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Aust N Z J Psychiatry
Aust N Z J Psychiatry
ANP
spanp
The Australian and New Zealand Journal of Psychiatry
0004-8674
1440-1614
SAGE Publications Sage UK: London, England

38642027
10.1177/00048674241246441
10.1177_00048674241246441
Articles
Research
Exploring the association of Indigeneity, social adversity status and externalizing symptoms in children and adolescents
https://orcid.org/0000-0002-7471-9769
Vance Alasdair 12
McGaw Janet 3
O’Meara Angel 2
https://orcid.org/0000-0002-0572-1179
Gone Joseph P 4
Eades Sandra 5
1 Academic Child Psychiatry Unit and Developmental Neuropsychiatry Program, The Royal Children’s Hospital, The University of Melbourne, Parkville, VIC, Australia
2 Wadja Aboriginal Family Place, The Royal Children’s Hospital, Parkville, VIC, Australia
3 Faculty of Architecture, Building and Planning, The University of Melbourne, Parkville, VIC, Australia
4 Department of Anthropology and Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Cambridge, MA, USA
5 Faculty of Medicine, Dentistry and Health Sciences, Melbourne School of Population and Global Health, Parkville, VIC, Australia
Alasdair Vance, Academic Child Psychiatry Unit and Developmental Neuropsychiatry Program, The Royal Children’s Hospital, The University of Melbourne, Flemington Road, Parkville, Melbourne, VIC 3052, Australia. Email: avance@unimelb.edu.au
20 4 2024
9 2024
58 9 800808
© The Author(s) 2024
2024
The Royal Australian and New Zealand College of Psychiatrists
https://creativecommons.org/licenses/by-nc/4.0/ This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
Objective:

The relationship between Indigeneity, social adversity status and externalizing symptoms is complex and unclear. This study investigates how Indigeneity, social adversity status and externalizing symptoms are related in young people.

Methods:

A total of 132 Indigenous and 247 non-Indigenous young people aged 6–16 years were recruited from a hospital mental health outpatient service. Normality plots with statistics for social adversity status and parent-reported externalizing symptoms were completed for the two groups, matched for age, gender, mental disorder symptom severity, symptom-linked distress and impairment. Standard multiple regression was used to examine how Indigeneity moderates the relationship between social adversity status and parent-reported externalizing symptoms. A scatterplot investigated the association between Indigeneity and social adversity status in young people with parent-reported externalizing symptoms.

Results:

The distributions of the two groups and (1) social adversity status and (2) parent -reported externalizing symptoms were non-normal but acceptable for a moderator analysis. Indigeneity and social adversity status made independent significant positive contributions to externalizing symptoms. In contrast the interaction between Indigeneity and social adversity status made a nonsignificant negative trend to externalizing symptoms. A scatterplot revealed Indigeneity moderated the link between social adversity status and externalizing symptoms.

Conclusions:

High social adversity status is linked to externalizing symptoms in non-Indigenous young people but despite higher social adversity, Indigenous young people don’t necessarily externalize. Potential protective resilience factors for externalizing symptoms in the Indigenous young people need to be ascertained and nurtured. Future systematic investigations of the contribution of these protective factors to Indigenous referral pathways and management are needed. It is also crucial that increased social adversity status is addressed and managed in all young people, regardless of Indigeneity.

Australian Indigenous children and adolescents
social adversity status
externalizing symptoms
Medical Research Future Fund Million Minds Program Grant 1179461 typesetterts1
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pmcIntroduction

Higher social adversity status (SAS) is associated with increased mental health conditions including externalizing symptoms in non-Indigenous young people. Bradley and Corwyn (2002) noted that the effects of increasing SAS begin before birth, extend into adult life and are associated with decreased material and social resources and increased stress inducing conditions affecting young people and/or their parents. Importantly, the deleterious effects of higher SAS are moderated by each child and family’s characteristics and available external support systems. Currie (2009) extends the association of increasing SAS with worsening mental health in young people to emphasize its pivotal role in future higher SAS later in life and transgenerational higher SAS. Diez Roux and Mair (2010) expounded the important roles housing and local neighborhood play in mediating the relationship between increased SAS and increased mental health conditions in young people. Two major mechanisms have sought to explain this link: The social causation model outlines how increased social adversity may then lead to increased mental health conditions. Dohrenwend et al. (1992) noted the importance of social causation for women with depressive disorders and men with substance abuse/dependence disorders. In contrast, the health selection model emphasizes that increased mental health conditions may then cause sufferers to experience greater social adversity. Dohrenwend et al. (1992) explained that this model may be important for people with psychotic disorders. Link and Phelan (1995) found that both models are crucial for understanding higher SAS being linked with increased mental health conditions in young people.

In contrast, the links between SAS and mental health conditions including externalizing symptoms in Indigenous young people are complex and unclear. Shepherd et al.’s (2012) findings in a large sample of 4- to 17-year old Indigenous young people in Western Australia supported higher SAS being linked with increased mental health conditions, including externalizing symptoms. Young et al. (2017) similarly reported that Indigenous young children’s mental health and wellbeing is adversely affected by increased social adversity and they share the same risk and protective psychosocial factors for mental health as for non-Indigenous children. Other authors focus on the particular adverse effects of colonization as a major determinant of increased mental health conditions in Indigenous young people (King et al., 2009) and specifically intergenerational trauma (Atkinson, 2002; Czyzewski, 2011). Silburn et al. (2006) expounded that increased stress experienced by Indigenous young people as a result of colonization regardless of SAS may limit the mental health benefits linked with lower SAS. However, Sarche and Spicer (2008) explored unique cultural protective factors that may ameliorate colonization’s effects, specifically extended family networks and traditional parenting and child-rearing beliefs as a few of the cultural strengths American Indian and Alaska Native young people can draw on. Similarly, Andrade et al. (2006) emphasized the importance of sociocultural factors that confer protection from psychopathology for Indigenous Hawaiian young people.

A number of authors specifically explore how Indigenous young people may experience lower rates of mental health conditions including externalizing symptoms despite having increased SAS: LaFromboise et al. (2006) investigated American Indian young people with moderate to high SAS and found that higher engagement, knowledge of and immersion in traditional cultural practices, perceived community support, a warm supportive mother and absent perceived discrimination were linked with lower rates of mental health conditions, including externalizing problems. Galliher et al. (2011) similarly reported that in Navajo adolescents affirmation, belonging and exploration of traditional cultural practices, and for some young people identification with Settler culture, protected against perceived discrimination’s association with increased mental health conditions, including externalizing behaviors and substance abuse. Mileviciute et al. (2013) noted that an optimistic explanatory style moderated the relationship between negative life events (increased SAS) and mental health conditions such as depression in American Indian young people. Hopkins et al. (2014) outlined that for high-risk Indigenous families, prosocial friendships and increased SAS conferred protection for better psychosocial functioning (and lower externalizing symptoms). Recently, Fatima et al. (2022) analyzed data from the Longitudinal Study of Indigenous Children (LSIC) and noted that Indigenous children with strong cultural identity and knowledge have less social and emotional difficulties, including externalizing problems.

To date, Indigeneity, SAS and externalizing symptoms have not been investigated in clinically referred children and adolescents. Therefore, 379 young people aged 6–16 years (Indigenous 132; non-Indigenous 247) were recruited from a hospital mental health outpatient service. The two groups were matched for age, gender, mental disorder symptom severity, symptom-linked distress and impairment. Standard multiple regression was used to examine how Indigeneity moderates the relationship between SAS and parent-reported externalizing symptoms.

Method

Participants

A total of 132 Indigenous children and adolescents, aged 6–16 years, were recruited from consecutive referrals to the Wadja Aboriginal Family Place and their tertiary hospital-based Indigenous mental health team over a 4-year period. The Indigenous young people, their families and community were cared for by the Victorian Aboriginal Health Service or Victorian Aboriginal Community Controlled Health Organisations and/or the Victorian Aboriginal Child Care Agency. They were referred for a range of difficulties that overlapped but can be grouped as follows: oppositional defiant rule breaking behaviors (59%), impulse control problems (20%), depression and anxiety difficulties (16%) and other (namely learning problems (6%); 71% of these children were medicated with stimulant medication being most common (84%).

An age, gender, mental disorder symptom severity, symptom-linked distress and impairment (Rutter et al., 1975) matched clinic referred group of non-Indigenous young people (N = 247), aged 6–16 years, from 50 local primary and secondary schools was recruited as a clinical control group over a 6-year period (see Table 1). These 247 children and adolescents were screened from a total sample of 596 children and adolescents identified by teachers and/or school support staff as having coping difficulties who then referred them to specialized university clinics in metropolitan Melbourne (Australia), over a 6-year period. All 596 young people were assessed but only 247 were age, gender, mental disorder symptom severity, symptom-linked distress and impairment matched to the Indigenous group. They were referred for a range of difficulties that overlapped but can be grouped as follows: oppositional defiant rule breaking behaviors (62%), impulse control problems (23%), depression and anxiety difficulties (13%) and other (namely learning problems (8%); 68% of these children were medicated with stimulant medication being most common (85%).

Table 1. Key demographic and clinical factors in the (1) Indigenous clinical (I) and (2) non-Indigenous clinical (NI) groups.

	1
I
N = 132
M (SD)	2
NI
N = 247
M (SD)	F	p	Group differences	
Age	10.74 (3.15)	11.06 (3.44)	1.01	0.32	1 = 2	
Gender M, F	95,37	174,73	0.18#	0.67	1 = 2	
SAS	9.01 (2.01)	7.95 (1.23)	29.56	<0.0005	1 > 2, Cohen’s d = 0.64	
Median	9.00	8.00				
Skewnes (SE)	0.36 (0.25)	0.78 (0.06)				
Kurtosis (SE)	-0.17 (0.49)	0.65 (0.11)				
K-S	< 0.0005	< 0.0005				
Ext	72.30 (9.53)	68.94 (10.80)	10.53	0.001	1 > 2, Cohen’s d = 0.33	
Median	74.00	71.00				
Skewness (SE)	−0.80 (0.23)	−0.65 (0.05)				
Kurtosis (SE)	0.94 (0.45)	0.18 (0.11)				
K-S	<0.005	<0.0005				
Parent symp	1.58 (0.65)	1.59 (0.61)	0.86*	0.39	1 = 2	
Parent distress	1.48 (0.61)	1.45 (0.66)	−0.34*	0.73	1 = 2	
Parent impair	1.68 (0.51)	1.55 (0.59)	1.06*	0.29	1 = 2	
SAS: social adversity status; Ext: parent-reported externalizing symptoms; SE: standard error; K-S: Kolmogorov-Smirnov with Lilliefors correction; Parent symp: parent symptom severity of their child; Parent distress: parent report of child stress due to symptoms; Parent impair: parent report of child impairment due to symptoms on Rutter and Graham Interview Schedule.

# = 2 × 2 χ2; * = independent sample t test (df = 377).

The two groups did not differ with respect to their referring problems, their medication status or the community-based psychosocial interventions that had been trialed. All the children and adolescents met the inclusion criteria of living in a family home (and not in an institution) and attending normal primary and secondary schools. All had non-age corrected Intelligence Quotients of 70 or above (Wechsler, 2003) and none had neurological disease, endocrine disease, substance abuse/dependence disorders, personality disorders, bipolar or psychotic disorders. There was no refusal to participate. The cultural validity and reliability of the impairing patterns of symptoms in the Indigenous group were carefully and systematically determined by Indigenous mental health staff or AHLOs ensuring that each carer-identified pattern of symptoms and associated functional impairment was correctly interpreted. Trained interviewers (mental health staff) interviewed all the remaining caregivers of the non-Indigenous young people.

Measures

The Achenbach Child Behavior Checklist (CBCL) (Achenbach and Rescorla, 2001) consists of 112 behavior problem items which are rated by a parent on a 3-point scale as to how applicable each is to the child (scale: 0 = not true, 2 = very/often true). The externalizing subscale is ascertained and includes the aggressive and delinquent behaviors subscales comprised relevant symptoms. The CBCL is well researched, has adequate psychometric properties (inter-rater reliability κ > 0.80 [κ = 0.91 current sample]; Cronbach’s α> 0.80 [α = 0.90 current sample]).

The Schedule for Affective Disorders and Schizophrenia for school age children-present and lifetime version (K-SADS-PL) (Kaufman et al., 2000) is a structured diagnostic interview schedule based on Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV criteria (0 = no information, 3 = threshold), with a parent version. It was used to determine DSM-IV mental disorders from a structured clinical interview with each child’s caregiver. It has proven clinical utility, reliability (inter-rater reliability kappa > 0.75 [kappa = 0.87 current sample]) and validity.

The Rutter and Graham Interview Schedule (Rutter et al., 1975) is a semi-structured clinical interview originally developed to ascertain mental disorders presence or absence from a parent perspective. It ascertains overall mental disorder symptom severity, symptom-linked distress and impairment rated on a 0—absent, 1—mild and 2—severe, Likert-type scale. The Rutter and Graham Interview Schedule has good test–retest reliability (κ = 0.85), consistency (Cronbach’s α= 0.92) and concurrent validity.

The Parental Account of Childhood Symptoms (PACS) (Taylor et al., 1986) is a semi-structured clinical interview which was originally developed as an instrument for the measurement of children’s behavior problems as experienced at home. A trained interviewer administered the demographic section of the interview. A SAS scale (range 3–) was formed from adding a total of family income level (1–2), mother’s educational level (1–2), single parent status (0–1), sibling size (0–) and broken home status (1–2). The PACS has been demonstrated to have adequate inter-rater reliability (κ = 0.69–0.96) and Cronbach’s coefficient alphas ranged from 0.87 to 0.89.

The fourth edition of the Wechsler Intelligence Scale for Children (WISC-4) (Wechsler, 2003) was used. This provides verbal comprehension, perceptual reasoning, working memory, processing speed, and full-scale scores of measured intelligence via 10 core subtests of known intelligence domain features. The WISC-4 is well established with valid and reliable (Cronbach’s α > 0.80) normative data.

Procedure

The clinical research protocol was Hospital Ethics Committee approved (2019.207/56941). All participants and their caregivers were given verbal and written information and written informed consent was obtained from each participant’s caregiver before entering the study. Testing occurred over one session (90 minutes maximum duration) with breaks as needed. Each parent and their child were assessed in separate rooms by different trained clinical researchers (a child and adolescent psychiatry Fellow; a probationary psychologist—both under approved supervision; an Indigenous child and adolescent psychiatrist; an Indigenous clinical psychologist; and AHLOs). During the session, the parent completed the CBCL and was interviewed using the PACS demographic section, Rutter and Graham Interview Schedule overall mental disorder symptom severity, symptom-linked distress and impairment scales, and K-SADS-PL while his or her child completed the WISC-IV. The WISC-IV (10 core subtests) was administered by a probationary psychologist under the supervision of a registered psychologist. Paper versions of the psychometric measures were used.

Statistical analysis

Data analysis was performed using the Statistical Package for the Social Sciences (SPSS/SC). The two groups and (1) SAS and (2) parent-reported externalizing symptoms distributions were investigated for normality (Mishra et al., 2019) (see Table 1 and Figures 1 and 2). Missing data were filled by contacting the participants in question. Participant demographic and key clinical characteristics were compared across the two groups using one-way analysis of variance (ANOVA) or independent sample t-tests for continuous variables and chi-square tests for categorical variables (see Table 1). Standard multiple regression was performed between parent-reported externalizing symptoms (z score) in their child—dependent variable, parent-reported SAS (z score)-independent variable and Indigeneity as the moderator variable. Preliminary assumption testing was performed to ensure there were no violations of normality, linearity, outliers, missing data, multicollinearity and homoscedasticity of residuals. A scatterplot of parent-reported SAS (z score) and parent-reported externalizing symptoms (z score) was composed with linear regression lines for Indigenous and non-Indigenous participants (see Figure 3).

Figure 1. Boxplot of social adversity status (raw score) for Indigenous (yes) and non-Indigenous (no) participants.

Figure 2. Boxplot of parent-reported externalizing symptoms (T score) for Indigenous (yes) and non-Indigenous (no) participants.

Figure 3. Scatterplot of social adversity status (z score) and parent-reported externalizing symptoms (z score) with linear regression lines for Indigenous and non-Indigenous participants.

Results

The Indigenous clinical group had higher parent-reported externalizing symptoms—small effect size difference—and SAS—medium effect size difference—than the non-Indigenous clinical group (see Table 1). DSM mental disorders and Intelligence quotients for these two groups are reported in Vance et al. (2022). Normality plots with statistics for the two groups with (1) SAS and (2) parent-reported externalizing symptoms revealed that none of the groups were normally distributed for either variable (Kolmogorov–Smirnov with Lilliefors correction—p < 0.05; see Table 1). However, relevant median values, Skewness and Kurtosis values (within ±1.0), and box plot graphs revealed all the distributions were acceptable for moderator analysis (see Table 1, Figures 1 and 2; Baron and Kenny, 1986; Mishra et al., 2019).

The findings revealed that Indigeneity, SAS and externalizing symptoms had small positive correlations with each other (see Table 2). Moreover, Indigeneity (B = 2.72 [95% CI = 0.24–5.20], p < 0.05) and SAS (B = 2.69 [95% CI = 2.22–3.16], p < 0.0005) made independent significant positive contributions to externalizing symptoms. In contrast, the interaction between Indigeneity and SAS (B = −1.94 [95% CI = −3.97 to −0.09], p = 0.06) had a nonsignificant negative trend to externalizing symptoms (see Figure 3). The non-Indigenous participants appeared to manifest a trend of increasing externalizing symptoms with increasing SAS but this was not evident to the same extent in the Indigenous group (see Figure 3).

Table 2. Bivariate correlations for parent-reported externalizing symptoms (z score), social adversity status (z score), Indigeneity, and interaction between Indigeneity and social adversity status.

	zExt	zSAS	Ind	M (SD)	
zExt				0.01 (0.99)	
zSAS	0.25***			0.02 (1.01)	
Ind	0.06**	0.12***		#Ind = 132, non-Ind = 247	
intIndSAS	0.04*	0.26***	0.45***	0.02 (0.26)	
zExt: parent-reported externalizing symptoms z score; zSAS: social adversity status z score; Ind: Indigenous status; intIndSAS: interaction between Indigeneity and social adversity status.

*** p < 0.0005; **p < 0.005; *p < 0.05; #Indigenous status actual numbers.

Discussion

The Indigenous group manifest increased parent-reported externalizing symptoms and higher SAS than the non-Indigenous clinical group, consistent with the extant epidemiological literature (AIHW, 2018, 2020; Australian Bureau of Statistics (ABS), 2016) and clinical literature (Vance et al., 2022; 2023). However, these factors have not led to worse clinical impairment as the two clinical groups were matched for parent-reported mental disorder symptom severity, symptom-linked distress and the degree of impairment due to the mental disorder symptoms. Their clinical homogeneity was further evident given they did not differ in the main types of clinical problems leading to their referral to mental health services, the psychological management and/or the medications trialed at the time of their referral. Increased externalizing symptoms in Indigenous young people are crucial to recognize and appropriately manage, given the potential to promote more adaptive behaviors and prevent development of conduct disorder (Rowe et al., 2010), antisocial personality disorder and future imprisonment (Olino et al., 2010).

Higher SAS is associated with externalizing symptoms in non-Indigenous young people consistent with the extant literature (Adler and Stewart, 2010; Elgar et al., 2015; Piotrowska et al., 2015). In contrast, despite higher social adversity, Indigenous young people do not necessarily externalize. This finding is consistent with a wide ranging literature noting the possible protective factors aiding Indigenous young people in their communities and potentially decreasing externalizing symptoms (Calma et al., 2017; Dudgeon et al., 2016; Hawthorne, 2018; Prehn and Ezzy, 2020; Zubrick et al., 2010). Social and emotional wellbeing is directly proportional to the network of relationships Indigenous young people have with their family, kinship network and community (Calma et al., 2017; Dudgeon et al., 2016; Zubrick et al., 2010). Their connections to Country, Cultural practices, Ancestral Spirits and Spirits of Country are also crucial (Dudgeon et al., 2016; Hawthorne, 2018; Prehn and Ezzy, 2020). Increased number of carers for Indigenous young people may be a direct result of the extended family, kinship and community networks available for them (Calma et al., 2017; Zubrick et al., 2010). These carers frequently provide deep secure attachments and add unique culturally deep life skills for Indigenous young people (Dudgeon et al., 2016; Hawthorne, 2018).

This stands in direct contrast to a western perspective that often emphasizes the attendant risks of multiple carers associated with insecure attachment and ad hoc internalization of life skills (Claessens and Chen, 2013). A similar argument can be made for increased numbers of siblings in the home—a common finding in Indigenous households (Vance et al., 2023). Similarly, a western viewpoint often sees an increased regional location for the home address for Indigenous young people as linked to limited to access to welfare, health and educational services and employment opportunities. In contrast, such regional locations are often linked to Indigenous enclaves (‘villages’) where there are many culturally safe and appropriate resources implicitly available for young people to learn from (Vance et al., 2023). Indeed Hopkins et al. (2014) and Gennetian et al. (2012) note that Indigenous young people that move from absolute and relative poverty into socioeconomically advantaged areas may experience substantial stresses linked to relative isolation from extended family, community and cultural supports, and possibly from smaller family size with decreased sibling number. This may then be linked with increasing parent-reported externalizing symptoms, although no extant research to date verifies this change.

It is therefore crucial that Indigeneity is identified early as part of the clinical mental health assessment of young people and their families. Targeted holistic management can follow a comprehensive cultural and bio-psycho-social formulation that ensures SAS features are addressed (Bhat et al., 2020; Twizeyemariya et al., 2017). This may involve social work, welfare/legal professionals, and other health and mental health professionals working together in a culturally safe and appropriate way so all the factors outlined in a young person’s comprehensive formulation may be managed and/or advocated for. Clearly, managing SAS is imperative for all young people regardless of Indigenous status. But potential protective factors for Indigenous young people need to be ascertained and nurtured by multidisciplinary teams. From a research perspective, future systematic investigations of the contribution of key SAS factors of different magnitude to mental health referral pathways, presenting symptoms, diagnoses, psychosocial management strategies and effective medications are needed. Then, the relative contribution of particular SAS features of a young person’s presentation can guide societal resource allocation to address those factors of greatest import.

The main limitation of this study is the narrow definition of SAS factors examined. Although defined through clinical interview in a culturally valid and reliable manner, there remain many further factors in this domain to be carefully and systematically investigated in future studies. It is clear that the primary strength is our Indigenous young people being assessed by Indigenous mental health staff or AHLOs, ensuring that each impairing pattern of symptoms and associated functional impairment were correctly interpreted in the Indigenous group. Also there are no ceiling or floor effects for our measures of externalizing symptoms and SAS affecting our statistical analysis.

In conclusion, this study finds that Indigeneity is associated with increased parent-reported externalizing symptoms and higher SAS. While non-Indigenous young people appear to manifest worse externalizing problems with increasing SAS, Indigenous young people do not necessarily externalize despite higher SAS. There are a wide range of potential cultural protective factors that may help ameliorate the effect of increasing SAS. It is crucial that SAS factors of greatest magnitude are dealt with first and are managed and/or advocated for as part of treatment plans for all young people, regardless of Indigeneity. It also remains imperative to not disrupt those features that provide protection and enhance resilience for Indigenous young people and their communities and for health policy to take these into account. Future systematic investigations of the contribution of these protective factors to mental health referral pathways, assessment and management are needed.

We thank our Elder’s board, especially Uncle Herb Patten and Aunty Esther Kirby for the counsel and leadership, Karen Dally for her administrative support and Janice Dally for her data entry.

Author’s Note: Aboriginal Heritage, Alasdair Vance matrilineal Northern Wathaurung Mt Emu people; Jo Winther matrilineal Wadi Wadi Wemba Wemba people. Aboriginal Heritage, Janet McGaw by marriage to Alasdair Vance Northern Wathaurung Mt Emu people. Aboriginal Heritage, Angel O’Meara matrilineal Iman/Ghungalu and patrilineal Wiradjuri people. Joseph Gone is an enrolled member of the Aaniiih-Gros Ventre Tribal Nation of Montana, USA. Sandra Eades is a Noongar woman from Mount Barker, WA.

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This project was funded by the Medical Research Future Fund Million Minds Program Grant (1179461). The funder of this study had no role in the study design, data collection, data analysis, data interpretation, and writing of the manuscript.

ORCID iDs: Alasdair Vance https://orcid.org/0000-0002-7471-9769

Joseph P Gone https://orcid.org/0000-0002-0572-1179

Data Sharing: All Indigenous data are under the control of our governing Victorian Traditional Custodian Elder’s board. Reasonable requests made to the corresponding author will be presented to the Elder’s board, and if approved, data will be made available.
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References

Achenbach T Rescorla L (2001) Manual for the ASEBA School-Age Forms and Profiles. Burlington, VT: University of Vermont.
Adler NE Stewart J (2010) Health disparities across the lifespan: Meaning, methods, and mechanisms. Annals of the New York Academy of Sciences 1186 : 5–23.20201865
AIHW (2018) Aboriginal and Torres Strait Islander Adolescent and Youth Health and Well-Being. Canberra, ACT, Australia: AIHW. Available at: www.aihw.gov.au/getmedia/b40149b6-d133-4f16-a1e8-5a98617b8488/aihw-ihw-202.pdf.aspx?inline=true (accessed 9 August 2023).
AIHW (2020) Aboriginal and Torres Strait Islander Health Performance Framework 2020 Summary Report. Canberra, ACT, Australia: AIHW. Available at: www.indigenoushpf.gov.au/ (accessed 9 August 2023).
Andrade NN Hishinuma ES McDermott JF , et al . (2006) The national center on Indigenous Hawaiian behavioral health study of prevalence of psychiatric disorders in native Hawaiian adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 45 : 26–36.16327578
Atkinson J (2002) Trauma Trails, Recreating Song Lines: The Transgenerational Effects of Trauma in Indigenous Australia. Melbourne, VIC, Australia: Spinifex Press.
Australian Bureau of Statistics (ABS) (2016) Aboriginal and Torres Strait Islander Population. Canberra, ACT, Australia: ABS. Available at: www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/2071.0~2016~Main%20Features~Aboriginal%20and%20Torres%20Strait%20islander%20Population%20Article~12 (accessed 11 August 2023).
Baron RM Kenny DA (1986) The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology 51 : 1173–1182.3806354
Bhat SK Marriott R Galbally M , et al . (2020) Psychosocial disadvantage and residential remoteness is associated with Aboriginal women’s mental health prior to childbirth. International Journal of Population Data Science 5 : 1–14.
Bradley RH Corwyn RF (2002) Socioeconomic status and child development. Annual Review of Psychology 53 : 371–399.
Calma T Dudgeon P Bray A (2017) Aboriginal and Torres Strait Islander social and emotional wellbeing and mental health. Australian Psychologist 52 : 255–260.
Claessens A Chen J-H (2013) Multiple child care arrangements and child wellbeing: Early care experiences in Australia. Early Childhood Research Quarterly 28 : 49–61.
Currie J (2009) Healthy, wealthy, and wise: Socioeconomic status, poor health in childhood, and human capital development. Journal of Economic Literature 47 : 87–122.
Czyzewski K (2011) Colonialism as a broader social determinant of health. The International Indigenous Policy Journal 2 : 1–14.
Diez Roux AV Mair C (2010) Neighborhoods and health. Annals of the New York Academy of Sciences 1186 : 125–145.20201871
Dohrenwend B Levav I Shrout P , et al . (1992) Socioeconomic status and psychiatric disorders: The causation-selection issue. Science 255 : 946–952.1546291
Dudgeon P Calma T Brideson T , et al . (2016) The Gayaa Dhuwi (proud spirit) declaration—A call to action for aboriginal and Torres strait islander leadership in the Australian mental health system. Advances in Mental Health 14 : 126–139.
Elgar FJ Pförtner TK Moor I , et al . (2015) Socioeconomic inequalities in adolescent health 2002–2010: A time-series analysis of 34 countries participating in the health behaviour in school-aged children study. The Lancet 385 : 2088–2095.
Fatima Y Cleary A King S , et al . (2022) Cultural identity and social and emotional wellbeing in Aboriginal and Torres Strait Islander children. In: Baxter J Lam J Povey J , et al . (eds) Family Dynamics Over the Life Course: Life Course Research and Social Policies, vol. 15 . Cham: Springer, pp. 57–70.
Galliher RV Jones MD Dahl A (2011) Concurrent and longitudinal effects of ethnic identity and experiences of discrimination on psychosocial adjustment of Navajo adolescents. Developmental Psychology 47 : 509–526.21142373
Gennetian LA Sanbonmatsu L Katz LF , et al . (2012) The long-term effects of moving to opportunity on youth outcomes. Cityscape 14 : 137–167.
Hawthorne M (2018) Traditional Aboriginal healing and western medicine meet with Ngangkari project. Australian Medicine 30 : 9–10.
Hopkins KD Zubrick SR Taylor CL (2014) Resilience amongst Australian aboriginal youth: An ecological analysis of factors associated with psychosocial functioning in high and low family risk contexts. PLoS ONE 9 : e102820.25068434
Kaufman J Birmaher B Brent DA , et al . (2000) Schedule for affective disorders and schizophrenia for school-age children—Present and lifetime version (K-SADS-PL). Journal of the American Academy of Child and Adolescent Psychiatry 39 : 49–58.10638067
King M Smith A Gracey M (2009) Indigenous health part 2: The underlying causes of the health gap. The Lancet 374 : 76–85.
LaFromboise TD Hoyt DR Oliver L , et al . (2006) Family, community, and school influences on resilience among American Indian adolescents in the upper Midwest. Journal of Community Psychology 34 : 193–209.
Link BG Phelan J (1995) Social conditions as fundamental causes of disease. Journal of Health and Social Behavior 35 : 80–94.
Mileviciute I Trujillo J Gray M , et al . (2013) The role of explanatory style and negative life events in depression: A cross-sectional study with youth from a North American plains reservation. American Indian and Alaska Native Mental Health Research 20 : 42–58.
Mishra P Pandey CM Singh U , et al . (2019) Descriptive statistics and normality tests for statistical data. Annals of Cardiac Anaesthesia 22 : 67–72.30648682
Olino TM Seeley JR Lewinsohn PM (2010) Conduct disorder and psychosocial outcomes at age 30: Early adult psychopathology as a potential mediator. Journal of Abnormal Child Psychology 38 : 1139–1149.20521096
Piotrowska PJ Stride CB Maughan B , et al . (2015) Income gradients within child and adolescent antisocial behaviours. British Journal of Psychiatry 207 : 385–391.
Prehn J Ezzy D (2020) Decolonising the health and wellbeing of Aboriginal men in Australia. Journal of Sociology 56 : 151–166.
Rowe R Costello EJ Angold A , et al . (2010) Developmental pathways in oppositional defiant disorder and conduct disorder. Journal of Abnormal Psychology 119 : 726–738.21090876
Rutter M Cox A Tupling C , et al . (1975) Attainment and adjustment in two geographical areas. I. The prevalence of psychiatric disorder. British Journal of Psychiatry 126 : 493–509.
Sarche M Spicer P (2008) Poverty and health disparities for American Indian and Alaska native children. Annals of the New York Academy of Sciences 1136 : 126–136.18579879
Shepherd CJ Li J Mitrou F , et al . (2012) Socioeconomic disparities in the mental health of Indigenous children in Western Australia. BMC Public Health 12 : 756.22958495
Silburn SR Zubrick SR De Maio JA , et al . (2006) The Western Australian Aboriginal Child Health Survey: Strengthening the Capacity of Aboriginal Children, Families and Communities. Perth, WA, Australia: Telethon Institute for Child Health Research.
Taylor E Everitt B Thorley G , et al . (1986) Conduct disorder and hyperactivity II: A cluster analytic approach to the identification of a behavioural syndrome. British Journal of Psychiatry 149 : 768–777.
Twizeyemariya A Guy S Furber G , et al . (2017) Risks for mental illness in Indigenous Australian children: A descriptive study demonstrating high levels of vulnerability. Milbank Quarterly 95 : 319–357.28589608
Vance A McGaw J Winther J , et al . (2023) Country and community vs poverty and conflict: Teasing apart the key demographic and psychosocial resilience and risk factors for First Nations clinic-referred children and adolescents. Australian and New Zealand Journal of Psychiatry 57 : 1538–1546.37480284
Vance A Winther J McGaw J , et al . (2022) Key demographic and mental disorder diagnostic differences between Australian First Nations and non-First Nations clinic-referred children and adolescents assessed in a culturally appropriate and safe way. Australian and New Zealand Journal of Psychiatry 56 : 1455–1462.34875892
Wechsler D (2003) Wechsler Intelligence Scale for Children (WISC-IV), 4th Edition. London: Pearson.
Young C Hanson C Craig JC , et al . (2017) Psychosocial factors associated with the mental health of Indigenous children living in high income countries: A systematic review. Australian Health Services Research Institute 16 : 153. Available at: https://ro.uow.edu.au/ahsri/867 (accessed 12 August 2023).
Zubrick S Dudgeon P Gee G , et al . (2010) Social determinants of Aboriginal and Torres Strait Islander social and emotional wellbeing. In: Purdie N Dudgeon P Walker R (eds) Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice. Canberra, ACT, Australia: Commonwealth of Australia, pp. 93–112.
