Correlates of mental disorders among minority Arab adolescents in Israel: results from the Galilee Study

Prevalence rates of any mental disorder in adolescents, according to worldwide community studies, range between 8.3 and 19.9% with a pooled prevalence of 13.4% [1]. Some studies have found higher rates of disorders in minority youth [2], while others have found lower rates [3].

Ethnic minorities are usually not homogenous and multiple inter and intra-group differences must be considered [4]. According to Adriaanse, Veling, Doreleijers & van Domburgh [5], inconsistent results related to whether minorities are better-off or worse-off than majority adolescents may depend on differing degrees of social disadvantage of the particular minority groups.

Risk factors that are particularly associated with belonging to a minority population include multiple stressors related to socio-economic disadvantage and adverse living circumstances, and limited access to health care. Daily encounters with discrimination is another risk factor for ethnic minorities [2], leading to lower self-esteem and social functioning [6]. Systematic reviews have found robust associations between perceived racial/ethnic discrimination and negative mental health outcomes, across different countries and cultures [7].

The Arab Palestinian citizens of Israel (Arabs in Israel) are an indigenous population, constituting about 18% of all Israeli citizens and 26.2% of those below 18 years of age. Over 80% of Arabs in Israel are Muslims, and the rest are mainly Druze and Christian. Ninety percent live in separated towns and villages [8]. Arabs in Israel are over-represented in all the indicators of poverty, distress and underdevelopment, with high unemployment rates and school drop-out rates [9]. In 2014, 63.5% of Arab children and adolescents lived below the poverty line compared with 21.6% of Jewish minors [10].

The Druze comprise a traditional and conservative Arabic-speaking cultural group [11] who participate in the Israeli military service. Druze men are usually employed in the security forces after completing their military service. This improves their economic status and increases their adoption of norms of the Jewish majority [12].

The Muslim Israeli citizens, on the other hand, are a non-assimilated minority, mainly due to the continuing state of conflict between Israel and the Arab world, which has placed them in the status of a hostile minority outside the national consensus [13].

The Israel Survey of Mental Health among Adolescents (ISMEHA) reported higher rates of internalizing and lower rates of externalizing disorders among Israeli Arab compared to Jewish adolescents [14]. The ISMEHA, however, assessed Israeli Arab adolescents as a single collective entity, possibly masking differences among the various subgroups [15].

The present study attempts to conduct a nuanced examination of the prevalence of mental disorders in two subgroups of adolescents comprising the Israeli Arab minority and to identify risk factors specific to these minority populations.

We hypothesized that: (1) Rates of psychopathology are higher among Muslim than among Druze adolescents; (2) Differences in rates of psychopathology are associated with economic factors rather than ethnic/religious factors.

Bi-variate analyzes on Table 1 show an association between gender and internalizing disorders only among Muslim adolescents, with females having higher rates than males. Regarding externalizing disorders, both Muslim and Druze males had higher rates of externalizing disorders than females. Regarding socio-economic index, a complex association was found among Muslim adolescents only: a very low socio-economic level was associated with a very high prevalence of internalizing disorders (19.8%) and with a very low prevalence of externalizing disorders (1.8%). Regarding number of siblings, fewer siblings were associated with higher rates of internalizing disorders among Muslim adolescents only. A high maternal GHQ score was associated with higher rates of internalizing disorders among both Muslim and Druze adolescents and with externalizing disorders among Muslim adolescents only. Regarding feelings of discrimination, a high score was associated with higher rates of internalizing disorders among Muslim adolescents only. Number of Druze adolescents with high FDI were few. Learning disability was associated with higher rates of internalizing and externalizing disorders in both Muslim and Druze groups, though number of Druze adolescents with a LD were few.

Table 2 shows that among Muslim adolescents, females were 1.5 times more likely than males to have an internalizing disorder. Those in the lowest socio-economic index were 2.4 times more likely to have an internalizing disorder than those in the low socio-economic index. Adolescents who had 1 or 2 siblings and those who had 3–4 siblings were 6.3 and 3.2 times more likely, respectively, than those who had 5 or more siblings to have an internalizing disorder. Adolescents with a learning disability were 4 times more likely than those without to have an internalizing disorder and those whose mother had a high GHQ score were 2 times more likely than those whose mother had a low GHQ score to have an internalizing disorder. Adolescents with high FDI score were 2.5 times more likely than those with a low FDI score to have an internalizing disorder.

The likelihood of having an externalizing disorder among Muslim adolescents, over and above the effect of the other variables, was as follows: males were 3.2 times more likely than females to have an externalizing disorder. Adolescents in the low socio economic index were 5 times more likely to have an externalizing disorder than those in the lowest socio-economic index. Adolescents with a learning disability were 21.8 times more likely than those without to have an externalizing disorder and those whose mother had a high GHQ score were 8.7 times more likely than those whose mother had a low GHQ score to have an externalizing disorder.

Table 2 shows that among Druze adolescents, when included in a multivariate analysis none of the independent variables examined were associated with a higher risk of having an internalizing disorder over and above the effect of the other variables, although in the bi-variate analyses LD and GHQ of the mother were found to be risk factors. Regarding externalizing disorders, LD and FDI were excluded from the regression analysis due to very small number of cases. We found that only gender represented a strong risk factor with males being 24.6 times more likely than females to have an externalizing disorder, over and above the effect of the other variables.

R-squared values ranged between .15 and .39.

The Galilee Study had as its goal to examine separately Muslim and Druze adolescents, which the ISMEHA study carried out in 2004–5 [14] had included as one single entity, in order to assess two questions. One, whether ethnicity/religion had a particular impact on prevalence of mental disorders, over and above the effect of other variables, mainly social disadvantage. The other, whether mental disorders were associated with different risk factors among Muslim and Druze adolescents. The fact that these different ethnic/religious groups reside in relatively segregated communities, have different degrees of neighborhood disadvantage and varying perceptions of suffering from discrimination by the majority population, offers a unique opportunity to examine underlying socio-economic factors that may be related to specific mental disorders in minority populations.

Regarding our first question, our findings seem reflected in Dogra’s et al., [4], statement that there is “a complex interplay between minority status and social class, with terms such as ethnicity being a proxy for multifaceted sociocultural and economic variables” (p. 265). We did find a higher prevalence of internalizing disorders among Muslim than among Druze adolescents. However, we cannot explain this finding without taking into consideration the socio-economic disadvantage of the Muslim population as compared to the Druze population or, in the words of Dogra et al. [4], the multifaceted sociocultural and economic variables that characterize the distinct ethnic/religious groups. Therefore, we cannot arrive at unreserved conclusions regarding the association between mental health and religion per se, as religion is not a discrete variable isolated from other socio-cultural and economic factors. In our study population, religion was associated with several measures of disadvantage. Muslim adolescents were in the low and lowest socio-economic levels, as compared to Druze who were in the medium and low levels. Muslim families had higher rates of welfare care than Druze families, had higher rates of adolescents with a learning disability, higher rates of maternal GHQ morbidity and much higher rates regarding feelings of discrimination than Druze adolescents. These factors present a picture of poverty and family stress, as exemplified by the fact that 23.3% of Muslim families were in welfare care, as compared to 15.3% of Druze families and by the fact that in 36.1% of Muslim families the mother had a high GHQ score, as compared to 22.8% among Druze families. Other socio-cultural factors that address the challenges facing adolescents belonging to minority groups in a disadvantaged social position are feelings of discrimination. In the case of Israel, decreed by law as a Jewish and democratic state (Basic Law: Human Dignity and Liberty, 17.3.1992), belonging to a religion/ethnicity other than Jewish brings additional discrimination and disadvantage. We also found in this respect a great disparity between Muslim and Druze adolescents, with 30.7% of Muslim declaring they feel discriminated as compared to 1.7% among Druze. Feeling discriminated against by the mainstream population and the negative impact of cultural or political mistrust are important factors affecting mental health, depression, conduct problems and well-being among minorities [6, 7, 28].

Regarding our second question, whether risk factors for internalizing and externalizing disorders differ between these two minority groups, we found marked variations that reflect the different socio-economic conditions between Muslim and Druze and their different relation vis-à-vis the dominant Jewish population. The risk factors for internalizing disorders among the Muslim adolescents were female gender, a very-low socio-economic index, having few siblings, having a learning disability, a high maternal GHQ score and feeling very discriminated. Regarding externalizing disorders (ADHD and ODD), the risk factors for Muslim adolescents were being male, having a medium socio-economic index, having 3–4 siblings having a learning disability and a mother with a high GHQ score. In contrast, these risk factors were found to be not significantly associated with internalizing disorders among Druze adolescents, over and above the effect of each other, while only gender was found to be a strong risk factor for externalizing disorders, with males being 24.6 times more likely than females to have an externalizing disorder.

Our study confirmed the finding of others [14, 29–31], regarding higher prevalence of internalizing disorders among females and higher prevalence of externalizing disorders among males. As well, our findings confirm what others have revealed, that socio-economic factors associated with ethnicity are most likely to explain mental health problems in ethnic minorities [5, 32, 33]. The socio-economic index used in this study [8], showed that nearly all Arab local authorities (N = 84), were ranked below the Israeli average and allowed to distinguish among different degrees of disadvantage, i.e., among the medium, low and very-low SES groups. Like McLeod [34], we found more internalizing disorders with decreasing socio-economic level among Muslim adolescents: those in the very- low socio-economic level were 2.4 times more likely to have an internalizing disorder than those in the level immediately above theirs. Langton, Collishaw, Goodman, Pickles & Maughan [35], claim that the gap between the very-low income group and the rest has widened and that the increase in relative inequality “might lead to a disproportionate increase in emotional problems in low-income groups” (p. 1086). This they attribute to the possibility that poorer families are exposed to more risk factors for emotional problems, such as loss of self-esteem and sense of control, and the possibility that factors associated with low income have become “more powerful risks for emotional difficulties over time” (p. 1086). Ford, Goodman and Meltzer [36] also found a greater gap between the very low socio-economic levels and those a slightly above them regarding exposure to adverse life events and maternal distress and family dysfunction. It is likely that among the Druze adolescents, who were all either in the medium or low socio-economic levels, the gap was less meaningful and the two groups were more homogenous than the Muslim adolescents who were either in the low or very-low socio-economic levels, where this gap was more significant. This would explain why among the Druze, internalizing and externalizing disorders in the bi-variate analyses showed an association with the youth’s particular characteristics (gender, LD and maternal GHQ score) rather than with measures of socio-economic level and neighborhood disadvantage.

Brody and colleagues [33] address the important contribution of economic hardship, neighborhood poverty and racial discrimination as risk factors associated with children’s and adolescents’ mental health. They acknowledge, though, that family- centered programs can provide health benefits by improving the resilience of those families living in the increased adversity of poverty and discrimination. Thiede and colleges [32] show that persistent and increasing racial inequality among Hispanic and Black Americans, compared with the White majority, bring America closer to a majority- minority society. They assess the multiple factors underlying race differences, such as having been born into poor families, being over-represented in high poverty areas and having less contact with social safety nets- all as factors associated with higher risk for mental health problems.

Over 30% of Muslim adolescents felt discriminated against by the majority, as opposed to 1.7% among the Druze. It seems that the participation of the Druze in the Israeli military and security services has given them a stronger sense of being appreciated and of being perceived as contributing to the well-being of the state of Israel, as compared with the Muslim citizens. The claim of Frantz Fanon [37] that dominant groups tend to implant their hegemony by inculcating an image of inferiority – a depreciating self-image - in the subjugated, is of particular relevance when dealing with the relations between the Jewish majority and the institutionally discriminated Muslim Israeli minority.

Regarding externalizing disorders, however, we found different trends: Muslim adolescents in the low socio-economic level were 5 times more likely to have an externalizing disorder than those in the very-low level. This finding may be explained by the excess of ADHD cases in the externalizing category and the socio-economic differential that exists in ADHD diagnoses in Israel where underdiagnoses in minorities might be very much influenced by lower socio-economic level [38]. The ISMEHA showed that in the total Israeli population, lower SES was less likely to be associated with ADHD [39]. Other studies, however, present different results and claim that ADHD is more prevalent among the more disadvantaged population [40].

We found, like Parry Langdon [41], higher rates of internalizing disorders among adolescents with fewer siblings: those with 1–2 siblings or 3–4 siblings were 7.7 and 3.1 times more likely, respectively, than those with 5 or more siblings to have an internalizing disorder. A possible link to our findings is the observation that in single-child families, children often report feelings of loneliness, boredom and inferiority [42]. Our finding, however, seems to be particular to the Israeli traditional minorities and seems not to reflect what occurs in other populations [36].

Regarding externalizing disorders, we found the opposite trend: adolescents in medium- sized families (3–4 siblings) were 3.8 times more likely than smaller families (1–2 siblings) to have an externalizing disorder. These findings may be explained by the fact that in our study almost 60% of medium-sized families were in the higher socio-economic index, where we find more diagnosed ADHD cases.

Comparing adolescents with LD and those without we found, like Prior et al., [43], a higher prevalence of internalizing disorders (5.2 times more likely) among adolescents with a LD and a much higher prevalence of externalizing disorders (20.8 times more likely), probably due to the co-occurrence of LD and ADHD.

Adolescents whose mothers had a high-risk GHQ score were 4.3 times more likely to have an externalizing disorder and 2.4 times more likely to have an internalizing disorder than those whose mothers had a low risk score. Gonzales et al., [44], describe how multiple overlapping contextual influences relevant to low-income status, like economic hardship and neighborhood disadvantage, operate together to shape parenting and ultimately affect adolescent mental health.

Our major findings stress the importance of socio-economic variables, rather than religious/ethnicity configurations, regarding adolescent psychopathology. An important finding, which needs further examination, is that adolescents in the lowest socio-economic level are at much higher risk for internalizing mental disorders than those with somewhat better socio-economic conditions. Our findings lead us to conclude that attributing mental health problems to religious affiliation alone is a mistake and that the focus of the establishment needs to shift toward changing the socio-economic conditions of minorities in the lowest socio-economic ranking and towards prevention of institutional and personal discrimination.

Before these desired structural social changes take place, however, there are measures that could be undertaken by the educational and mental health establishments to improve resilience and coping strategies of Muslim adolescents and their families living in the most adverse conditions. Schools in these localities should be prepared to provide support by increasing their counseling activities to adolescents and their families. As well, the HMOs serving these localities should be aware of the specific needs of adolescents and their families and be able to identify those in distress when preventive measures can still be employed and to refer those who need it to specialist services. Coordination between school services and community services provided by the mental health clinics for children and adolescents at the HMOs are warranted and efforts to achieve this should be carried out at the ministerial levels.

Regarding feelings of discrimination, efforts should be made to influence the judicial and legislative branches of government to enact antidiscrimination laws and protect minorities in Israel.

These findings refer to the indigenous population of Israeli Muslim and Druze citizens living in a Jewish State but have far-reaching implications for other countries where religious/ethnic variability exists.