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AUTHOR: ROBERT S. McKELVEY, LISA C. DAVIES, DAVID L. SANG, KEVIN R. PICKERING, AND HOANG C. TU
TITLE: Problems and Competencies Reported by Parents of Vietnamese Children in Hanoi
SOURCE: Journal of the American Academy of Child and Adolescent Psychiatry 38 no6 731-7 Je '99

The magazine publisher is the copyright holder of this article and it is reproduced with permission. Further reproduction of this article in violation of
the copyright is prohibited.

ABSTRACT
Objective: To determine the distribution of behavioral and emotional problems and competencies among a sample of Vietnamese children aged 4
through 18 years living in Hanoi. Method: A representative community sample of 1,526 children and adolescents was selected from 2 precincts in
Hanoi. Problems and competencies were assessed with the Child Behavior Checklist (CBCL). Results: Vietnamese children had lower mean raw scores
than U.S. norms on the CBCL's Total, Externalizing, Internalizing, and Competence scales. Boys were reported to have more externalizing problems
and girls more internalizing problems. Girls' levels of internalizing problems increased significantly with age. Conclusion: The lower levels of problems
and competencies reported in Vietnamese children may represent differences in the prevalence of psychiatric disorders, in parental perceptions of
what constitutes deviant behavior, or in parental comfort with reporting psychopathological behaviors. Further research is needed to clarify the
relationship between the reported behavioral and emotional problems of Vietnamese children and the presence of psychiatric disorders. From a clinical
perspective, the study's results suggest that levels of problems and competencies may vary significantly between different ethnic and cultural groups.
Specific clinical cutoffs used to identify children requiring further psychiatric assessment need to be established separately for different ethnic groups.
J. Am. Acad. Child Adolesc. Psychiatry, 1999, 38(6):731-737.
Key Words: behavior problems, emotional problems, psychiatric disorders, Vietnam.
The children of Vietnam have been, and continue to be, exposed to much trauma and adversity. Decades of war, disastrous postwar economic
policies, and the U.S. trade embargo left Vietnam impoverished and unable to meet the basic nutritional needs of its young and rapidly growing
population (Duiker, 1985; National Institute of Nutrition of Vietnam, 1993; San, 1991). Widespread infectious diseases, and a lack of effective
antibiotics and vaccines, left Vietnamese children vulnerable to the direct effects of insults to their developing central nervous systems and to the
indirect effects of parental loss and morbidity (Ahn and Tram, 1995; UNICEF, 1995). Economic reform and the introduction of a market economy have
led to a gradual improvement in Vietnam's standard of living, but rapid socioeconomic change has also brought new problems. As job seekers leave
the countryside for Vietnam's swelling cities, the protective structure of the traditional Vietnamese extended family is undermined, leading to an
expanding population of poorly supervised young people and street children and a sharp rise in rates of alcohol and drug abuse, conduct disorder, and
human immunodeficiency virus infection (Nhan, 1995; Trong, 1995).
Poverty, poor nutrition, chronic illness, and parental separation and loss would appear to place the children of Vietnam at high risk for the
development of psychiatric disorders (Institute of Medicine, 1989; McKelvey et al., 1997). Yet little is known of the nature and extent of
psychopathology among the children and adolescents of Vietnam. A study of an elementary school in Hanoi found that between 20% and 29% of 6-
to 12-year-old students had some type of psychiatric disorder (Tu, 1994a). A survey of patients seen in the psychiatry department of Hanoi's main
pediatric hospital, the Institute for Pediatrics, between 1990 and 1993 showed that the primary disorders treated were epilepsy and mental
retardation, with only 16% seen for "neurotic, anxiety and emotional disorders" and 2% for behavioral problems (Tu, 1994b). This distribution of
disorders seems more likely to represent the types of problems typically referred to Hanoi's 2 child psychiatrists than the true prevalence of child
psychiatric disorders in the community. Aside from these 2 studies, there are, to our knowledge, no other reports of the prevalence of psychiatric
disorders among Vietnam's child and adolescent population.
There have, however, been 2 prevalence studies of Vietnamese children and adolescents living abroad. Krupinski and Burrows (1987), using
symptom checklists followed by confirmatory clinical interviews, found that the prevalence of psychiatric disorders among Vietnamese children and
adolescents newly arrived in Australia was higher than rates found among the native-born population. Two years later, however, rates had fallen
below those of the general population. In 1988, Holzer et al. reported on a community sample of Vietnamese 10 years of age and older living in
Texas. Using the Diagnostic Interview Schedule for Children, they found that children aged 10 to 18 years had a prevalence rate of psychiatric
disorders of 36%, much higher than the rate of disorders found among community-based samples in the United States. These studies suggest that
Vietnamese-origin young people may have higher rates of disorder than the native-born populations of their host countries. However, they give little
insight into the situation of Vietnamese children in Vietnam, who, while not exposed to perilous migratory journeys, protracted stays in refugee
camps, and adjustment to vastly different cultures, nevertheless face other risks that may affect their mental health.
To plan for the mental health care of Vietnam's children and adolescents, there is a clear need for studies investigating the nature and extent of
psychopathology among Vietnam's young people (McKelvey et al., 1997). Such studies must also account for cross-cultural differences in parental
perceptions of what constitutes psychopathological symptoms in a child (Hackett and Hackett, 1993) and in the pathways by which children with
psychiatric problems enter care.
Given the very limited resources available in Vietnam for the assessment and treatment of psychiatric problems in children and adolescents, there
is also a need to develop reliable screening instruments for the detection of those with clinically significant levels of psychopathology (McKelvey et al.,
1997). The Child Behavior Checklist (CBCL) (Achenbach, 1991) is one of the most widely used and documented of such measures and has been
shown to be robust in assessing child behavioral and emotional problems in diverse cultures (Crijnen et al., 1997). CBCL results show similar age and
gender patterns across cultures (Crijnen et al., 1997). With increasing age, total and externalizing problems decrease, while internalizing problems
increase. Boys exhibit more total and externalizing problems than girls, and girls more internalizing problems than boys. While mean scores on the
CBCL across cultures are generally similar, there is a need to establish normative scores for different cultural and ethnic groups (Crijnen et al., 1997).
In this article we present the distribution of behavioral and emotional problems and competencies reported by parents in a representative
community sample of approximately 1,500 Vietnamese children and adolescents living in Hanoi. Given the multiple risk factors faced by children and
adolescents in Vietnam, we would expect parents to report higher levels of behavioral and emotional problems, and lower levels of competence, than
those reported in U.S. norms. However, given the stigma attached to psychiatric disorders within Vietnamese culture (Tung, 1980) and the reticence
of Vietnamese parents to share their children's behavioral and emotional problems with others (Lee, 1988), reported rates of problems may be lower
than otherwise predicted. Thus in this article exploring the distribution of parent-reported behavioral and emotional problems among Vietnamese
children 4 through 18 years of age, we are unable to predict whether higher or lower levels of problems and competencies will be found. On the basis
of results of previous research, however, we do predict that Vietnamese parental reports of children's behavior will show a distribution of problems
similar to those found in other cross-cultural studies, with boys reported to have more externalizing problems and girls more internalizing problems,
and with externalizing problems decreasing and internalizing problems increasing with age (Crijnen et al., 1997).

METHOD

MEASURES
The CBCL was designed to elicit parental reports of competencies and problems among children 4 through 18 years of age (Achenbach, 1991). The
first part of the CBCL asks for information about children's adaptive functioning in sports, hobbies, clubs, and friendships. Parents also rate children's
family and peer relationships and academic achievement. The second part of the CBCL consists of 120 problems scored on a 3-point scale (0 = not
true in the past 6 months, 1 = somewhat or sometimes true, 2 = very true or often true). Scores are reported in 8 syndrome profiles and 3 broad-
band scales: Total (all items except Allergy and Asthma), Externalizing (the sum of the Delinquent and Aggressive syndrome profiles), and

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Internalizing (the sum of the Withdrawn, Somatic Complaints, and Anxious/Drepressed syndrome profiles). CBCL raw scores rather than T scores will
be used for data analyses because T scores based on U.S. data are not necessarily appropriate and, in addition, have undergone truncation,
normalizing transformations, and equal-interval assignment of extreme scores (Achenbach, 1991).
The CBCL was translated and back-translated by professionally accredited Vietnamese translators.

STUDY POPULATION
Hanoi covers an area of 927 km[sup2] and has a population of 2,194,000 (Dieu, 1995). It is divided into 7 districts, each consisting of a number of
precincts. Precincts are subdivided into cells of 30 families each. We chose a district, Dong Da, referred to locally as "Hanoi in miniature" and thought
to be representative of the city as a whole. It has 2 precincts. The first, Kim Lien, has 107 cells and a population of 12,668. The second, Trung Tu,
also has 107 cells and a population of 13,250.
The study's goal was to have CBCLs completed for 50 male and 50 female children for each age from 4 through 18 years, a total of 1,500 subjects.
To achieve this goal, the following procedures were used. First, 40 cells from Kim Lien Precinct and 45 cells from Trung Tu Precinct were randomly
selected. A Vietnamese member of the research team approached the leaders of the selected cells, explained the purpose of the study, and asked
permission to conduct the study within their cells. Cell leaders then approached families within their cells, explained the purpose of the study, and
asked families whether they were willing to participate. All families approached by cell leaders agreed to do so (100%). Our team of Vietnamese
research staff, composed of a psychologist and several nurses specially trained for the study, then visited the homes of those families agreeing to
participate whose children met study selection criteria. They explained that the aim of the study was to increase understanding of Vietnamese
children's health problems and that all families in their area with children aged 4 through 18 years were being invited to participate. The research
team assured families of confidentiality and reassured them that they could decline to participate if they wished. Within participating families, all
children meeting selection criteria were included until the study's data sets for each age and gender group were filled. Only 18 children (1.1%) who
met selection criteria and whose families were approached did not participate, usually because they did not live at home. The child's primary
caregiver (in most cases the mother) was asked to complete a CBCL for each child aged 4 through 18 years while a member of the research team
waited. Caregivers were permitted to ask the research team member for clarification of items on the CBCL that they did not understand. Those
completing CBCLs received a participation fee of $1 (U.S.). In all, completed CBCLs for 1,526 children from 1,231 families were collected. The number
of CBCLs collected for each age and gender group is shown in Table 1.
Although it is preferable to sample only one child per family (Achenbach, 1991), it was decided, owing to resource limitations and transportation
difficulties, to include all children within selected families and to deal with the lack of independence in reports within families in the data analyses.
Moreover, large families were not expected to be overly problematic, as it was understood that most families in Hanoi have no more than 2 children.

STATISTICAL APPROACH
Data analyses took account of the issue of lack of independence in reports within families. This was necessary as children from the same family are
likely to have correlated adjustment measures due to reporter bias, shared environment, and shared genes. The procedure used in this report allowed
for these correlations by estimating standard deviations using Rogers' (1993) generalization of the robust variance estimation procedure developed by
Huber (1967). It was implemented using a procedure available in the statistical software package Stata (StatCorp, 1997). This procedure gave an
estimate of the mean and a robust estimate of the standard error based on an effective sample size which is equal to the number of clusters (i.e., the
number of families). From the robust estimate of standard error and this corrected sample size, we could calculate robust estimates of standard
deviation.
Two sets of analyses were conducted for this study. First, age and gender differences on the CBCL subscales and Total score were explored using
regression analyses performed in Stata to correct for correlated responses as described above. The mean differences of the adjustment measures
across age and gender groups were tested using a robustly estimated F statistic in the usual manner for ordinary least-squares regression. Second,
comparisons with U.S. CBCL means were made using mean difference analyses performed using the robust estimates of standard deviation described
above.

RESULTS
The parents of 1,587 children were initially approached. Along with the 18 children who no longer lived at home, an additional 43 children were lost
to data analyses because their parents failed to complete the CBCL. This left a sample of 1,526 children from 1,231 families, ranging in age from 4
through 18 years. For the most part, only 1 (59.8%) or 2 (37.7%) children were sampled per family. Only 2.5% of children came from families in
which more than 2 children were sampled. Although it was our intention, following Achenbach's methodology for establishing CBCL clinical norms
(Achenbach, 1991), to omit children who had received psychiatric treatment in the past year, this proved unnecessary as none of the children
sampled had received treatment. This reflects the very low rate of Vietnamese children in psychiatric treatment.
Of the 1,526 children with usable questionnaires, there were 799 males and 727 females; 61.1% of the sample were first-born children, 34.2%
second-born, 4% third-born, and 0.7% fourth-born. The majority of questionnaires (58.5%) were completed by mothers, 25.8% by fathers, and
15.7% by others such as siblings and aunts or uncles.

CBCL SCORES
The means and standard deviations of CBCL scores, with the standard deviations corrected for the clustering of children within families, are shown
for younger (4-11 years) and older (12-18 years) boys and girls separately (Table 2). The mean raw total score for the sample as a whole was 19.45
(SD 13.64). Although raw scores were used for data analyses, it is useful to examine the number of Vietnamese children scoring in the clinical range
by describing their T scores based on U.S. norms (Achenbach, 1991). T scores represent the conversion of raw scores to scores based on a normal
distribution with a mean of 50 and a standard deviation of 10. T scores permit comparisons between different CBCL scale scores, many of which have
different numbers of problems and, hence, different raw scores (Achenbach, 1991). The clinical cutoff is the total T score that best discriminates
between a clinically referred and nonreferred sample. Based on American norms, 18.0% of children are expected to have a total T score greater than
60 (Achenbach, 1991). In our Vietnamese sample, however, only 5.3% of boys and 7.7% of girls aged 4 through 11 and 9.5% of boys and 10.1% of
girls aged 12 through 18 scored in the clinical range (had total T scores greater than 60). The lower rate of Vietnamese children with scores within the
clinical range defined for a U.S. sample illustrates the need to establish separate Vietnamese norms and clinical cutoff points, especially for younger
children.
As a way of examining gender and age differences in this sample, a series of robust regression analyses was conducted on the Internalizing,
Externalizing, Total and Competence scores. Models allowing for the clustering of children within families were fitted for gender (boys and girls) and
age group (ages 4-11 and 12-18 years) interactions and for the main effects of gender and age group.
Results showed a gender by age interaction effect on the Internalizing scale (F[sub1,1213] = 5.7, p = .017). Older children had a higher rate of
internalizing problems than younger children, and boys showed fewer internalizing problems than girls. The significant interaction of gender and age
indicated that the combined effect of being female and older was associated with increasing internalizing problems. A gender difference was shown for
the Externalizing scale, with boys reported to have more problems than girls (F[sub1,1213] = 35.63, p < .001). An age group difference was shown
for the Competence scale (F[sub1,1010] = 8.74, p = .003), with older children reported to have higher levels of competence.
A comparison was made using independent-sample t tests between the Hanoi CBCL means (with corrected standard deviations and cell sizes) and
U.S. CBCL means (Achenbach, 1991). The means of the Total, Externalizing, Internalizing, and Competence scores were compared for younger and
older boys and girls. Owing to the number of comparisons, a more cautious significance level of .01 was used. Significant differences were shown for
the Hanoi and U.S. CBCL scores for boys aged 4 through 11, girls aged 4 through 11, and boys aged 12 through 18 on the Internalizing,
Externalizing, and Competence scores, with U.S. children reported to have higher Internalizing, Externalizing, and Competence scores than Hanoi
children (Table 3). Significant differences were also shown for girls aged 12 through 18 on the Externalizing and the Competence scores, with U.S.
girls having higher Externalizing and Competence scores. Significant differences were not shown for these older girls on the Internalizing and Total
scores--adolescent girls in Hanoi and the United States were shown to have similar rates of internalizing problems.

DISCUSSION
The study has several potential limitations reflective of the difficulties inherent in conducting population-based research within a developing country
such as Vietnam that has a culture so vastly different from the culture of the United States. First, despite the CBCL's impressive performance in other
cross-cultural settings (Crijnen et al., 1997), we cannot be certain that a list of problem behaviors derived from parental reports within a developed
Western culture will have the same or similar meaning to parents within a Vietnamese cultural context (Kinzie et al., 1982). In subsequent reports,
we will examine which behavioral and emotional problems are considered psychopathological by Vietnamese parents, identify those resources they
would use if they believed their child had psychiatric problems, determine the sensitivity and relevance of the CBCL for this population, and establish

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Vietnamese norms and clinical cutoffs for the CBCL.

Second, the logistic and practical problems that dictated our decision to sample all children who met selection criteria within participating families
could have led to an overrepresentation of larger families. Despite the design, however, large families were not overrepresented as only 2.5% of the
sample came from families in which more than 2 children were selected. In those cases in which more than one child per family was sampled, the
family was used to define the clustering structure, giving corrected standard errors and cell sizes. Third, while we believe that the precincts sampled
are reflective of Hanoi generally and include a broad range of socioeconomic groups, we cannot be certain that the sample is truly representative of
the city's overall population. In addition, as the sampling framework was based on families, street children, whose numbers are reportedly increasing
in Vietnamese cities and who are certainly at increased risk of psychopathology, were not included. Reliable estimates of the number of street children
present in the district sampled are not available to us, and we are thus unable to determine how their absence might affect the representativeness of
our sample. Fourth, because our sample was drawn exclusively from Hanoi, Vietnam's second-largest urban area, it may not reflect the behavioral
problems and competencies found among children in rural areas (where 80% of the Vietnamese population resides) or in southern and central
Vietnam, which have somewhat different cultural traditions.
Despite these limitations, however, we believe that the study is important in accomplishing the first population-based survey of mental health
problems among children and adolescents in Vietnam and that it has resulted in a number of interesting findings. The means of raw CBCL scores for
the Hanoi sample were generally lower than standardized U.S. means, especially for younger children. The importance of this difference is highlighted
by the substantially smaller number of Vietnamese children scoring above the total T score clinical cutoff derived from U.S. norms, suggesting that
different cutoff points need to be established for Vietnam to distinguish between clinically referred and nonreferred children. However, despite the
difference in means between the Vietnamese and U.S. samples, the gender differences reported in other cross-cultural studies (boys having higher
Externalizing scores and girls higher Internalizing scores) were apparent in this study, although the age effect (decreasing Externalizing and
increasing Internalizing scores for both genders with age) was not as clearly shown (Crijnen et al., 1997). In our study, the Internalizing score
increased with age for girls only, while the Total and Externalizing scores were not significantly affected by age. Our findings thus reinforce those of
Crijnen et al. (1997) that, although different cultures have different mean scores and require appropriate calibration of CBCL cutoff points to identify
those at risk of psychopathology, gender and age patterns on the CBCL are similar across cultures.
There are a number of possible explanations for why Vietnamese parents report fewer problem behaviors than parents in the United States. One
explanation is that the rate of psychiatric problems among American children is higher than the rate among Vietnamese children, despite the many
risk factors faced by Vietnamese children. While the limited prevalence data available for Vietnamese children do not support this explanation (Tu,
1994a), it cannot be ruled out. A second explanation is that mental illness is more stigmatized within Vietnamese than American culture, making
Vietnamese parents less likely to acknowledge psychopathological behaviors in their children, especially in a self-report format (Hickey, 1964; Lee,
1988; Tung, 1980). The higher scores found in the Holzer et al. (1988) and Krupinski and Burrows (1987) studies may reflect the fact that both were
based on face-to-face interviews during which interviewers had the opportunity to develop rapport with subjects and, perhaps, elicit a more accurate
representation of their children's problems. While our study involved researchers visiting families at home, the questionnaires were self-administered,
although parents could ask the research team member present for clarification of questions on the CBCL. Alternatively, the higher rates of
psychopathology found in the 2 prior studies may reflect the stresses on children of immigrating to a new country and culture, an experience to which
our subjects were not exposed. In addition, these studies also used interviews with both children and parents, and thus reflect combined prevalence
rates, while ours was based on interviews with parents only. Parents are not always privy to their children's inner worlds, and prevalence rates
determined using only parental reports may be lower than those combining parent and child reports, especially for symptoms of anxiety and
depression. A third explanation is that cross-cultural differences in socialization practices and expectations for children's behavior may cause
Vietnamese parents to discourage externalizing behaviors more forcefully in their children. Generally, traditional East and Southeast Asian cultures
such as the Vietnamese emphasize harmony and interdependence, and minimize interpersonal aggression, in contrast to Western developed countries
such as the United States, where children, and especially boys, are encouraged to be independent, boisterous, and assertive (Kagan, 1984; Lee,
1988).
A fourth explanation is that cross-cultural differences in parental perceptions of deviance may cause Vietnamese parents to report different
symptoms as psychopathological than do American parents (Hackett and Hackett, 1993). Vietnamese traditionally define psychiatric disorders more
narrowly than is the case in the developed West, usually including only those psychotic conditions such as schizophrenia which lead to a disruption of
the social order (McKelvey et al., 1997; Tung, 1980). A screening instrument based on Vietnamese parental perceptions of deviance might be
different from an instrument based on American parental perceptions. For example, there is evidence to suggest that parents in a neighboring
Southeast Asian country, Thailand, are less worried about children's behavioral problems, and are generally prepared to tolerate broader variations in
children's behavior, than parents in the United States (Weisz et al., 1991).
The finding of significant increases with age in Internalizing scores for girls only, in contrast to other cross-cultural studies reporting significant
increases in both boys and girls, may reflect differential socialization practices for boys and girls within Vietnamese society. Traditionally, Vietnam is a
strongly patriarchal society and women, although exercising power within the home, are normally expected to be docile and compliant (Hickey,
1964). Vietnamese society encourages everyone, and especially women, to manage their emotional problems internally, maintaining a "stiff upper lip"
and not expressing negative affects and personal problems to others, especially people outside the family (Tung, 1980).

CLINICAL IMPLICATIONS
The study's findings emphasize the importance of caution in interpreting the results of screening instruments developed for one cultural or ethnic
group when they are used with a different ethnic group. Cross-cultural differences in socialization practices, perceptions of deviance, and comfort in
reporting confidential information may strongly influence the cutoff point for clinically significant psychopathology. As suggested by this study, for
example, use of American T score norms for children of Vietnamese ethnicity may lead to underidentification of those requiring further psychiatric
assessment.
ADDED MATERIAL
ROBERT S. MCKELVEY, M.D., LISA C. DAVIES, PH.D., DAVID L. SANG, PH.D., KEVIN R. PICKERING, M.SC., AND HOANG C. TU, M.D.
Accepted December 1, 1998.
Dr. McKelvey was Professor of Child Psychiatry and Dr. Sang is Senior Lecturer in Psychology, University of Western Australia, Perth, Australia. Dr.
Davies is Adjunct Lecturer in Pediatrics, University of Western Australia, and is with the Institute of Psychiatry, London. Mr. Pickering is also with the
Institute of Psychiatry. Dr. Tu is Head of the Psychiatry Department, Institute for Pediatrics, Hanoi, Vietnam. Dr. McKelvey is currently Professor and
Director, Division of Child and Adolescent Psychiatry, Oregon Health Sciences University, Portland.
Funding for the study was provided by the Belnap Family Foundation and the University of Western Australia.
Reprint requests to Dr. McKelvey, Professor and Director, Division of Child and Adolescent Psychiatry, Oregon Health Sciences University (DC 7P),
3181 S. W. Sam Jackson Park Road, Portland, OR 97201-3098.
0890-8567/99/3806-0731 © 1999 by the American Academy of Child and Adolescent Psychiatry.
TABLE 1 Number of Child Behavior Checklists Collected for Each Age and Gender

Age (yr) Boys Girls Total

4 51 47 98
5 63 47 110
6 52 52 104
7 53 45 98
8 56 46 102
9 52 48 100
10 56 48 104
11 49 56 105
12 52 48 100
13 50 52 102
14 52 49 101
15 51 51 102
16 55 46 101
17 54 46 100
18 53 46 99

TABLE 2 Mean (SD) Child Behavior Checklist Scores for Girls and Boys Aged 4 Through 11 and 12 Through 18 Years, Corrected for Clustering
Within Families

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Measures Boys 4-11 Girls 4-11 Boys 12-18 Girls 12-18

n 431 389 368 338
Corrected n 401 368 342 312
Withdrawn 1.60 (1.62) 1.84 (1.65) 1.68 (1.96) 2.06 (2.04)
Somatic Complaints 1.08 (1.62) 0.96 (1.60) 1.39 (1.85) 1.98 (2.00)
Anxious/Depressed 1.87 (2.19) 2.14 (2.08) 2.33 (2.53) 3.02 (2.80)
Social Problems 2.32 (1.92) 2.13 (1.71) 2.17 (2.08) 2.16 (1.78)
Thought Problems 0.25 (1.26) 0.22 (0.56) 0.50 (2.92) 0.36 (2.02)
Attention Problems 3.57 (2.80) 3.05 (2.56) 4.35 (4.52) 3.60 (3.10)
Delinquent Behavior 1.70 (2.61) 1.13 (1.31) 2.02 (4.06) 1.30 (3.19)
Aggressive Behavior 5.11 (4.47) 3.77 (3.66) 4.56 (5.04) 3.74 (3.87)
Internalizing 4.54 (4.40) 4.94 (4.16) 5.32 (5.05) 6.93 (5.57)
Externalizing 6.67 (5.31) 4.89 (4.49) 6.08 (5.70) 4.78 (4.62)
Total 20.35 (13.78) 18.66 (12.88) 19.22 (14.61) 19.47 (14.26)
n(FNa) 273 246 360 334
Corrected n 266 235 334 308
Competence 15.03 (2.92) 15.39 (2.80) 15.64 (3.09) 15.77 (2.72)

FOOTNOTE
a The Competence scale is not completed for children aged 4 and 5 years, hence the difference in numbers.
TABLE 3 Comparing Corrected Hanoi Mean CBCL Scores and U.S. Mean CBCL Scores

Age 4-11 Years Age 12-18 Years

Boys Girls Boys Girls
N: Hanoi 401 368 342 312
N: U.S. 581 619 564 604
Total
Hanoi 20.4 (13.8) 18.7 (12.9) 19.2 (14.6) 19.5 (14.3)
U.S. 24.3 (15.6) 23.1 (15.5) 22.5 (17.0) 22.0 (17.7)
Statistics T = -4.03, df 980, p < .001 T = -4.58, df 985, p < .001 T = -2.98, df 904, p < .001 T = -2.16, df 914, p = NS
External
Hanoi 6.7 (5.3) 4.9 (4.5) 6.1 (5.7) 4.8 (4.6)
U.S. 9.8 (7.1) 8.2 (6.1) 8.7 (7.6) 7.1 (6.6)
Statistics T = -7.43, df 980, p < .001 T = -9.02, df 985, p < .001 T = -5.46, df 904, p < .001 T = -5.5, df 914, p < .001
Internal
Hanoi 4.5 (4.4) 4.9 (4.2) 5.3 (5.1) 6.9 (5.6)
U.S. 5.6 (4.7) 6.3 (5.5) 6.4 (5.5) 7.5 (6.6)
Statistics T = -3.7, df 980, p < .001 T = -4.21, df 985, p < .001 T = -3.0, df 904, p < .001 T = -1.37, df 914, p = NS
Age 6-11 Years Age 12-18 Years
N: Hanoi 266 235 334 308
N: U.S. 458 488 564 604
Competence
Hanoi 15.0 (2.9) 15.4 (2.8) 15.6 (3.1) 15.8 (2.7)
U.S. 18.6 (3.3) 18.7 (3.6) 19.0 (3.5) 19.1 (3.6)
Statistics T = -14.78, df 722, p < .001 T = -12.36, df 721, p < .001 T = -14.67, df 896, p < .001 T = -14.18, df 910, p <
.001

Note: U.S. norms from Achenbach (1991). CBCL = Child Behavior Checklist; NS = not significant.

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