.92]
SAD (0–21) ref -0.30 [-0.78, 0.17] -0.10 [-0.62, 0.43] 0.22 [-0.20, 0.66]
PD (0–27) ref 0.82 [0.19, 1.45] a0.74 [0.04, 1.44] a0.97 [0.40, 1.54] a
OCD (0–18) ref 1.17 [0.67, 1.67] a1.02 [0.47, 1.57] a0.98 [0.52, 1.43] a
Depression (0–30) ref -0.01 [-0.67, 0.46] 0.15 [-0.47, 0.77] -0.39 [-0.89, 0.12]
Model 2: Adjusted for age, gender, and SEP
Total anxiety (0-111) ref 1.37 [-1.28, 4.02] 1.84 [-1.08, 4,76] 2.29 [-0.19, 4.76]
GAD (0–18) ref 0.29 [-0.25, 0.84] 0.37 [-0.23, 0.97] 0.53 [0.02, 1.04] a
SP (0–27) ref -0.11 [-0.92, 0.71] 0.35 [-0.55, 1.25] 0.12 [-0.64, 0.88]
SAD (0–21) ref -0.37 [-0.88, 0.13] -0.17 [-0.72, 0.38] 0.15 [-0.31, 0.62]
PD (0–27) ref 0.71 [0.04, 1.38] a0.63 [-0.10, 1.37] 0.86 [0.24, 1.48] a
OCD (0–18) ref 0.99 [0.46, 1.51] a0.83 [0.25, 1.41] a0.78 [0.30, 1.27] a
Depression (0–30) ref -0.27 [-0.89, 0.34] -0.02 [-0.69, 0.65] -0.56 [-1.12, 0.00]
Model 3: Adjusted for age, gender, and social preference
Total anxiety (0-111) ref 1.94 [-0.58, 4.46] 2.12 [-0.67, 4.92] 2.44 [0.12, 4.77] a
GAD (0–18) ref 0.42 [-0.09, 0.94] 0.45 [-0.12, 1.02] 0.59 [0.12, 1.05] a
SP (0–27) ref 0.02 [-0.75, 0.79] 0.39 [-0.46, 1.25] 0.12 [-0.58, 0.83]
SAD (0–21) ref -0.29 [-0.76, 0.19] -0.10 [-0.63, 0.43] 0.20 [-0.24, 0.63]
PD (0–27) ref 0.83 [0.20, 1.46] a0.69 [-0.01, 1.39] 0.87 [0.30, 1.45] a
OCD (0–18) ref 1.18 [0.68, 1.68] a0.97 [0.42, 1.52] a0.90 [0.45, 1.36] a
Depression (0–30) ref -0.05 [-0.61, 0.51] 0.09 [-0.53, 0.70] -0.53 [-1.03, -0.03] a
Model 4: Adjusted for age, gender, SEP, and social preference
Total anxiety (0-111) ref 1.41 [-1.24, 4.06] 1.59 [-1.33, 4.51] 1.87 [-0.62, 4.36]
GAD (0–18) ref 0.29 [-0.26, 0.84] 0.31 [-0.29, 0.91] 0.44 [-0.06, 0.95]
SP (0–27) ref -0.09 [-0.91, 0.73] 0.28 [-0.62, 1.18] -0.09 [-0.91, 0.73]
SAD (0–21) ref -0.36 [-0.87, 0.14] -0.18 [-0.73, 0.37] 0.12 [-0.35, 0.59]
PD (0–27) ref 0.71 [0.04, 1.38] a0.58 [-0.16, 1.31] 0.75 [0.04, 1.38] a
OCD (0–18) ref 0.99 [0.46, 1.52] a0.77 [0.19, 1.35] a0.69 [0.21, 1.52] a
Depression (0–30) ref -0.25 [-0.86, 0.36] -0.12 [-0.78, 0.55] -0.73 [-1.29, -0.17] a
Model 5: Adjusted for age, gender, SEP, and social preference (rst generation migrant children
excluded)
Total anxiety (0-111) ref 1.03 [-1.66, 3.72] 2.14 [-0.80, 5.07] 1.69 [-0.83, 4.22]
GAD (0–18) ref 0.15 [-0.42, 0.71] 0.36 [-0.26, 0.97] 0.42 [-0.11, 0.94]
SP (0–27) ref -0.21 [-1.04, 0.63] 0.53 [-0.38, 1.44] -0.01 [-0.79, 0.76]
SAD (0–21) ref -0.37 [-0.89, 0.14] -0.14 [-0.70, 0.42] 0.02 [-0.46, 0.50]
PD (0–27) ref 0.63 [-0.06, 1.31] 0.63 [-0.11, 1.38] 0.73 [0.09, 1.37] a
OCD (0–18) ref 0.92 [0.39, 1.45] a0.90 [0.33, 1.48] a0.68 [0.19, 1.18] a
Depression (0–30) ref -0.33 [-0.96, 0.30] 0.03 [-0.66, 0.71] -0.77 [-1.35, -0.19] a, b
Table 2 Dierences in RCADS
scores in Dutch children aged
8–13 years from dierent migra-
tion groups: Results of multilevel
linear regression analyses
Note: RCADS = Revised Child
Anxiety and Depression Scale.
GAD = Generalized Anxiety
Disorder. SP = Social Phobia.
SAD = Separation A nxiety
Disorder. PD = Panic Disorder.
OCD = Obsessive Compul-
sive Disorder. Ref = reference
category. SEP = socioeconom ic
position. n varies slightly per
scale due to missing values.
a Signicantly dierent from
Dutch children (p < 0.0 5) . b Sig-
nicantly dierent from Turkish
children (p < 0. 05 )
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Child Psychiatry & Human Development (2024) 55:588–598
problems in children with a migrant background. For
example, professionals identied only 30% of Turkish and
Moroccan children with parent-reported elevated psychoso-
cial problem scores, compared to 60% of Dutch children
or children from comparable countries to the Netherlands
[59]. Our study ndings underscore the importance of using
child-reported data on internalizing problems, in research
[60], as well as in practice, as they might go unnoticed if
only parents’ or clinicians’ views are used.
Problem identication should be followed by eective
and accessible mental health care. In the Netherlands, a
migration background is associated with less mental health
care use in young children and adolescents [19, 56]. It
seems that dierences in beliefs about emotional problems
and attitudes toward mental health care play a role in this, as
it was found that Turkish and Moroccan parents advocated
less active solutions towards their children’s internalizing
problems, and that Surinamese and Moroccan parents had
more fear towards mental health care compared to Dutch
parents [61]. This fear appeared to be mainly driven by the
expected shame to the family if mental health problems
would be found out by others. School-based mental health
interventions may overcome these problems, by oering
equal access for all students in a non-stigmatizing environ-
ment. Indeed, a Dutch study into a school-based preventive
intervention for children with elevated anxiety or depres-
sion scores included children from various migrant groups,
and showed that the program was equally eective among
Dutch children with or without a migrant background com-
pared to a non-intervention control group, up to twelve
months post-intervention [63]. Further, migrant children
appraised the program equally enjoyable, and even more
useful than Dutch children [65].
In addition, our ndings suggest the need for further
research into potential dierences in the nature, background
and forms of expression of anxiety problems in children
from dierent migrant groups, given the notable dierences
in symptoms of PD and OCD, but not other types of anxiety.
Another note for further research regards the study of the
immediate impact of migration on children from migrant
families. Our sample consisted largely of second generation
migrant children (i.e., born in the Netherlands, but with one
or two foreign-born parents). We performed a sensitivity
analysis to examine whether outcomes were dierent if rst
generation migrant children were excluded. The pattern of
higher anxiety scores in migrant children remained largely
the same. It is nevertheless important to dene migrant gen-
eration status – as this is unclear in many previous studies
[60] – and to examine immediate eects of migration on
types of anxiety problems and potential dierences in these
between children from dierent migration generations,
Remarkable was the absence of dierences in depression
scores for Surinamese/Antillean and Turkish children com-
pared to Dutch children, and even more surprising were the
lower depression scores in Moroccan children compared to
Dutch children. Given the high comorbidity between anxi-
ety and depression [51], one would expect to nd higher
levels of depression symptoms in groups with more anxi-
ety symptoms. It is unlikely that this nding is related to
methodological factors of the questionnaire, as no evidence
was found for migrant group-related dierential item func-
tioning of the MDD scale [62]. It could be that (expectable)
migration related dierences in depression scores only
become visible in adolescence, given that the prevalence of
depression rises during this age period [14]. In Dutch stud-
ies including older adolescents and adults, Turkish immi-
grants reported more depressive disorder than both those
from Dutch and Moroccan groups [52–54].
Our two potential explanatory variables for ethnic dif-
ferences partly explained the observed dierences between
groups in anxiety scores. As expected, we found that family
SEP was signicantly lower in migrant groups, while social
preference was lower among Turkish and Moroccan chil-
dren compared to Dutch children. Although a lower SEP
is a risk factor for mental health problems and contributes
to dierences in mental health [5], like ours, other studies
also found that SEP cannot fully explain mental health dif-
ferences between migrant and non-migrant groups [55].
However, there are many denitions and measures of SEP.
Peer rejection hardly explained dierences in anxiety and
depression scores. Previous research linked peer rejection to
internalizing problems [27, 28]. However, as these studies
investigated this relation over a longer time period, it may
be dicult to nd the same link in a cross-sectional study
like ours.
Study Implications
The ndings of this study suggest that children from migrant
families are at elevated risk for some types of anxiety prob-
lems, and qualify for mental health care at least as much
as children from non-migrant families. Despite this, these
problems often seem to go unnoticed to both parents and
mental health professionals. Several studies have shown
that for young children and adolescents in the Nether-
lands, a migration background is associated with less men-
tal health care use [19, 56]. This may be partly due to the
fact that migrant parents report less internalizing problems
than Dutch parents [57, 58]. A lack of internalizing prob-
lem identication by parents was found to be an important
mediator between migrant status and mental health care use
[19]. Moreover, there is evidence that child health care pro-
fessionals have a lower identication rate of psychosocial
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Child Psychiatry & Human Development (2024) 55:588–598
small dierences in school-aged children may become
larger in later life, and dierences in depression scores may
occur later in adolescence. Disorder specic and self-report
questionnaires can provide more detailed information about
dierences in specic anxiety types and help to identify
those children in need of mental health services. We recom-
mend more research into the causes of dierences between
migrant and non-migrant children as well as accessible
prevention programs to prevent an increase in anxiety and
depression.
Summary
Migrant children form a substantial part of today’s soci-
ety. The majority of literature shows that internalizing
problems, among which anxiety and depression, are more
prevalent in migrant children. Some studies, however, did
not nd dierences between children with and without a
migration background. Methodological factors may play a
role in these inconsistencies. Therefore, we included a spe-
cic age group (i.e., pre-adolescent children), and used the
Revised Child Anxiety and Depression Scale (RCADS), a
self-report questionnaire that measures symptoms of ve
DSM-IV-classied anxiety disorders and depression. Our
large sample (n = 2063) consisted of children from the four
largest migrant and non-migrant groups in the Netherlands:
Dutch, Surinamese/Antillean, Turkish, and Moroccan. Most
migrant children were second generation migrants, i.e., they
were born in the Netherlands but their parents were not.
Peer rejection and socioeconomic position, which are often
less favorable in migrant children, were taken into account
as potential explanatory factors. We found that Surinamese/
Antillean, Turkish, and Moroccan children reported sig-
nicantly higher anxiety scores than Dutch children. SEP
and peer rejection partly explained higher anxiety scores.
Surinamese/Antillean and Turkish children reported com-
parable depression scores to Dutch children, but Moroccan
children reported lower depression scores after adjusting for
SEP and peer rejection. Girls reported higher anxiety and
depression scores across groups. Dierences between chil-
dren with and without a migration background were small,
but these may become larger in later life as the prevalence
of anxiety disorder increases with age. It may be that the
sample was too young to detect more dierences in depres-
sion scores, as the prevalence rises in adolescence, although
it may also be possible that dierent patterns in depression
prevalence exist. We recommend using self-reported and
disorder specic data in research and practice as well as
additional research into the causes of dierences between
migrant and non-migrant children. Further, the outcomes of
the present study underscore the importance of equal access
which have been found before in adolescent migrant sam-
ples [6].
Strengths and Limitations
To our knowledge, this is the rst study examining dier-
ences in anxiety and depression scores in a large sample of
pre-adolescent migrant and non-migrant children, using an
anxiety and depression disorder specic self-report ques-
tionnaire, which also took into account family SEP and peer
rejection using standardized measures. The large sample of
school-aged children allowed us to dierentiate between the
four largest migrant and non-migrant groups in the Neth-
erlands, rather than comparing children with and without a
migration background only. This is particularly important,
as our study showed that there are dierences in demo-
graphic characteristics as well as in symptoms per group.
The low non-response rate (7%) can be regarded as
an important strength of our study. However, the sample
in the present study was smaller than the original sample
[64], because children for whom no information on gender,
migration background and/or SEP was available (n = 747)
were excluded from the analyses. Children for whom no
information about family SEP was available were younger
and more often boys. However, as missing family SEP was
not related to migration background, these missing values
are unlikely to have inuenced our ndings.
Regarding measures our study has three limitations. As
our study design did not allow us to collect data from par-
ents directly, our measure of family SEP was calculated per
postal code area and not based on parent reports of individ-
ual household income or parental educational level. Chil-
dren’s report of the postal code may have been more prone
to error than when collected from the parents. Secondly, our
denition of migration background did not allow us to take
a bicultural background into account and was only limited
for rst en second generation migrant status. Finally, for
some subscales (SP, SAD, and PD) scales, in this sample
some minor violations of measurement invariance for some
migrant groups were found [62]. However, these impacted
the mean factor scores minimally.
Conclusion
Dutch school-aged children from migrant groups self-
reported higher scores for specic anxiety problems than
their Dutch peers without migrant background, while
depression scores were similar or lower. Dierences
between groups were partly explained by family SEP and
peer rejection. Dierences were small but signicant. None-
theless, as the prevalence of anxiety increases with age [13],
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Acknowledgements The authors would like to thank Milou Koldijk,
Frouke Karel, Lisette Kamps, Sanne Grolleman, Lenneke van Tol,
Marcelle van Putten, Ilona Steenkamer and Marloes van Ede for their
contribution to the data collection, Anton Janssen for the data manage-
ment, and Marieke Buil for input on measurement invariance.
Funding This study was funded by ZonMw, the Netherlands Organ-
isation for Health.
Compliance with Ethical Standards The study was conducted in accor-
dance with the ethical standards of the 1964 Helsinki Declaration and
its later amendments. Ethical permission for the study was granted by
the Medical Ethics Committee of the VU University Medical Center
Amsterdam, the Netherlands. Passive informed consent was obtained
from all individual participants included in the study.
Open Access This article is licensed under a Creative Commons
Attribution 4.0 International License, which permits use, sharing,
adaptation, distribution and reproduction in any medium or format,
as long as you give appropriate credit to the original author(s) and the
source, provide a link to the Creative Commons licence, and indicate
if changes were made. The images or other third party material in this
article are included in the article’s Creative Commons licence, unless
indicated otherwise in a credit line to the material. If material is not
included in the article’s Creative Commons licence and your intended
use is not permitted by statutory regulation or exceeds the permitted
use, you will need to obtain permission directly from the copyright
holder. To view a copy of this licence, visit http://creativecommons.
org/licenses/by/4.0/.
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