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Breaking down the wall

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Title:
Breaking down the wall an examination of mental health service utilization in African American and Caucasian parents
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English
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Binitie, Idia O
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University of South Florida
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Subjects / Keywords:
Children
Barriers
Attitudes
Race
Gender
Psychopathology
Dissertations, Academic -- Psychology -- Masters -- USF
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bibliography   ( marcgt )
theses   ( marcgt )
non-fiction   ( marcgt )

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Abstract:
ABSTRACT: This study investigated the influence of parents' gender, race, and psychopathology on barriers and attitudes to mental health utilization for themselves and for their children. It was hypothesized that mothers and Caucasian¹ parents would have more positive attitudes and would perceive fewer barriers to mental health services than fathers and African American² parents. A total of 194 African American and Caucasian parents were recruited from the community to participate in this study. Parents completed measures on barriers and attitudes toward treatment for themselves and their children, utilization of mental health services for themselves and their children, and their own current psychological symptoms. Results indicated that 36.3% and 19.4% of parents and children, respectively, had used mental health services during their lifetime. Parents perceived fewer barriers and had more positive attitudes toward seeking services for their children than for themselves. Race and gender differences were found in parental perceptions of barriers and attitudes toward treatment. Furthermore, barriers, attitudes, and psychopathology predicted parents' plan for future utilization of professionals for mental health services. The clinical implications of this study and directions for future research were discussed.
Thesis:
Thesis (M.A.)--University of South Florida, 2006.
Bibliography:
Includes bibliographical references.
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by Idia O. Binitie.
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Title from PDF of title page.
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Document formatted into pages; contains 98 pages.

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aleph - 001790608
oclc - 145063698
usfldc doi - E14-SFE0001516
usfldc handle - e14.1516
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Breaking Down the Wall: An Examination of Mental Health Service Utilization in African American and Caucasian Parents by Idia O. Binitie A thesis submitted in partial fulfillment of the requirements for the degree of Master of Arts Department of Psychology College of Arts and Sciences University of South Florida Major Professor: Vicky Phares, Ph.D. Marc Karver, Ph.D. Carnot Nelson, Ph.D. Date of Approval: April 13, 2006 Keywords: children, barriers, atti tudes, race, gender, psychopathology Copyright 2006, Idia O. Binitie

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Acknowledgments This project is dedicated to my family, who supported me through every painful moment of data collection, my hubby, Rashard Thurst on, who kept me inspired and always reminded me why I love research, and my a dvisor, Dr. Vicky Phares, who supported me every step of the way. I would like to th ank my committee members Dr. Marc Karver and Dr. Carnot Nelson, for their wonderful input and the Psychology Department for helping me fund my project. I hope to inspire future researchers to continue seeking out those hard to reach participants a nd choose those less appealing topics. Thank you.

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i Table of Contents List of Tables iii List of Figures iv Abstract v Background 1 Theories and Models 2 Barriers to Mental Heal th Service Utilization 7 Attitudes toward Mental Health Services 10 Race/Ethnicity and Ment al Health Utilization 12 Socioeconomic Status and Mental Health Utilization 14 Parental Gender and Mental Health Utilization 15 Parental Psychopathology and Mental Health Utilization 17 Hypotheses 20 Method 24 Participants 24 Measures 26 Demographics Questionnaire 26 Utilization of Mental Health Services Questionnaire 26 Attitudes toward Seeking Professional Psychological Help 27 Barriers to Treatment Utilization 28 Brief Symptom Inventory (BSI) 30 Procedure 31 Results 35 Descriptives 35 Hypothesis Testing 38 Post Hoc Analyses 44 Utilization Variables with Barriers and Attitudes 44 Utilization of Pastors for Mental Health Services 45 Utilization of Mental Health Professionals for Mental Health Services 46 Parental Psychopathology Subs cales and Future Utilization 48 Discussion 50 Theoretical Conceptualizations 58

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ii Limitations and Future Research 60 Conclusions and Clinical Significance 62 References 65 Appendices 78 Appendix A: Letter of Invitation 79 Appendix B: Demograp hic Questionnaire 80 Appendix C: Utilization of Mental Health Services Questionnaire 83 Appendix D: Attitudes toward Seeki ng Professional Psychological Help For Parent 88 Appendix E: Attitudes toward Seeking Professional Psychological Help For Child 89 Appendix F: Barriers to Treatme nt Utilization Questionnaire For Parent 91 Appendix G: Barriers to Treat ment Utilization Questionnaire For Child 93 Appendix H: Brief Symptom Inventory (BSI) 95 Appendix I: Letter of Referrals 97

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iii List of Tables Table 1 Demographic Variables fo r Parents by Race and Gender 26 Table 2 Parent and Child-related Inte rcorrelations between Utilization, Barriers, and Attitudes 39 Table 3 Multiple Regression Analysis for Parent Attitudes, Barriers, and Psychopathology Predicting Future Utilization in Parents 43 Table 4 Multiple Regression Analysis for Child-related Attitudes, Child-related Barriers, and Pa rental Psychopathology Predicting Future Utilization in Children 44 Table 5 Correlations of Parent and Child-related Barriers and Attitudes with Satisfaction and Quantity of Utilization 45 Table 6 Multiple Regression Analysis for Parent Attitudes, Barriers, and Psychopathology Predicting Parents’ Future Utilization of Mental Health Professionals 47 Table 7 Multiple Regression Analysis for Child-related Attitudes, Child-related Barriers, and Pa rental Psychopathology Predicting Children’s Future Utilization of Mental Health Professionals 48 Table 8 Multiple Regression Analyses for Parent and Child-related Attitudes, Barriers, and Parental Psychopathology Subscales Predicting Future Utilization of Mental Health Professionals 49

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iv List of Figures Figure 1 Andersen and Newman’s Mode l of Individual Determinants of Health Service Utilization 3 Figure 2 Adaptation of Andersen and Ne wman’s Model for Specific Variables that will be Tested 6

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v Breaking Down the Wall: An Examination of Mental Health Service Utilization in African American and Caucasian Parents Idia O. Binitie ABSTRACT This study investigated the influence of pa rents’ gender, race, and psychopathology on barriers and attitudes to mental health utiliza tion for themselves and for their children. It was hypothesized that mothers and Caucasian1 parents would have more positive attitudes and would perceive fe wer barriers to mental health services than fathers and African American2 parents. A total of 194 African Am erican and Caucasian parents were recruited from the community to participate in this study. Parents completed measures on barriers and attitudes toward tr eatment for themselves and their children, utilization of mental health services for themselves and their children, and their own current psychological symptoms. Results indicated that 36.3% and 19.4% of parents and children, respectively, had used mental health services durin g their lifetime. Parents perceived fewer barriers and had more positive attitudes toward seeking services for their children than for themselves. Race and gender differences were found in parental perceptions of barriers and att itudes toward treatment. Furthe rmore, barriers, attitudes, and psychopathology predicted parents’ plan fo r future utilization of professionals for 1 The terms Caucasian and White will be used interchangeably through out this paper. 2 The terms African American and Black will be used interchangeably through out this paper.

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vi mental health services. The clinical implica tions of this study and directions for future research were discussed.

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1 Background It is well established that mental health services are underutili zed in our society. The issues related to the underutilization of mental health services have plagued researchers and clinicians for years. The re port of the Surgeon General (U.S. Department of Health and Human Service, 1999) stated that 15 percen t of the U.S. adult population use mental health services each year. This number is relatively small compared to the individuals who actually need mental hea lth services. Research conducted by two nationwide epidemiological studies suggest that 50-60 percent of adults who would benefit from mental health services do not receive these services (Kessler, et al., 2001; Regier, et al., 1993). This disparity between the number of i ndividuals who need services and those who actually use mental health services is a dilemma referred to as the “service gap” (Cramer, 1999; Stefl & Prosperi, 1985). This dilemma is not limited to adults given that mental health services are also underutili zed by children (Horwitz, et al., 2001; Kuhl, Jarkon-Horlick & Morrissey, 1997). The Surge on General’s report stat ed that 70 percent of children and adolescents who need mental health services do not receive any services at all and about 75-80 percent fail to receive specialty se rvices (U.S. Department of Health and Human Services, 1999). Therefore, it is clear that utilization of mental health services is much lower than desi red in both adults and children.

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2 It is possible that these low rates of ment al health service ut ilization in children are influenced heavily by their parents. Ra tes of attrition in children’s mental health services have been associated with parental resistance to treatment of their children (Novick, Benson, & Renbar, 1981). In most cas es, before children can receive mental health services, parental consent must be sought for the child’s treatm ent. There are also other ways that parents influence their children’ s decisions to seek mental health services in addition to issues of consent. These issues include: the barriers influencing the parents’ capability to seek mental services fo r themselves and for their children, parents’ attitudes toward mental health services for themselves and their children, and parents’ psychopathology. In addition, parents’ cultural characteristics such as race/ethnicity3, socioeconomic status (SES), and gender co uld also have an in fluence on seeking treatment. These issues that influence the utilization of mental health services have been examined in Andersen and Newman’s sociobeh avioral model of Societal and Individual Determinants (1973). Theories and Models Andersen and Newman’s model of Soci etal and Individual Determinants of Health Service Utiliz ation (1973) is relevant in u nderstanding how individuals use services, and provides a method of investigating the influence of different factors on individuals’ utilization of h ealth services. Although this model focuses on individuals’ utilization of mental health services, it is rele vant to assessing the parental factors related to seeking mental health services for th eir children. The fr amework of the model identifies three main compone nts that influence health se rvice utiliza tion including: 3 Although race and ethnicity are often defined di fferently, in this study the terms will be used interchangeably.

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3 Societal Determinants (technology and norms), Health Services Sy stem (resources and organizations), and Individual Determinants (predisposing charac teristics, enabling resources and illness level). Both the Societal Determinants and Health Services System components directly influence the Individual Determinants component. The Individual Determinants component then has a direct influence on health se rvice utilization. To assess the various parental fact ors influencing health service utilization for their children, the Individual Determinants component will be the focus of this current study. The Individual Determinants component includes: predisposing characteristics (demographic, social structure and beliefs), enabling res ources (family and community) and illness level (perceived and evaluated; Figure 1). Figure 1 Andersen and Newman’s model of Individual Determinants of Health Service Utilization PREDISPOSING CHARACTERISTICS ENABLING RESOURCES ILLNESS LEVEL Demographic Social Structure Beliefs Family Community Perceived Evaluated USE OF HEALTH SERVICES

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4 Predisposing characteristics can be descri bed as the factors that predispose an individual to use mental hea lth services. These factors have been grouped into three categories: demographic characteristics, aspect s of social structure, and beliefs. Some examples of demographic characteristics th at can be measured include, age, gender, marital status, and past illness. Some exam ples of social structure include education, race/ethnicity, occupation, family size, religion, and residential mobility. Finally, examples of beliefs include, values concerning health and illness, attitudes toward health services, and knowledge about disease. Enabling resources are described as the conditions that allow a family to act on a valu e or satisfy a need concerning health service use. Enabling resources have been grouped into two categories: family, and community resources. Some examples of family resources that can be measured include income, health insurance, and other source of third party payment. Community resources include, ratios of health personnel and facilities to population, price of health services, region of country, and urban-rural char acter of the community. Th e final influence on health service utilization, according to th is model, is the illness/need level. This level can be described as the individual’s or family’s perc eption of their illness or evaluated illness. Illness level is grouped into tw o categories: perceived, and ev aluated need levels. Some examples of perceived need include, disa bility, perceived symptoms, diagnoses, and general state. Examples of evaluated n eed are evaluated symptoms, and diagnoses. According to Andersen and Newman (1973), illn ess level is the most immediate cause of health service use. Andersen has since revised this model (Andersen, 1995) to address other health care system issues, however, emphasis is st ill placed on the individual. The 1995 model

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5 is now more heavily focused on the health car e system and issues related to the medical sector specifically. The 1973 m odel is more relevant to this study and has been used in other recent studies of barriers to mental he alth (Hines-Martin, Malone, Kim, & BrownPiper, 2003). Thus, the current st udy was based on the 1973 model. Another theory that might appear relevant to this study is the Theory of Reasoned Action. Fishbein and Ajzen’s theory of reasoned action (1975) suggests that an individual’s behavior is base d on his/her intention to act. They further propose that this intention is based on the subjective norms about the behavior and the individual’s attitudes toward engaging in the behavior. An extension of this theory is the theory of planned behavior which includes the individual’s perceived be havioral control as another aspect influencing his/her intention to act (Ajzen, 1985, 1991). Although this theory appears relevant to this particular study, it only addresses issues related to attitudes, social norms, and perceived behavioral co ntrol. This study, however, is focused on barriers and attitudes to utiliza tion of mental health services. Furthermore, issues related to the influence of race/ethnicity, gender and psychopathology are not discussed in Fishbein and Ajzen’s models. Convers ely, Andersen and Newman’s 1973 model provides a more accurate and succinct method of investigating the variables relevant to this study that influence utiliz ation of mental health servic es and so was the base model for this study. Andersen and Newman’s (1973) model, how ever, does not accurately explain the relationship between the variable s and utilization of mental health service. It suggests that predisposing characteristics lead to en abling resources, which lead to illness level and finally lead to utilization of health services. It also implies a mediational model,

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6 where each step has to be accomplished before utilization occurs. However, this is not the case because predisposing characteristic s can lead to utilization without going through enabling resources (for example: how would aspects of soci al structure, like religion lead to aspects of family, like income). Therefore, this model has been revised to fit the current study’s h ypotheses, which are based on previ ous findings in the literature. The model has been reconstruc ted to show that each com ponent (predisposing factors, enabling resources, and illness level) can lead to future utilizati on of mental health services. It also includes th e influence of prior utilization on the va rious components and on future utilization (Figure 2). Figure 2 Adaptation of Andersen and Newman’s Model for Specific Variables that will be Tested Predisposing Characteristics Enabling Resources Illness level Future Utilization Gender Race Current Attitudes SES Current Barriers Parental Psychopathology Prior Utilization

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7 The solid lines indicate the relationships between variables as posited in the original model, while the dashed lines indicate relationships that are being investigated in this study. Using this theore tical framework, this study investigated the influence of parents’ and children’s prior ut ilization of mental health se rvices on current parental and child related barriers to mental health se rvices use (enabling resources-family and community), and parental attitudes toward ment al health services for themselves and their children (predisposing characterist ic-beliefs). It also invest igated the influence of gender (predisposing characteristic-demographic), race (predisposing ch aracteristic-social structure), and parental ps ychopathology (illness level-ev aluated) on barriers and attitudes. Finally, this study investigated the influence of parent al and child-related attitudes toward mental health services (pre disposing characteristics), SES (predisposing characteristics), parental and child-related barr iers to mental health service utilization (enabling resources), and parent al psychopathology (illness leve l) on future utilization of mental health services for parents and thei r children. Although ch ild-related issues are not explicitly shown in the model, it is hypothesized that the ch ild-related variables would be consistent with the model. The various components of this model and support for investigation of the component s are discussed in detail below. Barriers to Mental Heal th Service Utilization There are numerous barriers to the use of mental health services for parents and children that influence all races and ethniciti es. These barriers include: problems with cost, fragmentation of services, lack of ava ilability of services, and societal stigma toward mental illness (U.S. Department of Health and Human Services, 1999). There are additional barriers that differentially influe nce racial and ethnic minorities including:

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8 mistrust and fear of treatment, racism/dis crimination, differences in language and communication and cultural barriers in genera l (Thompson, Bazile, & Akbar, 2004). It is also important to note that most of the barriers to mental h ealth service utilization that influence all race and ethnicities tend to in fluence minorities more severely (Gary, 2005; Snowden & Yamada, 2005; U.S. Department of Health and Human Services, 2001). These findings appear to be due to the fact that a large proportion of racial and ethnic minorities are in lower socioeconomic classes an d most of the barriers to mental health service utilization have a bigger or more detrimental effect on individuals of lower SES. For example, 30 percent of African American families but only 13 percent of Caucasian families with children under 18 have incomes below the poverty level (Statistical Abstract of the United States, 2003). K azdin, Holland, Crowley and Breton (1997) identified socioeconomic disadvantage, diffi cult living circumstances, family stress and life events as predictors of dropping out of tr eatment among children and adolescents. It is also possible that even t hough barriers influence both childr en and their parents, there might be barriers that influence only parents’ utilization of mental health services for themselves and barriers that influence only utilization of mental health services for children. However, there has been no study f ound that investigates how parents’ barriers to utilization of mental health services might differ from child ren’s barriers to utilization of mental health services. Kessler and colleagues (2001) found that the most commonly reported reason by adults for failing to seek treatment and dr opping out of treatment was their wanting to solve the problem on their own. They also note d that a major barrier to seeking treatment was the individual’s belief that they did not have an emotional problem requiring

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9 treatment. In a study of parents of presc hool children, Pavluri, Luk, and McGee (1996) found that the most common parental barrier to seeking help for their children was the belief that the problems would get better by th emselves or that the parents were strong enough to handle the preschoolers’ problems on their own. A study by Ringel and Sturm (2001) reported that 7% of families with a child claimed financial barriers as the reason for not receiving mental health care. Unfortunately the researchers did not repor t the percentage for adult populations. Stigma has also been identified as a ma jor barrier to mental health service utilization in ch ildren (Kuhl, Jarkon-Horlick, & Morri ssey, 1997) and adults (Stefl & Prosperi, 1985). Both studies reported that fe ar of being stigmatized prevents adults and children from utilizing mental health servic es. Owens and colleagues (2002) found that about 35% of the parents in their study reporte d a barrier to mental health services and the most common perceived barrier was relate d to their perceptions of mental health services. These perceptions included, lack of confidence in those who recommended help, having negative experien ces with professionals, st igma, thoughts that treatment would not help, child refusing to go, and not knowing who to trust. In a study of treatment retention, decreased quality of life and increase d parental psychopathology predicted parental perception of barriers to treatment participation for their clinically referred children (Kazdin & Wassell, 2000). He nce, it appears that barriers to mental health services appear to influence ini tial utilization and treatment retention. Various intervention programs have attemp ted to address these issues related to barriers to treatment utilizati on with little or no success. For example, Leaf, Bruce, and Tischler (1986) found that increasing only accessi bility and availability of mental health

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10 services was insufficient in promoting higher levels of utilization. Bickman, Heflinger, Northrup, Sonnichsen, and Schilling (1998) cond ucted an intervention program created to increase the parent’s knowledge of mental h ealth services, teach them skills needed to interact with mental health personnel, and enhance their me ntal health services selfefficacy. This intervention program did increase the parent’s knowledge and selfefficacy but it did not increase treatment involvement, which was defined by how involved the parent/caregiver was in the chil d’s treatment. These findings suggest that there are other variables infl uencing the under-utilization of mental health services in addition to barriers to treatment. One such variable is the individual’s attitudes toward mental health services. Attitudes toward Mental Health Services Parents’ attitudes appear to influence their willingne ss to seek mental health services for their children. Gustafson, Mc Namara, and Jensen (1994) found that parents were more likely to seek mental health trea tment for their children when their children’s behavioral disorder was severe and when the parents had positive attitudes toward seeking treatment as measured by a questionn aire. At the individual level, various studies have also found an association betw een attitudes toward treatment and helpseeking behaviors. Fischer and Turner (1970) showed that individua ls’ attitudes toward seeking mental health services have an influe nce on their decisions to seek mental health services. Other researchers also found that individuals’ attitudes toward treatment predicted help-seeking behavior (Bayer, & P eay, 1997; Cramer, 1999). In contrast, Leaf, Bruce, and Tischler (1986) found that positiv e attitudes toward mental health services were only related to utilization in women and not men. They attributed this finding to the

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11 fact that women identified the need for treatm ent at lower thresholds than men and were less likely to postpone treatment than me n, once the need for treatment had been identified. Overall, it appears that parent s’ attitudes toward mental health service utilization play an important ro le in seeking mental health services for their children and for themselves. Although not previously inves tigated, it is also po ssible that parents’ attitudes could be different wh en seeking mental health serv ices for themselves and for their children. This possibility wa s further investigated in this study. There are numerous issues that influence parents’ attitudes toward seeking mental health services including: family attitudes towa rd mental health services (where family attitudes are positively related to parental at titudes), parents’ gender (where women have more positive attitudes) race and socioec onomic status (where blacks and lower SES individuals have more negativ e attitudes) and previous ut ilization of mental health services (where prior use is positively associ ated with parental attitudes; Alvidrez, 1999; Kessler, et al., 2001; Leaf, Bruce, & Tischler 1986; Leaf, Bruce, Tischler, & Holzer, 1987; Robbins & Greenley, 1983). Although not thoroughly investig ated, barriers to treatment might also be influenced by attit udes toward mental health services or vice versa. Due to the lack of research in this area, this study will inve stigate this relationship further. Based on the background research on each individual topi c (i.e., barriers to mental health services and attitudes toward s mental health service utilization), it is sensible to propose that there might be an i nverse relationship betwee n the two variables. As mentioned above, race has been found to influence parents’ attitudes toward mental health services. Race is also associ ated with the utilization of mental health services.

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12 Race/Ethnicity and Mental Health Utilization The Surgeon General’s report states that the prevalence of mental disorders for racial and ethnic minorities are equal to those for Whites, yet utilization of mental health services is extremely low for racial and et hnic minorities (U.S. Department of Health and Human Services, 2001). A study of an in sured population found that Whites had 1.7 times greater odds of making a mental health visit than Blacks and Hispanics (Padgett, Patrick, Burns, & Schlesinger, 1994). This study also reported that Whites were estimated to make 2.64 more mental health visits during that y ear than Blacks and Hispanics (Padgett, Patrick, Burns, & Schles inger, 1994). The Surgeon General’s report describes several disparities that exist be tween racial and ethnic minorities and Whites that influence mental health service utilization including, minorities having less access to and availability of mental health services, th ey are less likely to receive needed mental health services, and they tend to receive poorer treatment (U.S Department of Health and Human Service, 2001). Other researchers ha ve also shown that under-utilization of mental health services in ethnic minorities is significantly influenced by higher levels of cultural mistrust between the clients and th e providers of mental health services (McDermott, 2001; Nickerson, Helms, & Te rrell, 1994; Thompson, Bazile, & Akbar, 2004). This pattern results in racial a nd ethnic minorities experiencing a greater disability burden from mental illness than whites because of the reduced and poor quality of care they receive. Another issue related to race and the underut ilization of mental h ealth services is the use of alternate sources for the provision of mental health services. The utilization of the church for counseling is a characteristic that is highly associated with African

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13 Americans (Boyd-Franklin & Lockwood, 1999; Neighbors, 1985). The National Survey of Black Mental Health found that of thos e African Americans who did seek help for mental health problems, only 9% of them us ed a psychologist, psychiatrist or community mental health facility, whereas the major ity of them sought help from physicians, ministers, family and friends (Jackson, Neighbors, & Gurin, 1986). In a college population, Ayalon and Young (2005) found that Bl ack students were more likely than White students to seek help from religious services. Neighbors (1985) also found that most African Americans seek mental health services from their minister, from their primary physician or from emergency room pe rsonnel. The opinions of family members and friends tend to be valued highly in th e African American community, as individuals who were advised by family members and friend s to seek mental health treatment sought out services over the course of time (Hines-Martin, Malone, Kim, & Brown-Piper, 2003). Alvidrez (1999) also found that having family /friends who had visited a mental health clinic was a marginally significant predictor of mental health se rvice use in African Americans, Latina and European American women. In addition to lower rates of utilization, drop out rates during treatment are also higher with ethnic minorities. Sue and Su e (1990) found that 50 percent of African American clients stop treatment after the first session compared with 30 percent of Caucasian clients. This pattern shows th at not only are racial and ethnic minorities underutilizing mental health se rvices but when they do use me ntal health services, they are not staying in treatment.

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14 Socioeconomic Status and Me ntal Health Utilization It seems almost impossible to discuss u tilization issues related to race and ethnicity without mentioning socioeconomic st atus (SES) because a large proportion of racial and ethnic minorities are in lower socioeconomic classes. Approximately 30 percent of African American families with children under age 18 compared with 13 percent of Caucasian families have incomes be low the poverty level (S tatistical Abstract of the United States, 2003). It is also importa nt to note that financial problems and even risk of poverty tend to be one of the burdens associated with rais ing children in single parent (usually single moth er) households due to low wage s, low education attainment, unfavorable economic conditions, and low ra tes and levels of child support (McLoyd, 1998). Yet 52.5 percent of African American ch ildren are being raised by single mothers compared with 15.5 percent of Caucasian children being raised by single mothers (Hofferth, Stueve, Pleck, Bianchi, & Sayer, 2002). Most of the issues related to underutilization of mental health se rvices have more detrimental effects on individuals of lower SES. An epidemiological study found that low socioeconomic status individuals perceived more barriers to using mental hea lth services than higher SES individuals due to having fewer financial resources and the least educational atta inment (Leaf, et al, 1987). Pumariega, Glover, Holzer, and Nguye n (1998) found that socioeconomic status had a positive impact while family compositi on had a negative impact on utilization of mental health services. Kazdin (1996) f ound that stress and socioeconomic disadvantage accounted for most of the racial and ethnic di fferences in dropout rates from treatment. Hence, race/ethnicity and socioeconomic st atus appear to have major influences on utilization of services due to the strong re lationship between race/ethnicity and SES and

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15 the influence of financial barrie rs on utilization of mental hea lth services. Another factor influencing utilization of mental health services is gender. Parental Gender and Mental Health Utilization It is well known that parents have a tr emendous genetic and environmental impact on the lives of their children. In comparison to mothers, however, less information is known about the father’s role in predicting ch ild outcome because the majority of studies that include parents tend to include only mothers rather than mothers and fathers (Johnson & Jacob, 2000; Phares & Compas, 1992). In a review of articles related to child and/or parental psychopathol ogy, Phares and Compas found that out of 577 articles published over an eight year period, 1.4% of studies involved the father only, 48.0% involved mothers only, 26.2% involved fa thers and mothers and analyzed them separately, and 24.4% either did not specify ge nder or did not analyze parents separately (Phares & Compas, 1992). A more recent review suggested that fathers continue to be ignored in studies of both developmenta l psychopathology and pediatric psychology (Phares, Lopez, Fields, Kamboukos, & Duhig, 2005). This pattern is a problem given that when mothers and fathers are studied, both appear to have tremendous influence on their children’s lives (Lamb, 2004). To incl ude only one parent is to ignore a large portion of the child’s life. It is well established that women tend to ut ilize mental health services more often than men (Mahalik, Good, & Englar-Carls on, 2003; Pescosolido & Boyer, 1999). A review of the literatu re suggests that this gender di fference might be due to various reasons such as the possibility that there is a higher prevalence of symptoms and disorders in women, the greater likelihood of women to recognize, acknowledge and

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16 report symptoms, or the gender biases in th e measures and judgments of clinicians (Pescosolido & Boyer, 1999). It has been shown that girls an d adolescent females tend to have more positive help-seeking attitudes (Cohen, 1999) and lower barriers to helpseeking (Kuhl, Jarkon-Horlick, & Morrissey, 19 97) than their male counterparts. Other researchers have also shown that regardless of age, nationality, race/ethnicity or parental status, men tend to under-utilize mental he alth services (Addis & Mahalik, 2003; Duhig, Phares, & Birkeland, 2002). It seems that wh en men do seek servic es they are heavily influenced by others. Cusack, Deane, Wils on and Ciarrochi (2004) found that 96% of the male participants in their study reported that they were influenced by others to seek mental health services. Notably, 37% suggested that they would not have sought services without the influence of others. Unfortunate ly the researchers did not include women in their study. The influence of parental gender on childre n’s use of mental h ealth services has not been investigated thoroughly. Since women utilize mental health services more often than men, it is reasonable to assume that moth ers might be more inclined than fathers to seek mental health services for their children. There is also evidence that fathers are less inclined to participate in tr eatment than mothers (Carr, 1998; Duhig, et. al., 2002). FalsStewart, Fincham, and Kelley (2004) found th at substance-abusing fathers were less willing than substance-abusing mothers to allow their children to receive treatment. It was noted in another review that men may of ten believe that problematic behavior is normal for children or that therapy is a waste of time (Phares, Fields, & Binitie, in press). These beliefs might also influence fathers when deciding to seek help for their children. This issue of parental gender and utilization of mental health services will be investigated

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17 in the current study. Another issu e that is related to utilizatio n of mental health services for children and their parents is th e issue of parental psychopathology. Parental Psychopathology and Mental Health Utilization Parental psychopathology can influence ch ildren differently. In a review of studies conducted over 10 year s, Beardslee and colleagues f ound that in children with an affectively ill parent, there is a 40% ch ance that the child will experience a major depressive episode by age 20 (Beardslee, Ve rsage, & Gladstone, 1998). This rate increases to 60% by age 25. In a study by Ja ffee, Moffitt, Caspi, and Taylor (2003), results showed that higher levels of conduct problems were seen in children raised by antisocial fathers and lower levels were seen in children with an antisocial father who were not raised by their antisocial father (J affee et. al., 2003). These findings could be attributed to the fact that children who were raised by their mother and antisocial father had a double dosage of environmental and genetic risk factors. In a meta-analytic study, Connell and Goodman (2002) found that external izing problems in children were related to psychopathology in both mothers and father s to a comparable extent. On the other hand, internalizing behaviors were more closely related to psychopathology in mothers than in fathers. This difference, however, was small and was attributed to methodological differences in the various st udies. When the e ffects of parental depression were explored, child ren were at increased risk for emotional/behavioral problems regardless of whether the mother or the father was experiencing depression (Kane & Garber, 2004). These findings estab lish that parental psychopathology has an influence on children’s psychopathology.

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18 Individuals’ psychopathology has an influence on their own decisions to seek mental health services. In an overview of factors influencing mental health care utilization, Pescosolido and B oyer (1999) stated that the need for care was the best predictor of utilization, regard less of how “need” was defined. They described “need” as the level of psychological distress, number of psychiatric symptoms, limitations in mental health functioning, self reports of mental he alth, risk factors asso ciated with mental health illness or an actual psychiatric di agnosis. Alvidrez (19 99) found that having a self-reported drug problem was a significant pred ictor of seeking mental health treatment in African American, Latina and European Am erican women. In this same study, having a probable alcohol disorder was also a predicto r of mental health se rvice use but was only marginally significant. However, as menti oned above, these results only refer to adult utilization of mental he alth services and not ch ildren’s utilization. Just as individuals’ psyc hopathology has been shown to influence help-seeking behaviors, children’s psychopathology has al so been shown to influence parents’ decisions on seeking mental health services for their children. An epidemiological study conducted by Leaf and colleagues (1996) found that youth with psychiatric disorders and poor functioning were 6.8 times more likely to have seen a mental health professional than youth with no psychiatric disorder a nd higher level of functioning. However, Kazdin, Holland, and Crowley (1997) found th at both the child’ s psychopathology and the parents’ psychopathology in fluence child treatment. They found that parental psychopathology (specifically, history of antisoc ial behavior), severity of the child’s problem and child history of antisocial beha vior significantly pred icted dropping out of child-related treatment prematurely. Hence it appears that both parental and child

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19 psychopathology influence children’s use of mental health services. Most of the research on psychopathology and utilization of mental health services has been conducted on the influence of adult psychopathology on adult utilization (Alvidrez, 1999; Pescosolido & Boyer, 1999) and child psychopathology on child u tilization (Leaf, et. al, 1996). Little is known about the specific influence of parent al psychopathology on ch ildren’s utilization of mental health services. This issue was investigated in the current study. Overall, it appears that those indivi duals who are young, white, educated, middleclass, and female seek mental health services more often than indi viduals who are older, black, in minority status, have less than a high school education, and are in the working and lower classes (Gourash, 1978).

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20 Hypotheses The current study aimed to investigate the reasons behind underutilization of mental health services for children and thei r parents by exploring parents’ race, gender, socioeconomic status, parents’ psychopathol ogy, and parent and ch ild-related barriers, and attitudes to treatment. Although barrier s to treatment tend to influence all individuals’ decisions on seeki ng mental health services, the ma jority of these barriers are more pronounced in ethnic minorities due to their minority status and the history of professionals’ treatment of ethnic minoritie s (Guthrie, 1998). This study specifically investigated the differences and similarities in attitudes and barriers to treatment in African American and Caucasian parents. Pa rents were the populati on of choice because not only do their attitudes and barriers to tr eatment influence their own use of services, but they usually seek mental health servic es for their children and as such their own perceived child-related attitudes and child-rel ated barriers would probably influence their decisions on seeking mental hea lth services for their children. The specific aims and hypotheses of this study were as follows: 1) To investigate the relationship between parents’ and their children’s previous utilization of mental health services and current parental and child -related attitudes toward mental health services. Based on previous research (Fischer & Turner, 1970; Gustafson, McNamara, & Jensen, 1994), it is hypothesized that both parental and child

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21 utilization will have positive relationships with parental and child-related attitudes toward mental health services, respectively. 2) To investigate the relation ships between parents’ and their children’s previous utilization of mental health services, and current perceived barriers to mental health service utilization for parents and for child-related therapy. Based on previous research (U.S. Department of Health and Hu man Services, 1999), it is hypothesized that both parental and child utiliza tion will have inverse relations hips with parents’ perceived barriers to their own and their child’s trea tment, respectively. 3) To investigate the relationship between current perceived barriers to mental health service utilization in parents and children, and current perceived attitudes toward mental health servic es for parents and children. Based on previous research (Alvidrez, 1999; Kessler, et al., 2001; Leaf, Bruce, Tisc hler, & Holzer, 1987), it is hypothesized that there will be an inverse relationship betw een both parental and childrelated perceived barri ers to treatment and parental a nd child-related attitudes toward mental health services, respectively. 4) To investigate the relationship between parents’ current barriers to treatment and parents’ perceptions of current barri ers to their children’s treatment. Based on previous research (Kuhl, Ja rkon-Horlick, & Morrissey, 1997; Pavluri, Luk, & McGee, 1996; Stefl & Prosperi, 1985), it is hypothesized that there wi ll be a positive relationship between parents’ reports of th eir own barriers to treatment a nd their reports of barriers to child-related treatment. 5) To investigate the relationship between parents’ current attitudes toward treatment and parents’ perceptions of cu rrent attitudes toward their children’s

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22 treatment. Based on previous research (Fischer & Turner, 1970; Gustafson, McNamara, & Jensen, 1994), it is hypothesized that ther e will be a positive relationship between parents’ reports of their own attitudes toward mental health services and their reports of their attitudes toward child-related treatment. 6) To investigate the differences in current parental attitudes and parents’ report of current child-related attitudes toward mental health service utilization in African American and Caucasian mothers and fathers. Based on previous research (Alvidrez, 1999; Cohen, 1999; Kessler, et al., 2001), it is hypothesized that mothers and Caucasian parents will have more positive attitudes toward mental health services for themselves and their children than fathers and Af rican American parents, respectively. 7) To investigate the influence of paren ts’ own current perceived barriers and parents’ current perception of barriers to me ntal health service utilization for their children on African American and Caucasian mothers and fathers. Based on previous research (Kuhl, Jarkon-Horlick, & Morrisse y, 1997; Thompson, Bazile, & Akbar, 2004), it is hypothesized that mothers and Caucasian parents will perceive fewer barriers to mental health serv ice utilization for themselves a nd their children than fathers and African American pa rents, respectively. 8) To investigate the influence of current parental and child-related attitudes toward mental health services, current parental and child-related barriers to treatment, and parental psychopathology on future utilization of mental health services for parents and their children. Based on previous research (Gustafson, McNamara, & Jensen, 1994; Kazdin, Holland, & Crowley, 1997), it is hypothesized that higher parental and child-relate d attitudes, lower parental and child-related barriers, and

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23 higher levels of parental psychopathology will predict higher plans for future utilization of mental health services fo r parents and their children.

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24 Method Participants A total of 2104 parents were recruited to partic ipate in this study. The sample comprised of parents of various racial/et hnic groups, including 47.6% African American, 44.8% Caucasian, 3.3% Asian, 3.3% Hispanic, .5% Native American/Alaskan, and .5% who reported their race as “Oth er”. No parents were denied participation in the study, however, only the African American and Cau casian participants were used in the analyses, as this was the focus of this study. Thus the final sample used in the analyses was 194 parents; 51.5% African Amer ican and 48.5% Caucasian. Parents ranged in age from 20 to 62 year s of age, with a mean age of 37.71 years (SD = 8.19). The sample consisted of appr oximately equal number s of fathers (49.5%) and mothers (50.5%), and majority of th e parents, 70.5%, were married, 12.4% were single without a partner, 7.8% were divorced, 5.2% were single with a partner, and 4.1% were separated. The percentage of married pa rticipants in this st udy is fairly high. The national average of married individuals in the United States is 51.7% (S tatistical Abstract of the United States, 2003). However, particip ants were required to have monthly faceto-face contact with their child and since mo re married individuals (especially married fathers) tend to have more contact with thei r children, this might e xplain the high rates of married parents in this study. 4 There were 211 questionnaires returned, but one partic ipant was left out of all the analyses because he only completed 36% of the questionnaires.

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25 Parents had an average of 2.31 children (SD = 1.17). Fathers had a mean of 16.29 years (SD = 3.26) of education and mothers had a mean of 15.46 years (SD = 2.48) of education. A total of 10.8% of parents were receiving some kind of public assistance and based on Hollingshead criteria for socioeconom ic status(Hollingshead, 1975), the social strata for the average participating pare nt represented medium businesses, minor professionals, and technical jo bs (M = 48.98; SD = 10.06). A majority of parents had physical hea lth care insurance for themselves (92.7%) and their children (97.4%). When asked a bout mental health care insurance there was some variability in responses. A total of 69.1% of parents had insurance for themselves, 16.8% did not, and 14.1% did not know if their insurance covered mental health needs. Similarly, 69.3% of parents had insurance cove rage for their children, 12.7% did not, and 18.0% did not know if their insurance covered ment al health care needs for their children. Based on a power analysis with power set at .80, alpha set at .05, and expecting a medium effect size, 45 participants per gr oup were required to adequately test the hypotheses via multiple regressions and analys es of covariance (ANCOVAs). Since the focus of this study was to examine similarities and differences between African American and Caucasian mothers and fathers, a mi nimum of 180 parents (45 per group) was necessary to test for a medium effect size. The demographic information for parents by gender and race/ethnicity is presented below (see Table 1). Similarities and differences in these groups are discussed in the Results section.

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26Table1 Demographic Variables for Parents by Race and Gender Variable Statistic African American Cau casian African American Caucasian Fathers Fathers Mothers Mothers (n = 50) (n = 46) (n = 50) (n = 48) Age Mean 38.54 39.26 35.75 37.33 SD 7.92 8.10 8.56 7.97 Socioeconomic Status Mean 49.58 52.52 45.53 48.34 SD 11.15 9.17 9.89 9.20 Years of Education Mean 15.40 17.22 14.96 15.96 SD 2.98 3.31 2.15 2.70 Number of Children Mean 2.28 2.37 2.40 2.19 SD 1.42 1.12 1.11 1.02 Note. SD = Standard deviation Measures Demographics questionnaire. The demographics ques tionnaire included questions about basic background informati on on each parent’s marital status, age, ethnicity/race, gender, occupati on, yearly income, years of ed ucation completed (for self and spouse/partner), and number of indivi duals in the household (Appendix B). The mothers and fathers who participated in this study were not necessari ly dyads; therefore demographic data on both the parent and his/ her spouse/partner were collected from the parent who completed the questionnaires. Socioeconomic Status (SES) was measured based on the four-factor index of socioeconom ic status (Hollingshead, 1975), which uses gender, marital status, educati on, and occupation to calculate th e SES of the participants. These variables were included in the demographics questionnaire. Utilization of mental health services questionnaire. A questionnaire was given to parents, which inquired about th eir previous use of mental health services including: psychiatrists, psychologists, social workers, pastoral counseling, and primary care doctors

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27 for mental health problems (Appendix C). Parents answered these questions for themselves, and their children. Parents were as ked if they or any of their children needed mental health services and how likely they w ould be to seek treatment for themselves or their children from various professionals. Parents who had seen a professional for mental health services were asked about their re ferral reason, termination reason, number of sessions attended, and therapist’ s race and gender. They were also asked to rate how satisfied they were with the services they received on a scale from 1-10. This questionnaire was based on a utilization meas ure developed by Healy (1997). Previous and future utilization of all five professionals (psychiatr ists, psychologists, social workers, pastoral counselor, and primary car e doctor) for mental health services were used in the final analyses. However, pos t hoc analyses were conducted using other variables including, satisf action with mental health servic es, quantity of mental health services used, future utilization of a pastor for mental health services, and future utilization of mental health professionals (i.e. psychiatrist s, psychologists, and social workers) for mental health services. Attitudes toward seeking professional psychological help. The shortened version of Fischer and Turner’s or iginal 1970 scale-Attitudes toward Seeking Professional Psychological Help (ATSPPH)-was used in this study to assess parent s’ attitudes toward seeking treatment for themselves and their children. This new measure (Appendix D), which was developed by Fischer and Farina ( 1995) is a 10-item uni dimensional version of the old scale that had 29 items. The new s cale correlates .87 with the old scale and has an internal consistency of .84 (Cronbach’s al pha). The new scale also has a test-retest reliability of .80 (Cronbach’s alpha; Fische r & Farina, 1995). The questionnaire asks

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28 participants about their a ttitudes toward seeking psyc hological help by responding to each statement in a likert-type format c onsisting of the following answer choices: strongly disagree, disagree, agree and str ongly agree (response choices were changed from “partly” to “strongly” to allow for clar ity in the responses). The items can be totaled from 0-30, but mean scores were us ed for the analyses to control for missing items, with means ranging from 0-3. Higher scor es indicate a pro-he lp seeking direction (i.e., more positive attitudes toward seeking he lp). Parents were asked to report on their attitudes toward seeking mental health services for themselves and their attitudes towards seeking services for their ch ildren on two separate questionn aires. The phrasing of the original questionnaire was modi fied slightly for the second questionnaire, in order to focus on parental perceived child-related attit udes towards seeking ment al health services (Appendix E). In the current sample, intern al consistency (Cronb ach’s alpha) was strong for both the parent ( = .83) and the child-related ( = .88) measures. Barriers to treatment utilization. This measure inquires about possible barriers to seeking treatment that parents might face for themselves and their children. The questionnaire was developed by Healy (1997) based on the work of Lorion and Parron (1987) and based on Parron’s ( 1982) findings that four ma in factors contribute to underutilization of mental heal th services in minorities5. The four factors are: Accessibility, Availability, Acceptability and Accountability (Parron, 1982). The Accessibility factor can be de scribed as barriers due to co st issues. The Availability factor can be described as having too few choices where se rvices can be obtained. The 5 The Barriers to Treatment Participation Scale (Kazdin, Holland, Crowley, & Breton, 1997) was not used in this study because it measures barriers that occur once in treatment, the focus of this study was to measure barriers to accessing treatment.

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29 Acceptability factor can be described as barr iers that influence the unique needs, values and beliefs of those seeking services. Finally, the Account ability factor describes the accountability of services to those who are being served. Since Healy’s 1997 questionnaire was developed to be used only with African American participants, some of the questions were changed slightly to gene ralize to all races for the purposes of this study (for example: Item 18, “The therapist will not be blac k, so cannot be trusted” was changed to “The therapist will not be the same race as me, so cannot be trusted”). Finally, six additional items were incl uded based on a recent study by Kessler and colleagues (2001). Item 4 (“my mental health insurance would not cover this type of treatment”) was added to the Accessibility f actor, Item 16 (“I went to a mental health professional in the past but it did not help”) was added to the Accep tability factor and Items 22-25 (“I would think my problem woul d get better by itself”, “I would be concerned about what others might think of me”, “I would want to solve the problem on my own”, and “I would be scared about bei ng put in the hospital against my will”) were added to a new category labeled as “Other”. Parents’ perceived barriers to treatment for themselves and for their children were meas ured using a likert-type response format consisting of the following answer choices: strongly disagree, disagree, agree and strongly agree (response choices were cha nged from “somewhat” to “strongly” to correspond with ATSPPH response choices). Pare nts were asked to report on the barriers that might arise when seeking services for themselves (Appendix F) and to report on the barriers that might arise when seeking serv ices for their children (Appendix G). The measure for parents’ barriers to services was modified to create the questionnaire for child-related barriers to services. An addi tional open ended item was included in both

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30 measures asking participants to describe any other barriers to treatment that they might perceive. The mean scores of parents’ perc eived barriers for themse lves and child-related treatment were used in the analyses, with m ean scores ranging from 0-3. The open ended questions were not included in the analyses and were only included in the questionnaires for informative purposes. In the current samp le, internal consistency (Cronbach’s alpha) was strong for the parent ( = .94)6 and child-related ( = .94) 6 barriers measures. Brief symptom inventory (BSI). This questionnaire is a measure of current psychological symptom status wi th well-established reliabil ity and validity (Derogatis, 1993). It is a 53 item self-re port questionnaire for psychiat ric, medical, and non-patient populations (Cundick, 2004). The BSI can be used with individuals age 13 and above and requires at least a sixth gr ade education. Partic ipants are asked how much they have been distressed by various symptoms dur ing the last seven days (Appendix H). Responses are given in a likert-type format, ranging from 0-4 with 0 being “not at all” and 4 “being extremely” distressed by sy mptoms. There are nine primary symptom dimensions including: somatization, obsessi ve-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. There are also three global indices including: Globa l Severity Index (GSI), Positive Symptom Total (PST), and Positive Symptom Distre ss Index (PSDI). The GSI indicates the individual’s current le vel of distress and is calculated by adding all the items and dividing by the total number of responses (Derogatis, 1993). The PST is the total number of positive responses that were endorsed by the individual. The PSDI is derived by adding all the items and dividing by the PST. For th e purposes of this study, the Global Severity 6 Internal consistency reliability was run with out items 15 and 16, which were optional items.

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31 Index (GSI) will be used because it is designed to help quantify an individual’s level of overall psychological symptoms. It is releva nt because the goal of this study is to determine if psychopathology in general has an effect on future utilization. Higher numbers on this index represent more distress. The BSI has acceptable internal cons istency reliabilities from .71 on the Psychoticism dimension to .83 on the Obsessi ve-Compulsive dimension (Cundick, 2004). The test-retest reliability fo r the three global indices are above .80 and range from .68 on the Somatization dimension to .91 on the P hobic Anxiety dimension. Specifically, the test-retest reliability for the Global Severity index (GSI) is .90 (Peterson, 2004). The BSI also has good concurrent validity with th e MMPI (Peterson, 2004). In the current sample, internal consiste ncy (Cronbach’s alpha) was strong for the BSI ( = .97). Procedure Parents were recruited to participate in the study through the use of flyers, advertisements, and direct in vitation (snow-balling and direct approach ). Flyers were displayed on notice boards at schools including: elementary schools, daycare facilities, and throughout the University of South Florid a (USF). Flyers were also displayed at children’s hospitals, grocery stores, community centers, li braries, laundromats, and apartment complexes. Recruiting minorities in research is a difficult task and recruiting low SES minorities is even more taxing (M iranda, 1996). However, including only low SES individuals is misrepresentative of the Caucasian populations si nce a large majority fall in a higher SES bracket. On the othe r hand, including only high SES individuals is misrepresentative of the Af rican American population, wh ere a large proportion of individuals fall in a lower SES bracket. Hence extra effort was made to recruit a wide

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32 variety of individuals from varying SES range s by placing flyers in well-off, moderate, and impoverished areas. Advertisements were placed in the Sentinel (a magazine geared toward the African American community) and on severa l listserves that targeted both African American and Caucasian parents. Parents were also approached directly at various places including grocery stores, and hair salons, and asked to participate in the study. The snow-ball method was used where parents w ho participated in the study and non-parents who were approached to participate in the study were asked to invi te other parents to participate. Leaders of vari ous organizations (churches, da ycare facilities, and parent groups) were also approached and the parents at these organizations were invited by the researcher or the leader of the orga nization to particip ate in the study. Effort was made to recruit biological, step, and/or adoptive parents who had a child between ages 2-17 and w ho had at least monthly face to face contact with their child. The age range was selected to ensure th at parents would still ha ve an active role in the child’s life and the lower age limit was chosen because empirically supported treatments usually begin at age two (Barkley, 1997). Parents did not have to be dyads. This decision was important in order to ensure that a large proportion of African American families would not be excluded, b ecause 52.5% of African American children are being raised by single mothers (Hofferth, Stueve, Pleck, Bianchi, & Sayer, 2002). Since this study was based on a community sample and because participants were just asked to complete questionnaires, data collection took place larg ely through the mail. Although no order effects were expected, ques tionnaires were presented in randomized order so that possible biases due to order e ffects were minimized. However, in order not

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33 to confuse participants, ques tionnaires for parent and ch ild-related information were randomized as a block. When interested partic ipants called or sent an inquiry via email, the requirements of the study were reiterated and they were asked to provide their mailing address. The questionnaires along with a co ver letter explaining the study (Appendix A), a business reply envelope, and a business repl y postcard for their contact information (if they wanted to be included in the drawing) were mailed to them. Participants who were approached directly had the option of co mpleting the questionnaires immediately or mailing them back. If they chose to comple te the questionnaires im mediately, and filled out the business reply postcard with thei r contact information, it was immediately separated from their questionnaires to pr otect their privacy. Questionnaires took approximately 20 minutes to complete. A total of 541 surveys were distributed and a total of 211 were returned. Thus, there was a 39% participation rate. This numbe r is consistent with other survey research in the community with adults (Kropf & Blair, 2005; Shumway, Unick, McConnell, Catalano, & Forster, 2004). Af ter the participant target number was reached (45 parents from each gender and racial group to be analyz ed), the data were entered into SPSS and the various analyses were run. Once the st udy is complete (results have been defended), participants who filled out the business reply postcards will be entered into a drawing with a chance of winning one of six prizes wh ich will be sent to the winners by mail. The prizes include: one $100 mone tary prize, two $50 monetary prizes, and three $30 gift certificates for Walmart, Target, and Publix. A referral list of mental health facilities (Appendix I) will also be sent at that tim e to all participants who provided contact information, in case they wish to seek mental health treatment for themselves or for their

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34 children. Those parents who requested the results of the study will also be sent a brief synopsis of the results.

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35 Results Descriptives To ensure that active parent s were recruited to particip ate in this study, effort was made to invite those parents who had a child between ages 2-17 and had monthly face to face contact with the child. However, 17% of those parents whose children had used services (N = 6) reported utilization information on child ren who were older than 17. Nevertheless, because they still had monthly face to face contact with their children and thus appeared to still have an active role in their children’s lives, they were included in the analyses. A total of 1.5% of the parent s (N = 3) who particip ated in the study had contact with their children but not face to f ace contact on a monthly basis. None of these parents, however, had children who had used mental health services and so they were still included in the study. Of the 194 parents included in the tota l sample, 36.3% had used mental health services for themselves in the past. Thes e parents ranged in ag e from 24-56 years ( M = 37.94, SD = 8.22), 69.6% were female and 30.4% were male, and 68.1% were Caucasian and 31.9% were African American. A total of 19.4% of the childre n mentioned in the total sample had used mental health services in the past. These children ranged in age from 5-23 years ( M = 12.60, SD = 4.75) and were 71.0% male and 29.0% female. Furthermore, 67.6% of their parents had also us ed mental health services in the past.

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36 The scores on the Attitudes toward Se eking Professional Psychological Help measure (ATSPPH) have a potential range from 0-3, with higher scores indicating a prohelp seeking direction. This samp le had scores ranging from .50 2.90 ( M = 1.73, SD = .47) for parent attitudes and .10 3.00 ( M = 1.97, SD = .49) for child-related attitudes. The parent attitudes scores are cons istent with the normative sample ( M = 1.75, SD = .60) which were generally normally distributed but slightly positively skewed (Fischer & Farina, 1995). Unfortunately, there is no comp arison sample for child-related attitudes. The scores for the Barriers to Treatment Utilization range from 0-3, with higher scores indicating more perceived barriers to treatment utilization. The current sample had scores ranging from .00 1.89 ( M = .98, SD = .46) for parent barriers and .00 1.91 ( M = .91, SD = .43) for child-related barriers. No comparison information to a normative sample is available. The three most fre quently endorsed parent barriers to seeking services were, “I would want to solve the problem on my own”, “Men tal health services are not in my budget”, and “I would be scared about being put into a hospital against my will” (44.8%, 41.5%, and 32.0%, respectively). The three most frequently endorsed child-related barriers to seeking services were “I would be scared about my child being put into a hospital against my will”, “I woul d want to solve my child’s problem on my own”, and “Mental health services are not in my budget for my child” (34.1%, 33.4%, and 27.9%, respectively). On the Brief Symptom Inventory (BSI), those individuals w ho had 13 or more missing items were excluded from the anal yses, as was suggested in the manual (Derogatis, 1993). The Global Se verity Index (GSI) scores fo r parents’ overall level of psychopathology were calculated by summing all the items and dividing by the total

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37 number of responses. This was done to co rrect for missing data (Derogatis, 1993). The scores for the GSI are represented by T sc ores and were normed for various male and female populations including inpatient, out patient, and non-patient populations. The norms for the non-patient population will be used for this sample. The fathers in the current sample had GSI scores ranging from .00 1.83 ( M = .34, SD = .45), representing an average T-score of 57, based on the ma nual (Derogatis, 1993). The mothers in the current sample, however, had GSI scores ranging from .00 2.27 ( M = .44, SD = .51), representing an average Tscore of 56.5, based on the manual (Derogatis, 1993). This indicates that on average neither fathers nor mothers were experiencing significant levels of psychopathology. The nine primary symptom dimensions of the BSI were calculated by summing the total items for each dimensi on and dividing by the total number of responses in that dimension. The nine prim ary symptom dimensions were only used in post-hoc analyses. Analyses of Variance (ANOVAs) were c onducted to determin e if the groups (African American fathers, African American mothers, Caucasian fathers, and Caucasian mothers) were significantly different from each other on any of the major demographic variables (socioeconomic status, age, and number of children) and symptom severity (GSI scores). For the socioeconomic status (SES) variable, there was a significant main effect for gender, F (1, 169) = 7.54, p < .01, where fathers showed significantly higher SES ( M = 51.05) than mothers ( M = 46.94). There was no main effect for race/ethnicity and the interaction effect wa s not significant. Given the confounded nature of SES and race/ethnicity nationwide (M cLoyd, 1998), it is notable that this sample did not differ significantly on SES across racial/ethnic groups.

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38 For the age variable, there was a significant main effect for gender, F (1, 188) = 4.03, p < .05, where fathers were significantly older ( M = 38.90) than mothers ( M = 36.54). The main effect for race/ethnicity was not significant nor was the interaction effect for age. There was no significant e ffect for number of children or GSI scores. Since socioeconomic status was already planne d to be statistically controlled in the analyses, the gender difference in SES was c ontrolled. Although age was not controlled statistically for the analyses, post hoc analys es were completed with age controlled. When age was statistically cont rolled, the results of the an alyses were the same, so it appeared that the difference in age did not in fluence the results either. Therefore, the analyses were run as proposed. Hypothesis Testing Correlations were used to determine the various relationships between previous utilization for parents, child utilization, pa rent barriers, parent attitudes, child-related barriers, and child-relate d attitudes (see Table 2). Consis tent with Hypothesis 1, previous utilization of mental health se rvices and parental attitudes to ward mental health services were positively correlated (r = .33) while prev ious utilization and child-related attitudes were also positively correlated (r = .28).

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39Table 2 Parent and Child-related Intercorrelations be tween Utilization, Barriers, and Attitudes Variable P Utilization P Attitudes P Barriers C Utilization C Attitudes C Barriers P Utilization .33*** -.21** .32*** .27*** -.20** P Attitudes -.50*** .22** .76*** -.54*** P Barriers -.09 -.45*** .85*** C Utilization .28*** -.18* C Attitudes -.55*** C Barriers Note. P = Parent; C = Child-related. p < .05, ** p < .01, *** p < .001 Consistent with Hypothesis 2, previous util ization of mental health services and perceived parental barriers to mental health service utilization (r = -.21) was inversely correlated while previous utilization and perceived child-related barriers was also inversely correlated (r = -.18). Pearson correlations were used to determ ine the relationships between parent and child-related barriers and attit udes (see Table 2). Consiste nt with Hypothesis 3, parent barriers and parent attitudes have a negativ e relationship (r = .50) and child-related barriers and child-related att itudes also have a negative relationship (r = -.55). Pearson correlations were also used to determine the relationships between parents’ perceived barriers a nd child-related barriers to ut ilization, and parents’ reported attitudes and child-relate d attitudes toward mental health utilization. Consistent with Hypothesis 4, there was a str ong positive relationship betw een parents’ barriers and child-related barriers (r = .85). Consistent with Hypothesis 5, there was also a strong positive relationship between pare nts’ attitudes and child-rela ted attitudes (r = .76). Due

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40 to the strong relationships between these va riables, further analyses were conduct. A paired samples T-test indicated that parents’ barriers ( M = .98, SD = .46) were significantly higher than child-related barriers ( M = .90, SD = .43), t (187) = 4.52, p < .001. Another paired samples T-test indicated that parents had signi ficantly less positive attitudes ( M = 1.74, SD = .48) toward seeking mental hea lth services for themselves than for their children ( M = 1.97, SD = .49), t (179) = -9.02, p < .001. Thus, although there were strong correlations between the parent and child-related measures, the mean differences suggest different le vels of perceived barriers and attitudes for parents’ therapy than for child-related therapy. Due to the strong relationship between SES and race, the influence of SES on the sample was controlled in all the relevant analys es in order to investig ate the direct effect of race on the sample. This procedure was achieved by covarying out the influence of SES on the participants’ scores. Note, however, that this procedure is sometimes seen as a methodological limitation because it does not actually remove the socioeconomic differences but rather only statistically controls for its influence on the sample. In order to test Hypothesis 6, a two-wa y Analysis of Covariance (ANCOVA) was conducted between parent attitudes and the independent variables of race (African American and Caucasian) and gender (male an d female), covarying for the influence of SES. The main effect for gender was significant, F (1, 165) = 7.45, p < .01, indicating that mothers ( M = 1.83) had more positive attitudes to ward seeking services than fathers ( M = 1.63). The main effect for race was also significant, F (1, 165) = 4.74, p < .05, indicating that Caucasian parents ( M = 1.81) had more positive attitudes toward seeking services for themselves than African American parents ( M = 1.65). However, the

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41 interaction effect was non-significant, F (1, 165) = .39, p = .53. In order to test the childrelated portion of Hypothesis 6, a sec ond two-way ANCOVA was conducted between child-related attitudes and parent s’ race and gender, covarying for the influence of SES. The main effect for gender was significant, F (1, 162) = 6.19, p < .05, showing that mothers ( M = 2.06) had more positive at titudes toward seeking se rvices for their children than fathers ( M = 1.88). However, neither the main effect of race, F (1, 162) = 1.95, p = .17, nor the interaction effect, F (1, 162) = .001, p = .97 were significant. Thus, there was support for the parental portion of Hypothesi s 6 but only partial s upport for the childrelated portion of Hypothesis 6. In order to test Hypothesis 7, a th ird two-way Analysis of Covariance (ANCOVA) was run between pa rent barriers and the two le vels of race (African American and Caucasian) and gender (male and female), with the covariate of SES. The results indicated a significant main effect of race, F (1, 164) = 10.28, p < .01, such that African American parents ( M = 1.09) reportedly perceived mo re barriers to utilization than Caucasian parents ( M = .89). The main effect for gender was non-significant, F (1, 164) = 1.52, p = .22 and neither was the interaction effect, F (1, 164) = .33, p = .56. In order to test the child-re lated portion of Hypothesis 7, a fourth two-way ANCOVA was conducted between child-related barriers and ra ce and gender, covarying for SES. These results also indicated a significant main effect for race, F (1, 165) = 11.03, p < .01, showing that African American parents ( M = 1.02) perceived more child-related barriers to utilization than Caucasian parents ( M = .81). However, neither the main effect for gender, F (1, 165) = 2.07, p = .15, nor the interaction effect, F (1, 165) = .01, p = .92 were

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42 significant. Thus, there was partial support for both the parental and child-related portions of Hypothesis 7. Note that when all of the variables we re run with Analyses of Variance (i.e. without SES as a covariate), the results were almost identical. The only difference was for child-related attitudes, wh ere the main effect of race, F (1, 176) = 5.12, p < .05 was significant, such that Caucasian parents (M = 2.04) had more positive attitudes toward mental health than African American parent s (M = 1.88). Overall, the results with and without SES covaried were predominan tly consistent with the hypotheses. In order to test Hypothesis 8, a multiple regression analysis was performed to predict parents’ future utilization of services from parent attitudes, parent barriers, and parent psychopathology. Due to the poten tial confound between race and SES, the influence of SES was controlled statistically and then the remaining variables were added to the model. This second model, with SES controlled, was significant, F (4, 146) = 6.41, p < .001, R2 = .15, however the parental barrie r variable was the only predictor accounting for a significant amount of variance in the model (see Table 3). These results suggested that the more barriers parents perc eive toward treatment, the less likely they will be to seek mental health services for themselves in the future. Thus, there was partial support for the pare ntal portion of Hypothesis 8.

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43Table 3 Multiple Regression Analysis for Parent Attitudes, Barriers, and Ps ychopathology Predicting Future Utilization in Parents Variable B SE B Socioeconomic Status -.03 .10 -.02 Parent Attitudes 3.99 2.31 .16 Parent Barriers -7.79 2.52 -.29** Global Severity Index 3.92 2.12 .15 Note. R2 = .15 ** p < .01 As a test of the second part of Hypothesis 8, a second multiple regression analysis was conducted to predict child’s future utilization of mental health services from childrelated attitudes, child-related barriers, and parent psychopathology. The influence of SES was also taken out before the rest of th e other variables were added to the model. This second model, with SES controlled, was significant, F (4, 144) = 3.76, p < .01, R2 = .10, however the child-related barrier variable was the only predictor that accounted for a significant amount of variance in this model (see Table 4). These results suggested that the more barriers parent perceive toward child -related treatment, the less likely they will be to seek mental health serv ices for their children in the future. Thus, there was also partial support for the child-rel ated portion of Hypothesis 8.

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44Table 4 Multiple Regression Analysis for Child-related Attitudes, Child-related Barriers, and Parental Psychopathology Predicting Future Utilization in Children Variable B SE B Socioeconomic Status -.04 .12 -.03 Child-related Attitudes 2.53 2.69 .09 Child-related Barriers -7.62 3.07 -.25* Global Severity Index 3.21 2.49 .11 Note. R2 = .10 p < .05 Overall, the majority of the proposed hypotheses were supported, but there were some unexpected null results. Therefore, mo re analyses were conducted to explore the variables in a more thorough manner. Post Hoc Analyses Several post hoc analyses were run to e xplore the relationships between the parent and child variables further. These results are presented in this section because they were not proposed with the original hypotheses. Utilization variables with barriers and attitudes. Pearson correlations were conducted to determine the relationships betw een parental and child -related satisfaction with prior mental health services and pare ntal and child-related ba rriers, respectively. Correlations were also used to determine th e relationships between parental and childrelated satisfaction and parental and child-relat ed attitudes, respectiv ely. Correlations can be seen in Table 5. There was a non-signifi cant correlation between parents’ satisfaction with their treatment and parents’ satisf action with their children’s treatment ( p = .08). Pearson correlations were also run to dete rmine the relationships between quantity of

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45 mental health services used by parents a nd children (i.e., number of sessions) and parental and child-related barrier s, respectively. Correlations we re also used to determine the relationships between quantit y of mental health services used by parents and children and parental and child-related attitudes, respec tively. These correlations can also be seen in Table 5. There was a strong positive correl ation between quantity of services used by parents and quantity of se rvices used by children r (22) = .79, p < .001. Table 5 Correlations of Parent and Child-related Barriers an d Attitudes with Satisfaction and Quantity of Utilization Variable Satisfaction with MHS Quantity of MHS used Parent Attitudes .37** .36** Parent Barriers -.06 -.32** Child-Related Attitudes .40* .33 Child-Related Barriers -.10 -.40* Note. MHS = Mental Health Service. p < .05, ** p < .01 Utilization of pastors for mental health services. Because religious leaders have been posited as a resource for the African American community more so than other communities, analyses were conducted to expl ore this pattern. A two-way Analysis of Covariance (ANCOVA) was performed between fu ture utilization of a pastor for mental health services and the independent variable s of race (African American and Caucasian) and gender (male and female), covarying for th e influence of SES. The main effect for race was significant, F (1, 151) = 5.95, p < .05, indicating that Af rican American parents ( M = 5.01) are more likely to seek mental hea lth services for themselves from a pastor than are Caucasian parents ( M = 3.63). However, neither the main effect for gender, F (1,

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46 151) = .40, p = .53, nor the interaction effect, F (1, 151) = .61, p = .44 were significant. Another two-way ANCOVA was performed betw een future utilization of a pastor for child mental health services a nd race and gender, with SES as the covariate. Neither the main effect for gender, F (1, 151) = .03, p = .86, the main effect for race, F (1, 151) = 2.50, p = .12, nor the interaction effect, F (1, 151) = .32, p = .58 were significant. Thus, it appeared that African American parents are willing to seek mental health services from pastors more often than Caucasian parents wh en therapy is for themselves but not when therapy is being sought for their children. Utilization of mental health professionals for mental health services. A multiple regression analysis was performed to predict pa rents’ future utilization of mental health professionals (psychologists, psychiatrists, and social workers) from parent attitudes, parent barriers, and parent psychopathology. The influence of SES was taken out before the rest of the variables were added to th e model. This second model, with SES controlled, was significant, F (4, 146) = 18.02, p < .001, R2 = .33. In addition, all the variables including parent barr iers, parent attitudes, a nd parent psychopathology were significant predictors and account ed for significant amounts of variance in the model (see Table 6). Thus, in contrast to the regression that tested Hypothesis 8, which used all five professionals (psychiatrists, psychologists, social workers, past oral counselors, and primary care doctors) and which had modest results, the focus on only mental health professionals appears to be more relevant to parental barrie rs, attitudes, and psychopathology.

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47Table 6 Multiple Regression Analysis for Parent Attitudes, Barriers, and Ps ychopathology Predicting Parents’ Future Utilization of Ment al Health Professionals Variable B SE B Socioeconomic Status .05 .06 .07 Parent Attitudes 5.06 1.25 .32*** Parent Barriers -4.97 1.36 -.30*** Global Severity Index 3.47 1.15 .21** Note. R2 = .33 ** p < .01, *** p < .001 Another multiple regression was conducted to predict children’s future utilization of mental health professionals from child-rel ated attitudes, child -related barriers, and parent psychopathology. The influence of SES was also taken out before the rest of the variables were added to the model. This second model, with SES controlled, was significant, F (4, 144) = 12.76, p < .001, R2 = .26. In addition, ch ild-related at titudes and child-related barriers accounted for significant amounts of va riance in the model (see Table 7). Thus, in contrast to the regre ssions that tested the child-related portion of Hypothesis 8, which used all five professiona ls (psychiatrists, psychologists, social workers, pastoral counselors, and primary care doctors), and which also had modest results, the focus on only mental health prof essionals appears to be more relevant to child-related barriers and child-related attitudes.

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48Table 7 Multiple Regression Analysis for Child-related Attitudes, Child-related Barriers, and Parental Psychopathology Predicting Children’s Future Utilization of Mental Health Professionals Variable B SE B Socioeconomic Status .03 .06 .03 Child-related Attitudes 4.68 1.45 .29** Child-related Barriers -5.21 1.66 -.28** Global Severity Index 1.63 1.35 .09 Note. R2 = .26 ** p < .01 Parental psychopathology subsca les and future utilization. Although the Global Severity Index (GSI) of the BSI is a robus t measure of psychological symptoms, there may be fine-grained details that can be asce rtained by exploring the subscales on the BSI. Therefore, multiple regression analyses were conducted to determine if the subscales of the BSI, along with attitudes and barriers, w ould predict future ut ilization of mental health professionals for mental health servic es in parents and child ren. The influence of SES was taken out before the rest of the vari ables were added to the model. For parent future utilization, the second model, with SES controlled, was significant, F (12, 138) = 6.29, p < .001, R2 = .35. However, parent attitudes and parent barriers were the only predictors accounting for signi ficant amounts of variance in th e model (see Table 8). For child future utilization, the second model, with SES controlled, was also significant, F (12, 136) = 5.04, p < .001, R2 = .31. However, child-related attitudes, child-related barriers, and the Obsessive-Compulsive subscale were the only predic tors that accounted for a significant amount of variance in the model (see Table 8). Thus, none of the BSI subscales significantly predicted parent utilizat ion of mental health professionals from

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49 themselves in the future, however, the higher parents scored on the ObsessiveCompulsive subscale, the more likely they would be to seek services from mental health professionals for their children in the future. Table 8 Multiple Regression Analyses for Parent and Ch ild-related Attitudes, Barriers, and Parental Psychopathology Subscales Predicting Future Utilization of Mental Health Professionals Variable Group B SE B Socioeconomic Status Parent .05 .06 .07 Child-related .05 .07 .05 Attitudes Parent 4.39 1.35 .28** Child-related 3.88 1.53 .24* Parent Barriers Parent -5.03 1.40 -.30*** Child-related -4.86 1.68 -.26** Somatization Subscale Parent 1.82 1.71 .10 Child-related 2.51 1.91 .13 Obsessive-Compulsive Subscale Parent 1.38 1.28 .14 Child-related 3.01 1.51 .28* Interpersonal Sensitivity Subscale Parent 1.06 1.32 .09 Child-related -.49 1.66 -.04 Depression Subscale Parent .88 1.53 .07 Child-related -.09 1.78 -.01 Anxiety Subscale Parent 1.71 2.16 .12 Child-related 1.13 2.65 .07 Hostility Subscale Parent -1.21 1.34 -.10 Child-related -1.32 1.55 -.10 Phobic Anxiety Subscale Parent -.62 2.29 -.03 Child-related 1.61 2.79 .07 Paranoid Ideation Subscale Parent -1.57 1.53 -.13 Child-related -2.88 1.80 -.22 Psychoticism Subscale Parent -.15 2.25 -.01 Child-related -1.44 2.47 -.08 Note. Parent R2 = .35; Child R2 = .31. p < .05, ** p < .01, *** p < .001

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50 Discussion The aim of this study was to investig ate the relationship between African American and Caucasian parent al and child-related barriers and attitudes toward mental health services. The relations hips between prior utilizati on and parent an d child-related barriers and attitudes were also examined. In addition, this study explored the predictors of future utilization for parents and childre n among barriers, att itudes, and parental psychopathology. Overall, in terms of utilizati on of mental health services, more mothers had utilized services than fath ers; however more boys had uti lized services than girls. This pattern has been well es tablished in the literature, where boys tend to receive services more often than girls before a dolescence; and then females take over in adolescence and adulthood (Costello & Janis zewski, 1990; Pescosolido & Boyer, 1999). There were also racial differences in utiliza tion such that Caucasians parents used more services than African Americans parents, an other well established f act (U.S. Department of Health and Human Services, 2001). In addition, parents did not differ by race or gender in terms of current psychopathology, indicating another consistency with the literature (U.S. Department of Health and Human Services, 2001). Thus, in terms of utilization of mental health services and parental psychopa thology, the current sample is similar to those described in the literature. The specific aims of this study were explored by eight hypotheses.

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51 The analyses confirmed the first hyp othesis which predicted a positive relationship between parent utilization and pa rent attitudes and also predicted a positive relationship between child utiliz ation and child-related attitude s. The finding that parents with more positive attitudes toward seeking services for themselves and their children used services more in the past for themselves and their children is consistent with the literature. For example, Gustafson, McNa mara, and Jensen (1994) found that parents were more likely to seek treatment for their children when they had positive attitudes toward seeking treatment. Other researchers have also shown that individuals’ attitudes toward treatment predicted help-seek ing behaviors (Bayer & Peay, 1997). The second set of hypotheses, which pred icted a negative re lationship between parent utilization and parent barriers and also predicted a negative relationship between child utilization and child-related barriers, we re also confirmed. The finding that parents who perceived fewer barriers to utilization fo r themselves and their children used more services in the past for themselves and thei r children is consistent with the literature (Owens et al., 2002; Snowden, 2001). Howeve r, the relationship between child-related barriers and child utilization was quite weak, thus it appear s that other issues may be involved when parents are seeking services for their children and for themselves too. The results confirmed the third hypothesis as well, which predicted a negative relationship between parental barriers a nd attitudes and also predicted a negative relationship between child-related barriers a nd attitudes. The finding that parents who perceived fewer barriers for themselves a nd their children had more positive attitudes toward mental health services for themselves and their children has not been previously examined specifically in the literature. No studies were found that investigated the

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52 specific relationship between barriers and attitudes. However, based on the well established literature that fewer barriers are associated with higher utilization and positive attitudes are also associated w ith higher utilization, these results are consistent with the literature. A unique aspect of this study involved as king parents to report on their barriers and attitudes for seeking treatment for them selves and their barri ers and attitudes for seeking treatment for their children. The f ourth hypothesis, which predicted a positive relationship between parents’ ba rriers and child-related barriers to seeking services was confirmed. The finding that parents who perceive d barriers to mental health treatment for themselves also perceived barriers for their children was further i nvestigated and results indicated that parents perceive d significantly more barriers for themselves than for their children. Thus, it appeared that parents we re able to overcome certain barriers when seeking services for their children in contrast to themselves. In fact, the most frequently endorsed barrier for parents (“I would want to solve the problem on my own”) was different from the most frequently endorsed ba rrier for child-related treatment (“I would be scared about my child being put into a hospital against my will”). The analyses also confirmed the fifth hypothesis. This hypothesis predicted a positive relationship between parents’ attitude s and child-related attitudes toward seeking services. The finding that parents who had more positive attitudes toward seeking services for themselves also had more positiv e attitudes toward seeking services for their children was investigated further. The findi ngs indicated that pa rents had significantly more positive attitudes toward seeking services for their children than for themselves. These results provide important informati on for developing programs geared toward

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53 increasing utilization of mental health serv ices. Researchers inte rested in developing such programs might want to ta rget different issues for pa rent treatment versus child treatment because it appears th at the barriers influencing pare nts’ utilization differ from those influencing them when seeking se rvices for their children (Bannon & McKay, 2005; Pavluri, Luk, & McGee, 1996). Furtherm ore, since parents have more positive attitudes toward seeking services for their children, they might be more open to programs focused on increasing service use in their childr en first before increasing their own use of mental health services. The sixth hypothesis predicted that moth ers and Caucasian parents would have more positive attitudes toward mental health services for themselves and their children than fathers and African American parents. This hypothesis was mostly supported, such that mothers and Caucasian parents had significantly more positive attitudes toward mental health services for themselves a nd mothers also had more positive attitudes toward services for their children. However, there were no racial differences in attitudes toward services for children. This fi nding that gender has such a strong impact on attitudes for parents and their children’s mental health is consistent with the literature (Fisher & Turner, 1970; Mahalik, Good, & E nglar-Carlson, 2003). Furthermore, the finding that African American parents have less positive attitudes toward services for themselves is also well established (Diala et al., 2000). However, the fact that African American parents were not signi ficantly different from Caucas ian parents in child-related attitudes was unexpected. Again, it is likely that parents regard less of race put aside their attitudes when considering serv ice utilization for their children and try to do what is best for their children regardless of their own attitudes toward me ntal health. The fact that

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54 gender differences were found in child-relate d attitudes to treatment, speaks to the strong effect of parents’ gender on me ntal health service utilization. Thus it appears that fathers tend to have less favorable attitudes toward me ntal health services regardless of whether it is for themselves or their children while moth ers are able to modify their attitudes when their children are concerned. The seventh hypothesis predicted that mothers and Caucasian parents would perceive fewer barriers to mental health util ization for themselves and their children than fathers and African American parents. This hypothesis was partially confirmed, such that Caucasian parents perceived fewer barriers to utilization of mental health services for themselves and their children than African Am erican parents. However, there were no gender differences in parents’ perception of barriers for them selves or their children. The finding that African American parents perc eived more barriers to mental health utilization has been found consistently (Snowden, 2001; Thompson, Bazile, & Akbar, 2004). Several ideas have been offered to e xplain this relationship. For example, Gary (2005) suggested that minorities are concer ned about prejudice and discrimination and feel that they might suffer “double stigma” from being in a minority group and having a mental health illness. Thompson and colle agues found that their sample of African American participants believed that psychologi sts would be insensitive to the “African American experience” (Thompson, Bazile, & Akbar, 2004). It was interesting that African Americans perceived mo re barriers than Caucasians for themselves and for their children. Thus it seemed that th e racial issues were so strong that they persevered even when utilization for their children was con cerned. However, the finding of no gender differences in perception of barriers was unexpected. This finding indicates that although

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55 men (fathers) use services less often than wo men (mothers), their underutilization is not due to perception of more barriers. This finding could be because men perceive similar barriers to services but other issues such as less positive attitudes toward mental health, might prevent them from using services as often as women do. Mahalik and colleagues found that masculinity was associated with less help-seeking and negative attitudes toward mental health because help seek ing implies dependence and vulnerability (Mahalik, Good, & Englar-Carlson, 2003). Finally, the eighth hypothesis predicted that higher parent al and child-related attitudes, lower parental and child-related barriers, and higher levels of parental psychopathology would predict higher rates of futu re utilization of ment al health services for parents and children as re ported by parents. This hypot hesis was partially supported, such that the variable of lower rates of pare ntal barriers was the only significant predictor of future utilization in parent s and the variable of lower rate s of child-related barriers was the only significant predictor of future ut ilization in children, accounting for 15% and 10% of the variance, respectively. These resu lts were surprising si nce attitudes have a moderate relationship with pr ior utilization and le vel of distress has been shown to be related to help seeking (Pesco solido, & Boyer, 1999). Parent s in this study were asked about future utilization of mental health services from various individuals including mental health service professionals (psychologi sts, psychiatrists, a nd social workers/other mental health professionals), pastors, primary care doctors, and family/friends. Research has shown that individuals (especially Afri can Americans) are often willing to seek mental health services from sources other than mental h ealth professionals, such as pastors, physicians, family members, a nd friends (Boyd-Franklin & Lockwood, 1999).

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56 Thus it is possible that because future uti lization was compiled into one category across mental health professionals and professionals in other disciplines (i .e., primary care, and spirituality), the influence of attitude s and psychopathology were not seen. Post hoc analyses were conducted and fu ture utilization of mental health professionals (psychologists, psychiatrists, and social workers/other mental health professionals) for mental health services was explored. These results indicated that all the variables (parent barriers, parent attitudes, and pare ntal psychopathology) were significant predictors of parent al future utilization of mental health professionals (MHP) for services and accounted for 33% of the varian ce. The results also indicated that childrelated barriers and child-related attitudes were significant predic tors of future utilization of MHPs in children and accounted for 26% of the variance. Pare ntal psychopathology, however, was not a significant predictor of child utilizati on of MHPs. This finding was probably due to the fact that child psychopat hology rather than parental psychopathology might be influencing parents’ decision to seek services for their children. In fact, Gustafson and colleagues found that child probl em severity and pare nt attitude toward treatment were positively rela ted to seeking treatment (Gustafson, McNamara, & Jensen, 1994). Further post hoc analyses i nvestigated how specific clus ters of symptoms on the BSI would predict future utilization of MH Ps in parents and children. The results indicated that for parent MHP utilization, on ly parent attitudes and barriers were significant predictors, accounting for 35% of the variance. However, for child MHP utilization, child-related barri ers, child-related attitudes, and the Obsessive-Compulsive subscale were significan t predictors, accounting fo r 31% of the variance. It is not clear

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57 why the Obsessive-Compulsive subscale was si gnificant for parents’ report of childrelated utilization but not for parental utilization. It is possible that parents with these symptoms are so highly distresse d that they are more apt to ge t help for their children to help reduce the likelihood of them developing similar symptoms. Further post hoc analyses th at were conducted on future utilization of mental health services indicated that African Americans were more likely to seek mental health services for themselves from their pastor than were Caucasians. This pattern is a consistent finding in the literature (Ayalon, & Young, 2005; Boyd-Franklin, & Lockwood, 1999) and provides further confir mation that these underserved populations need to be reached through pastors and othe r well respected member s of their community in order to increase service utilization. In teresting, African American parents were not more likely than Caucasian parents to seek services for their children in the future from a pastor. Thus it appeared that African American parents were more likely to seek services from a pastor for themselves but not for thei r children. This finding again speaks to the issue of differential parental attitudes and opi nions when service utilization concerns their children versus themselves and provides imp lications for programs aimed at increasing utilization in parents and child ren. Perhaps parents feel th at pastors would be better equipped to deal with adults’ problems rather than children’s problems. Further research is needed in this area. The final set of post hoc analyses in vestigated the relationships between satisfaction with mental health services and quantity of services w ith parental and childrelated barriers and attitudes toward mental health. The relationship between parental satisfaction and satisfaction with child-relate d services was non-significant; however, the

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58 relationship between quantity of services parent s used and quantity of services used by their children was strong. Thus it appeared that parents judg ed their services differently from their children’s services but were willi ng to expose their children to more sessions, if they themselves were using more sessions Furthermore, parental and child-related attitudes were significantly correlated with sa tisfaction whereas barriers were not. This finding is consistent with the literature wher e attitudes and expecta tions have been shown to be related to satisfaction (Garland, Aar ons, Saltzman, & Kruse, 2000). On the other hand, parental attitudes and ba rriers were significantly corr elated with quantity of services used by parents while only child-rela ted barriers were signi ficantly correlated with quantity of services used by children. The finding that parental attitudes and barriers are significantly correla ted with quantity of services used by parents is logical because more positive attitudes and less percei ved barriers would enable an individual to seek services more, if there is a need. However, the finding that only child-related barriers and not child-related a ttitudes are related to quantity of services used by children is surprising. It appears that parents again, put attitudes asid e and expose their children to more sessions regardless of their own attitude s toward mental health but as has been now consistently shown barriers still mattered. Theoretical Conceptualizations The results of this study were generally consistent with the theoretical model that guided this study (Andersen & Newman, 1973). The finding that parental and childrelated barriers were related to parental and child-related attitudes, respectively, was consistent with the theoretical model, which described a relationship between predisposing characteristics (att itudes) and enabling resources (barriers). In addition, the

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59 finding that parental attitudes toward treatment were related to parental race and gender while child-related attitudes were related to pa rental gender was part ially consistent with the theoretical model, which described a relationship between all the predisposing characteristics (attitudes, race, and gender). The finding that perceived parental and child-related barriers to treatment were related to race was also partially consistent with the theoretical model, which described a relationship betw een the predisposing characteristics (race and gender) and enabling resources (barriers). Furthermore, the finding that parental barri ers, parental attitu des, and parental psychopathology predicted parental future utiliz ation of mental health professionals for mental health services was consistent with the theoretical model, which described the relationship between predisposing characte ristics (attitudes), enabling resources (barriers), illness level (psyc hopathology), and future utilization. The finding that childrelated barriers, and child-related attitudes predicted children’s future utilization of mental health professionals for mental health services was partially consistent with the theoretical model which described the relatio nship between predisposing characteristics (attitudes), enabling resources (barriers), illness level (psychopathology) and future utilization. Thus, although the results of this study were not consistent with all aspects of the theoretical model for child-r elated utilizati on, the model was almost completely consistent for parental utiliz ation. Therefore, it is possi ble that this model, while appropriate for parent related va riables, is not as applicable to variables related to child utilization of mental hea lth services. Future rese arch should investigate the generalizability of this model to child-related treatment.

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60 Limitations and Future Research There were several limitati ons to this study. First, pa rents were asked to report lifetime use of mental health services and mi ght have exaggerated or underreported actual service use for themselves and their children. Research indicates that parents are fairly accurate in reporting whether their children used services or not but the rate of false reporting increases when parents are asked to report on specific service providers or specific settings (Bean et al., 2000). Another limitation is that parents were the only informants used in this study and thus it was not possible to confirm the information they reported especially on utilization of mental health services. Future studies should attempt to collect information from the child and/or s pouse/significant other, if one is available. However, researchers should be cognizant of the fact that recruiti ng only parental dyads for such studies would limit generalizability because a large per centage of African American children are being raised by their si ngle mothers. Future studies could also verify parents’ reports of utilization by c ontacting their mental health providers; however, this option is more research intensive. In terms of procedures, there are some limitations to the use of surveys by mail versus having parents fill out the questionnaires in the presence of the researcher because parents might not have answered questions tr uthfully or some fathers might have given the surveys to mothers to co mplete (Phares, 1995). However, conducting the surveys by mail provided a certain level of anonymity for the parents, which could have resulted in more truthful responses. Anothe r limitation is related to the ge neralizability of this study. It is notable that SES did not differ across racial groups, ther efore it is possi ble that this study did not sample a wide enough range of i ndividuals from lower SES groups. Future

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61 research should endeavor to collect da ta from all SES groups to enhance the generalizability of the results. A fifth limitation is that this study examined perceived barriers to treatment utilization as opposed to actual barriers to treatment utilization, thus there was no way to determine if these barriers actually existed or if parents just felt that they did. However, research has been estab lished that perceived ba rriers are related to underutilization of services, so regardless of if thes e are true barriers or not, they are likely affecting utilization and thus need to be addressed. Another limitation of this study is the possible confound of collecting both the pa rent and child-related information at the same time; however, the fact that differenc es were found in parent and child-related variables indicates that the re lationship is fairly robust. Although a strength of this study was th e assessment of parental psychopathology, future research should include a measure of child psychopathology. It has been shown in previous research that child psychopathology influences parents’ decisions to seek mental health services for their children (Gustafson, McNamara, & Jensen, 1994), thus this variable is important to assess. The psychom etric properties of the barriers to treatment utilization measure should be investigated in future studies and factor analyses can be used to group barriers. Findings from thes e types of studies might provide a method for program developers to target specific groups of barriers that might be influencing parent and child utilization. In addition, future re searchers should develop help-seeking models that are geared to the investigation of underu tilization of services in minorities (Snowden & Yamada, 2005). Future resear ch should also focus on other ethnic minority groups and determine whether barriers and attitudes are similar across various ethnicities and thus determine if interventions should differ de pending on ethnicity. Finally, researchers

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62 should also provide cost-benefit analyses of how underutilization of mental health services by parents and children in need contribute to overuti lization of resources in the long run. This information should help pol icy makers develop programs to increase awareness and utilization of mental health services, such as national screenings for mental health problems in school age children. Conclusions and Clinical Significance Overall, findings from th is study can be instrumental in providing researchers with specific issues to target when devel oping programs to increase utilization of mental health services in parents and children. Th is study will inform researchers about the relationships between barriers to treatment and attitudes toward mental health services and how this relationship differs for child-rel ated treatment and treatment for parents. This information can be used to create tailored intervention programs to improve attitudes, decrease perception of barriers, and increase utilization of mental health services in children and parents. Fathers and ethnic minorities utilize serv ices the least, so researchers and clinicians should work on increasing utiliza tion in these populations when the services are needed. This goal can be achieved by cr eating preventive inte rvention programs. Programs should address increasing utilizati on in parents and incr easing utilization in children separately and should be tailored to different ethnic groups. Researchers creating such programs should focus on the va rious stages of help seeking including recognizing the problem, deciding to seek he lp, and selecting wher e to get services (Cauce et al., 2002). Psychoeducation is an important part of dispelling some of the myths and negative attitudes about mental h ealth services and to educating the public

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63 about the benefits of mental he alth services. Research on pa rents’ explanatory models of mental health indicate that African Amer ican parents often express less worry over certain behavior problems than Caucas ians and have less mental-health-minded explanations for behavior problems in their children (Bussing, Gary, Mills, & Garvan, 2003). Program developers should also target sp ecific barriers to treatment utilization by reducing access barriers, being more flexible with mode of delivery of treatment, developing strategies to decrease premature drop-out from treatment, matching interventions to family’s needs, and being cu lturally sensitive to clients (Phelps, Brown, & Power, 2002; Snell-Johns, Mendez, & Smit h, 2004). Phares and colleagues described several strategies that can be used to enga ge fathers in treatment including, increasing family related training in graduate programs, inviting fathers to participate in treatment and intervening when they are hesitant, creating a father-fri endly environment, and being flexible in the structure of each session (Phare s, Fields, & Binitie, In press). Satisfaction with mental health services is important in engagement and continuation of treatment (Garland, Aarons, Saltzman, & Kruse, 2000). T hus clinicians should work closely with their clients to build good relati onships and ensure that client s are satisfied with treatment every step of the way. Special attention should al so be paid to recruiting and retaining minorities in clinical outcome research, especially those of low SES. Developing treatments that are tailored to minority client s should improve treatment outcome and reduce premature drop-out from treatment. This can be done by reaching out to “key informants” in the community (such as pastors), providing ade quate training to res earch assistants, and

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64 being culturally sensitive to issues of ethnicity (Miranda, 1996; Thompson, Neighbors, Munday, & Jackson, 1996). As this paper has shown, there are several ways that researchers and clinicians can increase the uti lization of mental hea lth services, so let’s get started.

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65 References Addis, M. E., & Mahalik, J. R. (2003). Me n, masculinity, and the contexts of help seeking. American Psychologist, 58, 5-14. Ajzen, I. (1985). Intention, perceived contro l, and weight loss: An application of the theory of planned behavior. Journal of Personality & Social Psychology, 49, 843851. Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior & Human Decision Processes, 50, 179-211. Alvidrez, J. (1999). Ethnic va riations in mental health at titudes and service use among low-income African American, Latina, and European American young women. Community Mental Health Journal, 35, 515-530. Andersen, R. M. (1995). Revisiting the be havioral model and access to medical care: Does it matter? Journal of Health and Social Behavior, 36, 1-10. Andersen, R. M., & Newman, J. F. (1973). Societal and individual determinants of medical care utilization in the United States. Milbank Memorial Fund Quarterly, 51, 95-124. Ayalon, L., & Young, M. A. (2005). Racial Group Differences in Help-Seeking Behaviors. Journal of Social Psychology, 145, 391-403.

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66 Bannon, W. M., & McKay, M. M. (2005). Ar e Barriers to Service and Parental Preference Match for Service Related to Ur ban Child Mental Health Service Use? Families in Society, 86, 30-34 Barkley, R. A. (1997). Defiant Children: A clinician’s manual for assessment and parent training (2nd ed.). New York, NY: Guilford Press. Bayer, J. K., & Peay, M. Y. (1997). Predicti ng intentions to seek help from professional mental health services. Australian and New Zealand Journal of Psychiatry, 31, 504513. Bean, D. L., Leibowitz, A., Rotheram-Borus, M. J., Duan, N., Horwitz, S. M., Jordan, D., & Hoagwood, K. (2000). False-negative re porting and mental health services utilization: Parents’ reports about child and adolescent services. Mental Health Services Research, 2, 239-249. Beardslee, W. R., Versage, E. M., & Gladston e, T. R. (1998). Children of affectively ill parents: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry 37, 1134-1141. Bickman, L., Heflinger, C. A., Northrup, D ., Sonnichsen, S., and Schilling, S. (1998). Long term outcomes to family caregiver empowerment. Journal of Child and Family Studies, 7, 269-282. Boyd-Franklin, N., & Lockwood, T. W. (1999). Spirituality and Relig ion: Implications for Psychotherapy with African American Clients and Families. In F. Walsh (Ed.), Spirituality resources in family therapy (pp. 90-103). New York, NY: Guilford press.

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67 Bussing, R., Gary, F. A., Mills, T. L., & Garv an, C. (2003). Parental explanatory models of ADHD: Gender and cu ltural variations. Social Psychiatry and Psychiatric Epidemiology, 38, 563-575. Carr, A. (1998). The inclusion of fathers in fa mily therapy: A research based perspective. Contemporary Family Therapy, 20, 371-383. Cauce, A. M., Domenech-Rodriguez, M., Para dise, M., Cochran, B. N., Shea, J., Srebnik, D., & Baydar, N. (2002). Cultural and contex tual influences in mental health help seeking: A focus on ethnic minority youth. Journal of Consulting and Clinical Psychology, 70, 44-55. Cohen, B. (1999). Measuring th e willingness to seek help. Journal of Social Service Research, 26, 67-82. Connell, A. M., & Goodman, S. H. (2002). The association between psychopathology in fathers versus mothers and children’s in ternalizing and externalizing behavior problems: A meta-analysis. Psychological Bulletin, 128, 746-773. Costello, E. J., & Janiszewski, S. (1990). W ho gets treated? Fact ors associated with referral in children with psychiatric disorders. Acta Psychiatrica Scandinavica, 81, 523-529. Cramer, K. M. (1999). Psychological anteceden ts to help-seeking behavior: A reanalysis using path modeling structures. Journal of Counseling Psychology, 46, 381-387. Cundick, B. C. (2004). Review of the brief symptom inventory. Mental Measurements Yearbook, Vol. 10. Retrieved March 10, 2006, from EBSCOhost database.

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68 Cusack, J., Deane, F. P., Wilson, C. J., & Ciar rochi, J. (2004). Who influence men to go to therapy? Reports from men attending psychological services. International Journal for the Advancement of Counselling, 26, 271-283. Derogatis, L. R. (1993). Brief Symptom Inventory (BSI): Administration, scoring, and procedures manual (3rd ed.). Minneapolis, MN: National Co mputer Systems, Inc. Diala, C., Muntaner, C., Walr ath, C., Nickerson, K. J., LaVeist, T. A., & Leaf, P. J. (2000). Racial differences in attitudes towa rd professional mental health care and in the use of services. American Journal of Orthopsychiatry 70, 455-464. Duhig, A. M., Phares, V., & Birkeland, R. W. (2 002). Involvement of fathers in therapy: A survey of clinicians. Professional Psychology: Re search and Practice, 4, 389-395. Fals-Stewart, W., Fincham, F. D., & Kelley, M. L. (2004). Substance-abusing parents attitudes’ toward allowing their custodial children to participate in treatment: A comparison of mothers versus fathers. Journal of Family Psychology, 18, 666-671. Fischer, E. H., & Turner, J. L. (1970). Orientations to seeki ng professional help: Development and research utility of an attitude scale. Journal of Consulting and Clinical Psychology, 35, 79-90. Fischer, E. H. & Farina, A. (1995). Attitude s toward seeking professional psychological help: A shortened form and considerations for research. Journal of College Student Development, 36, 368-373. Fishbein, M. & Ajzen, I. (1975). Belief, attitude, intention, and behavior: An introduction to theory and research. Phillipines: Addison-Wesley Publishing Company.

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69 Garland, A. F., Aarons, G. A., Saltzman, M. D., & Kruse, M. I. (2000). Correlates of adolescents’ satisfaction with mental health services. Mental Health Services Research, 2, 127-139. Gary, F. A. (2005). Stigma: Barrier to me ntal health care among ethnic minorities. Issues in Mental Health Nursing, 26, 979-999. Gourash, N. (1978). Help-seeking: A review of the literature. American Journal of Community Psychology, 6, 413-423. Gustafson, K. E., McNamara, J. R., & Jensen, J. A. (1994). Parents’ informed consent decisions regarding psychotherapy for their children: Consideration of therapeutic risks and benefits. Professional Psychology: Research and Practice, 25, 16-22. Guthrie, R. V. (1998). Even the rat was white: A hist orical view of psychology (2nd ed.) Needham Heights, MA: Allyn & Bacon. Healy, C. D. (1997). African American’s per ceptions of psychotherapy: An analysis of utilization and barrier s to utilization. Dissertation Abstracts International, 58 (9-B). (UMI No. 9807472). Hines-Martin, V., Malone, M., Kim, S., & Br own-Piper, A. (2003). Barriers to mental health care access in an Af rican American population. Issues in Mental Health Nursing, 24, 237-256. Hofferth, S. L., Stueve, J. L., Pleck, J., Bian chi, S., & Sayer, L. (2002). The demography of fathers: What fathers do. In C.S. Tamis-LeMonda & N. Cabrera (Eds.), Handbook of father involvement: Multidisciplinary Perspectives (pp. 63-90). Mahwah, NJ: Lawrence Erlbaum Associates.

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70 Hollingshead, A. B. (1975). Four Factor index of social status. New Haven, CT: Yale University, Department of Sociology. Horwitz, S. M., Hoagwood, K., Stiffman, A. R ., Summerfield, T., Weis z, J. R., Costello, E. J., Rost, K., Bean, D. L., Cottler, L., Leaf P. J., Roper, M., & Norquist, G. (2001). Reliability of the Services Assessment for children and adolescents. Psychiatric Services 52, 1088-1094. Jackson, J. S., Neighbors, H., & Gurin, G. ( 1986). Findings from a national survey of Black mental health: Implications for pract ice and training. In M. R. Miranda & H. L. Kitano (Eds.), Mental health research and prac tice in minority communities: Development of culturally se nsitive training programs (pp. 91-116). Washington, DC: U.S. Government Printing Office. Jaffee, S. R., Moffitt, T. E., Caspi, A., & Tayl or, A. (2003). Life with (or without) father: The benefits of living with two biological parents depend on the father’s antisocial behavior. Child Development 74, 109-126. Johnson, S. L., & Jacob, T. (2000). Modera tors of child outcome in families with depressed mothers and fathers. In S. L. Johnson, A. M. Hayes, T. M. Field, N. Schneiderman & P. M. McCabe (Eds.), Stress, coping, and depression (pp. 51-67). Mahwah, NJ: Lawrence Erlbaum Associates. Kane, P., & Garber, J. (2004). The relations among depression in fathers, children’s psychopathology, and father-child conflict: A meta-analysis. Clinical Psychology Review, 24, 339-360. Kazdin, A. E. (1996). Dropping out of child psychotherapy: Issues for research and implications for practice. Clinical Child Psychology and Psychiatry, 1, 133-156.

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71 Kazdin, A. E., Holland, L., & Crowley, M. ( 1997). Family experi ence of barriers to treatment and premature termination from child therapy. Journal of Consulting and Clinical Psychology, 65, 453-463. Kazdin, A. E., Holland, L., Crowley, M., & Breton, S. (1997). Barriers to treatment participation scale: Evaluation and validation in the context of child outpatient treatment. Journal of Child Psychology and Psychiatry, 38, 1051-1062. Kazdin, A. E., & Wassell, G. (2000). Predicto rs of barriers to treatment and therapeutic change in outpatient therapy for an tisocial children and their families. Mental Health Services Research, 2, 27-40. Kessler, R. C., Berglund, P. A., Bruce, M. L ., Koch, J. R., Laska, E. M., Leaf, P. J., Manderscheid, R. W., Rosenheck, R. A., Wa lters, E. E., & Wang, P. S. (2001). The prevalence and correlates of untreated serious mental illness. Health Services Research, 36, 987-1007. Kropf, M. E., & Blair, J. (2005). Eliciting survey cooperation: Incentives, self-interest, and norms of cooperation. Evaluation Review, 29, 559-575. Kuhl, J., Jarkon-Horlick, L., & Morrissey, R. F. (1997). Measuring barriers to helpseeking behavior in adolescents. Journal of Youth and Adolescence 26, 637-650. Lamb, M. E. (Ed.) (2004). The role of the father in child development (4th ed.). Hoboken, NJ: John Wiley & Sons. Leaf, P. J., Bruce, M. L., & Tischler, G. L. (1986). The differential effect of attitudes on the use of mental health services. Social Psychiatry, 21, 187-192.

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72 Leaf, P. J., Bruce, M. L., Tischler, G. L ., & Holzer, C. E. (1987). The relationship between demographic factors and attitude s toward mental health services. Journal of Community Psychology, 15, 275-284. Leaf, P. J., Alegria, M., Cohen, P., Goodma n, S. H., Horwitz, S., Hoven, C. W., Narrow, W. E., Vaden-Kiernan, M., & Regier, D. A. (1996). Mental health service use in the community and schools: Results from the four-community MECA study. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 889-897. Lorion, R. P. & Parron, D. L. (1987). Counter ing the countertransfer ence: A strategy for treating the untreatable. In P. Pedersen (Ed.), Handbook of cross-cultural counseling and therapy (pp. 79-86). Westport, CT: Greenwood Press. Mahalik, J. R., Good, G. E, & Englar-Carlson, M. (2003). Masculinity scripts, presenting concerns, and help seeking: Impli cations for practice and training. Professional Psychology: Research and Practice 34, 123-131. McDermott, D. (2001). Parenting and ethnicit y. In M. J. Fine & S. W. Lee (Eds.), Handbook of diversity in parent educa tion: The changing face of parenting and parent education (pp. 73-96). San Diego, CA: Academic Press. McLoyd, V. C. (1998). Socioeconomic disadvantage and child development. American Psychologist, 53, 185-204. Miranda, J. (1996). Introduction to the sp ecial section on recruiting and retaining minorities in psychotherapy research. Journal of Consulting and Clinical Psychology, 64, 848-850.

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73 Neighbors, H. W. (1985). Seeking profe ssional help for personal problems: Black Americans’ use of health a nd mental health services. Community Mental Health Journal, 21, 156-166. Nickerson, K. J., Helms, J. E., & Terrell, F. (1994). Cultural mistrust, opinions about mental illness, and black students’ attitude s toward seeking psychological help from white counselors. Journal of Counseling Psychology, 41, 378-385. Novick, J., Benson, R., & Renbar, J. (1981). Patterns of termination in an outpatient clinic for children and adolescents. Journal of the Americ an Academy of Child Psychiatry, 20, 834-844. Owens, P. L., Hoagwood, K., Horwitz, S. M., Le af, P. J., Poduska, J. M., Kellam, S. G., & Ialongo, N. S. (2002). Barriers to ch ildren’s mental health services. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 731-738. Padgett, D. K., Patrick, C., Burns, B. J., & Sc hlesinger, H. J. (1994) Ethnicity and the use of outpatient mental health serv ices in a national insured population. American Journal of Public Health, 84, 222-226. Parron, D. L. (1982). An overview of minority group mental health needs and issues as presented to the president’s commission on me ntal health. In F. U. Munoz & R. Endo (Eds.), Perspectives on minority group mental health (pp. 3-22). Washington, DC: University Press of America. Pavuluri, M. N., Luk, S., & McGee, R. (1996) Help-seeking for behavior problems by parents of preschool chil dren: A community study. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 215-222.

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74 Pescosolido, B. A., & Boyer, C. A. (1999). How do people come to use mental health services? Current knowledge a nd changing perspectives. In A. V. Horwitz & T. L. Scheid (Eds.), A handbook for the study of mental he alth: Social contexts, theories, and systems (pp. 392-411). Cambridge, UK: Cambridge University Press. Peterson, C. A. (2004). Review of the brief symptom inventory. Mental Measurements Yearbook, Vol. 10. Retrieved March 10, 2006, from EBSCOhost database. Phares, V. (1995). Fathers’ and moth ers’ participation in research. Adolescence, 30, 593-602. Phares, V. & Compas, B. E. (1992). The ro le of fathers in child and adolescent psychopathology: Make room for daddy. Psychological Bulletin, 111, 387-412. Phares, V., Duhig, A. M., & Watkins, M. M. (2001). Family context: Fathers and other supports. In S. H. Goodman & I. H. Gotlib (Eds.), Children of depressed parents: Mechanisms of risk and imp lications for treatment (pp. 203-225). Washington, DC: American Psychological Association. Phares, V., Fields, S., & Binitie, I. (in pr ess). Getting fathers involved in child and family therapy. Cognitive and Behavioral Practice Phares, V., Lopez, E., Fields, S., Kamboukos D., & Duhig, A. M. (2005). Are fathers involved in pediatric psychol ogy research and treatment? Journal of Pediatric Psychology, 30, 631-643. Phelps, L., Brown, R. T., & Power, T. J. (2002). Pediatric Psychopharmacology: Combining Medical and Psychosocial Interventions. Washington, DC: American Psychological Association.

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75 Pumariega, A. J., Glover, S., Holzer, C. E., & Nguyen, H. ( 1998). Utilization of mental health services in a tri-et hnic sample of adolescents. Community Mental Health Journal, 34, 145-156. Regier, D. A., Narrow, W. E., Rae, D. S., Manderscheid, R. W., Locke, B. Z., & Goodwin, F. K. (1993). The de facto US mental and addictive disorders service system: Epidemiological catchment area pr ospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry, 50, 85-94. Ringel, J. S., & Sturm, R. (2001). National estimates of mental health utilization and expenditures for children in 1998. Journal of Behavioral Health Services and Research, 28, 319-332. Robbins, J. M., & Greenley, J. R. (1983). Th inking about what’s wr ong: Attributions of severity, cause, and duration in the problem definition stage of psychiatric helpseeking. Research in Community and Mental Health, 3, 209-232. Samaan, R. A. (1998). The influences of race, ethnicity, and poverty on the mental health of children. Journal of Health Care for the Poor and Underserved, 11, 100110. Shumway, M., Unick, G. J., McConnell, W. A., Catalano, R., & Forster, P. (2004). Measuring community preferences for public me ntal health services : Pilot test of a mail survey method. Community Mental Health Journal, 40, 281-295. Snell-Johns, J., Mendez, J. L., & Smith, B. H. (2004). Evidence-based solutions for overcoming access barriers, decreasing, attrition, and promoting change with underserved families. Journal of Family Psychology, 18, 19-35.

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76 Snowden, L. R. (2001). Barriers to effec tive mental health services for African Americans. Mental Health Services Research, 3, 181-187. Snowden, L. R. & Yamada, A. (2005). Cultural differences in access to care. Annual Review of Clinical Psychology, 1, 143-166. Statistical Abstract of th e United States (2003). 2000 Census of population and Housing. U.S. Census Bureau, September, 2003. Stefl, M. E., & Prosperi, D. C. (1985). Ba rriers to mental health service utilization. Community Mental Health Journal, 21, 167-178. Sue, D. W., & Sue, D. (1990). Counseling the culturally diff erent: Theory and practice. New York, NY: John Wiley & Sons. Thompson, V. L., Bazile, A., & Akbar, M. ( 2004). African Ameri cans’ perceptions of psychotherapy and psychotherapists. Professional Psychology: Research and Practice, 35, 19-26. Thompson, E. E., Neighbors, H. W., Munday, C ., & Jackson, J. S. (1996). Recruitment and retention of African American patients for clinical research: An exploration of response rates in an urban psychiatric hospital. Journal of Consulting and Clinical Psychology, 64, 861-867. U.S. Department of Health and Human Services (1999). Mental health: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Servi ces Administration, Center for Mental Health Services, National Institute of Mental Health.

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77 U.S. Department of Health and Human Services (2001). Mental health: Culture, race, and ethnicity – a supplement to mental health: A report of the Surgeon General. Rockville, MD: U.S. Department of Hea lth and Human Services, Substance Abuse and Mental Health Services Administrati on, Center for Mental Health Services.

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78 Appendices

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79 Appendix A Dear Sir/Madam, I would like to invite you to participate in a study about mental health services. The purpose of this research proj ect is to better understand how typical parents and their children use mental health serv ices and the reasons why they use mental health services. You are being asked to respond to questions about you and your children’s previous use of mental health services. You do not need to have received mental health services in order to participate in this study. You ar e also asked to complete a series of questionnaires about how you are currently feeling, your beliefs and some background information. The entire task should take about 15-20 minutes. Your participation in this survey is complete ly voluntary. You are free to participate in the study or withdraw at any tim e without penalty. Your consent to participate is shown by your decision to complete the questionnaires. We will not need to contact your child. The potential benefits for participating in this study are raisin g your awareness about mental health services. There are no known ri sks for those who take part in this study. All participants who provide their contact information, using the business-reply post cards, will be entered into a drawing for one of six prizes. All contact information provided will be kept separate from questionnaires whic h will be identified by subject code to protect your privacy. The prizes include: one $100 cash prize, two $50 cash prizes and three gift certificates from merchants in the surrounding community. Your privacy and research records will be kept confidential to the extent of the law. Authorized research personnel, employees of the Department of Health and Human Services, and the USF Institutional Review Bo ard, its staff and other individuals acting on behalf of USF may inspect the records from this research project. If you have any questions about your rights as a person who is taking part in a research study, you may contact the Division of Research Compliance of the University of South Florida at (813) 974-5638. If you have any questions about this rese arch study, please cont act Idia Binitie, Department of Psychology, University of S outh Florida, 4202 E. Fowler Avenue., PCD 4118G, Tampa, FL 33620, 813-974-9222, ibinitie@mail.usf.edu Thank you. Sincerely, Idia Binitie Graduate Student

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80 Appendix B INSTRUCTIONS: Please respond to the following questions on background information about you and your family. 1. What is your gender? ____ Male ____ Female 2. How old are you? _____ 3. What is your race/ethnicity? _____ African American /Black _____ American Indian /Alaskan Native _____ Asian /Pacific Islander _____ Caucasian _____ Hispanic/Latino (a) _____ Other (specify _______________) 4. Are you: ____ Married ____ Single, living with partner ____ Single, no partner ____ Separated ____ Divorced ____ Widowed ____ Other (specify ________________) 5. How many people, including your self, live in your home? __________ 6. How many children (biological, stepchil dren, adopted and ot her children) do you have? _____ 7. List the ages and gender of your children: ________________________________________ 8. How many of these children are currently living in your home? _______

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81 Appendix B (Continued) 9. List the ages and gender of your children currently living in your home: ___________________ 10. Do you see at least one of your children (ages 2 to 17) at least once per month? ____ Yes ____ No 11. Employment status: Self Your Spouse/Partner Employed as (list job): ________________ Employed as (list job): _______________ Unemployed ________________________ Unemployed _______________________ Retired ____________________________ Retired ___________________________ Other ______________________________ Other _____________________________ 12. Highest level of education comp leted (please circle response): Self Grade School Middle School High School College Graduate School 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Your Spouse/Partner Grade School Middle School High School College Graduate School 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 13. Total household income per year (optional): _________________________ (This information is confidential and w ill not be seen by anyone other than the research staff) 14. What type of public assi stance do you receive (if any)? ____ Food Stamps ____ Welfare ____ Help with Housing ____ Temporary Assistance for Needy Families ____ Medicaid ____ Other, please describe: _______________________________ ____ None 15. Do you have insurance coverage for physical health care needs? For Self: For your Children: ____Yes ____ Yes ____ No ____ No

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82 Appendix B (Continued) ____ Don’t know ____ Don’t know 16. Do you have insurance that covers mental health needs? For Self: For your Children: ____ Yes ____ Yes ____ No ____ No ____ Don’t know ____ Don’t know

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83 Appendix C INSTRUCTIONS: Please respond to these questions below on background information about you and your children. 1. Have you ever seen any professional for mental health services (including: Psychologist, Psychiatrist, Soci al worker, Pastoral Counselor or Primary care doctor)? _____ Yes _____ No (Skip to #9) 2. How many separate times/sessions di d you use any of these services for mental health purposes? ____ Psychologist ____ Psychiatrist ____ Social worker/other ment al health professional ____ Pastoral Counselor ____ Primary care doctor 3. How many different pr ofessionals have you seen for mental health purposes (Please write the number seen by each category, i.e. 1, 2, 3 …)? ____ Psychologist(s) ____ Psychiatrist(s) ____ Social worker(s)/other ment al health professional(s) ____ Pastoral Counselor(s) ____ Primary care doctor(s) 4. Why did you seek mental health se rvices (Check a ll that apply)? _____ Voluntary _____ Required (by ______________________________________) _____ Other (___________________________________________) 5. Why did you stop receiving mental health services (Check all that apply)? _____ Still in treatment _____ Felt better/No longer needed

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84 Appendix C (Continued) _____ Dissatisfied with treatment _____ No longer required (If involuntary) _____ Money reasons _____ Moved _____ Other (__________________________________) 6. What was the gender of your therapis t (If more than one therapist, write the number seen by each category)? _____ Male Psychologist(s) _____ Female Psychologist(s) _____ Male Psychiatrist(s) _____ Female Psychiatrist(s) _____ Male Social worker(s)/other _____ Female Social worker(s)/other _____ Male Pastor(s) _____ Female Pastor(s) _____ Male Primary care doctor(s) _____ Female Primary care doctor(s) 7. What was the race of your therapist (If more than one therapist, write the number seen by each category)? _____ African American _____ American Indian /Alaskan Native _____ Asian /Pacific Islander _____ Caucasian _____ Hispanic/Latino/Latina 8. On a scale of 1-10 (with 1 being LEAST and 10 being MOST), how satisfied were you with the mental health services you received from each of the following? ____ Psychologist ____ Psychiatrist ____ Social worker/other ment al health professional ____ Pastoral Counselor ____ Primary care doctor 9. Do you think you currently need to see a professional for mental health services (including: Psychologist, Psychiat rist, Social worker, Pastoral Counselor, or Primary care doctor)? _____ Yes _____ No

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85 Appendix C (Continued) 10. If you needed services, on a scale of 1-10 (with 1 being LEAST and 10 being MOST), how likely are you to see each of the followi ng individuals for mental health services in the future? ____ Psychologist ____ Psychiatrist ____ Social worker/other ment al health professional ____ Pastoral Counselor ____ Primary care doctor ____ Family/friends 11. Have any of your children ever seen a ny professional for mental health services (including: Psychologist, Psychi atrist, Social worker, Pastor al Counselor, or Primary care doctor)? _____ Yes _____ No (Skip to #21) 12. How many of your children have ever used mental health services? ______ Please respond to the items belo w for your child who has used the most mental health s ervices in the past. 13. What is the age and ge nder of this child? _______ 14. How many separate times/session s did your child use any of these services for mental health purposes? ____ Psychologist ____ Psychiatrist ____ Social worker/other ment al health professional ____ Pastoral Counselor ____ Primary care doctor 15. How many different professional s has your child seen for mental health purposes (Please write the number seen by each category)? ____ Psychologist(s) ____ Psychiatrist(s) ____ Social worker(s)/other ment al health professional(s) ____ Pastoral Counselor(s) ____ Primary care doctor(s)

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86 Appendix C (Continued) 16. Why did you seek mental health services for your child (Check all that apply)? _____ Voluntary _____ Required (by _______________________________________) _____ Other (____________________________________________) 17. Why did your child stop receiving me ntal health services (Check all that apply)? _____ Still in treatment _____ Felt better/No longer needed _____ Dissatisfied with treatment _____ No longer required (If involuntary) _____ Money reasons _____ Moved _____ Other (__________________________________) 18. What was the gender of your ch ild’s therapist (If more than one therapist, write the numbe r seen by each category)? _____ Male Psychologist(s) _____ Female Psychologist(s) _____ Male Psychiatrist(s) _____ Female Psychiatrist(s) _____ Male Social worker(s)/other _____ Female Social worker(s)/other _____ Male Pastor(s) _____ Female Pastor(s) _____ Male Primary care doctor(s) _____ Female Primary care doctor(s) 19. What was the race of your child’s ther apist (If more than one therapist, write the number seen by each category)? _____ African American _____ American Indian /Alaskan Native _____ Asian /Pacific Islander _____ Caucasian _____ Hispanic/Latino/Latina 20. On a scale of 1-10 (with 1 being LEAST and 10 being MOST), how satisfied were you with the mental health services that you r child received from each of the following? ____ Psychologist ____ Psychiatrist ____ Social worker/other ment al health professional

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87 Appendix C (Continued) ____ Pastoral Counselor ____ Primary care doctor 21. Do you think your child currently needs to see a professional for mental health services (including: Psychologist, Ps ychiatrist, Social worker Pastoral Counselor, or Primary care doctor)? _____ Yes _____ No 22. If your child needed serv ices, on a scale of 1-10 (with 1 being LEAST and 10 being MOST), how likely are you to seek mental health servic es for your child from each of the following individuals in the future? ____ Psychologist ____ Psychiatrist ____ Social worker/other ment al health professional ____ Pastoral Counselor ____ Primary care doctor ____ Family/friends

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88 Appendix D INSTRUCTIONS: In this questionnaire, you will read statements about your attitudes towards seeking mental health services for yourself Please circle a response to each statement according to how you currently feel. Strongly Disagree Disagree Agree Strongly Agree 1. If I believed I was having a mental breakdown, my first inclination would be to get professional attention. SD D A SA 2. The idea of talking about problems with a psychologist strikes me as a poor way to get rid of emotional conflicts. SD D A SA 3. If I were experiencing a serious emotional crisis at this point in my life, I would be confident that I could find relief in psychotherapy. SD D A SA 4. There is something admirable in the attitude of a person w ho is willing to cope with his or her conflicts and fears without resorting to professional help. SD D A SA 5. I would want to get psychological help if I were worried or upset for a long period of time. SD D A SA 6. I might want to have psychological counseling in the future. SD D A SA 7. A person with an emotional problem is not likely to solve it alone; he or she is likely to solve it with professional help. SD D A SA 8. Considering the time and expense involved in psychotherapy, it would have doubtful value for a person like me. SD D A SA 9. A person should work out his or her own problems; getting psychological counseling would be a last resort. SD D A SA 10. Personal and emotional troubles, like many things, tend to work out by themselves. SD D A SA

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89 Appendix E INSTRUCTIONS: In this questionnaire, you will read statements about your attitudes towards seeking mental health services for your children Please circle a response to each statement according to how you currently feel. Strongly Disagree Disagree Agree Strongly Agree 1. If I believed my child was having a mental breakdown, my first inclination would be to get him/her professional attention. SD D A SA 2. The idea of my child talking about his/her problems with a psychologist strikes me as a poor way to get rid their emotional conflicts. SD D A SA 3. If my child were experiencing a serious emotional crisis at this point in their life, I would be confident that they could find relief in psychotherapy. SD D A SA 4. There is something admirable in the attitude of a person w ho is willing to let their child cope with his or her conflicts and fears without resorting to pr ofessional help. SD D A SA 5. I would want to get psychological help for my child if they were worried or upset for a long period of time. SD D A SA 6. I might want to have psychological counseling for my child in the future. SD D A SA 7. A child with an emotional problem is not likely to solve it alone; he or she is likely to solve it with professional help. SD D A SA 8. Considering the time and expense involved in psychotherapy, it would have doubtful value for my child. SD D A SA 9. A child should work out his or her own problems; getting psychological counseling would be a last resort. SD D A SA

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90 Appendix E (Continued) 10. Personal and emotional troubles, like many things, tend to work out by themselves for my child. SD D A SA

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91 Appendix F INSTRUCTIONS: Below are statements about various ba rriers or obstacl es that prevent individuals from seeking mental health services for themselves Please circle a response for each statement that best represents how you currently feel a bout seeking mental health services for yourself If you are not currently seeking mental heal th services for yourself, please respond to each statement as if you were seeking services for yourself. Strongly Disagree Disagree Agree Strongly Agree SD D A SA SELF SD D A SA 1. To get counseling or therapy for myself is too expensive. SD D A SA 2. I would have to travel t oo far to get these services. SD D A SA 3. Mental health services are not in my budget. SD D A SA 4. My health insurance woul d not cover this type of treatment. SD D A SA 5. I am not aware of any available services for myself. SD D A SA 6. There would not be an available therapist who shares my cultural background. SD D A SA 7. The hours that these servic es are available are not good for me. SD D A SA 8. It takes a lot of time to get an appointment to see a mental health professional. SD D A SA 9. The therapist would proba bly not deal with the issues I want to work on. SD D A SA 10. Whatever treatment a ment al health professional could offer would probably not be of use to me. SD D A SA 11. If there were affordable and nearby services, I still doubt that I would use them. SD D A SA 12. I doubt that the quality of the services I would receive would be acceptable to me. SD D A SA

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92 Appendix F (Continued) 13. Going to therapy would be like admitting I am a weak person. SD D A SA 14. I would not get the kind of help I want from a mental health professional. SD D A SA 15. I have talked to family members/friends who have had experiences with thera py, and this influenced me seeking therapy for myse lf (leave blank, if not applicable). SD D A SA 16. I went to a mental health professional in the past but it did not help (leave bl ank, if not applicable). SD D A SA 17. The therapist could not possibly understand my experience. SD D A SA 18. The therapist will not be the same race as me, so cannot be trusted. SD D A SA 19. I do not trust mental hea lth professionals to help me. SD D A SA 20. The therapist would not really care about me, he/she is only in it for the money. SD D A SA 21. The therapist would proba bly not be trustworthy and would let others know my business. SD D A SA 22. I would think my problem would get better by itself. SD D A SA 23. I would be concerned about what others might think of me. SD D A SA 24. I would want to solv e the problem on my own. SD D A SA 25. I would be scared about being put into a hospital against my will. SD D A SA 26. The therapist would treat me badly because of my race. SD D A SA 27. The therapist would treat me like a child because of my race. SD D A SA Other Barriers Please list other reasons (not listed above) that prevent you fr om seeking mental health services for yourself. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

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93 Appendix G INSTRUCTIONS: Below are statements about various ba rriers or obstacl es that prevent parents from seeking mental health services for their children Please circle a response for each statement that best represents how you currently feel a bout seeking mental health services for your child If you are not currently seeking mental health services fo r your child/children, please respond to each statement as if you were seeking services. If you have more than one child, please respond for the child who might be most in need of services. Strongly Disagree Disagree Agree Strongly Agree SD D A SA CHILD/CHILDREN SD D A SA 1. To get counseling or therapy for my child is too expensive. SD D A SA 2. I would have to travel too far to get these services for my child. SD D A SA 3. Mental health services are not in my budget for my child. SD D A SA 4. My child’s health insuran ce would not cover this type of treatment. SD D A SA 5. I am not aware of any available services for my child. SD D A SA 6. There would not be an available therapist who shares my child’s cultural background. SD D A SA 7. The hours that these servic es are available are not good for my child. SD D A SA 8. It takes a lot of time to get an appointment for my child to see a mental health professional. SD D A SA 9. The therapist would probably not deal with the issues I want to work on for my child. SD D A SA 10. Whatever treatment a ment al health professional could offer would probably not be of use to my child. SD D A SA 11. If there were affordable and nearby services, I still doubt that I would use them for my child. SD D A SA

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94 Appendix G (Continued) 12. I doubt that the quality of the services I would receive would be acceptable for my child. SD D A SA 13. Going to therapy would be like admitting my child is a weak person. SD D A SA 14. I would not get the kind of help I want from a mental health professional for my child. SD D A SA 15. I have talked to family members/friends who have had experiences with thera py, and this influenced me seeking therapy for my child (leave blank, if not applicable). SD D A SA 16. My child went to a mental health professional in the past but it did not help (leav e blank, if not applicable). SD D A SA 17. The therapist could not possibly understand my child’s experience. SD D A SA 18. The therapist will not be the same race as my child, so cannot be trusted. SD D A SA 19. I do not trust mental health professionals to help my child. SD D A SA 20. The therapist would not really care about my child, he/she is only in it for the money. SD D A SA 21. The therapist would probabl y not be trustworthy and would let others know my child’s business. SD D A SA 22. I would think my child’s problem would get better by itself. SD D A SA 23. I would be concerned about what others might think of my child. SD D A SA 24. I would want to solve my child’s problem on my own. SD D A SA 25. I would be scared about my child being put into a hospital against my will. SD D A SA 26. The therapist would treat my child badly because of my race. SD D A SA Other Barriers Please list other reasons (not listed above) that prevent you fr om seeking mental health services for your children. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

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95 Appendix H Brief Symptom Inventory (BSI) Instructions: Below is a list of problems people sometimes have. Please read each one carefully, and circle the number to the right that best describes HOW MUCH THAT PROBLEM HAS DISTRESSED OR BO THERED YOU DURING THE PAST 7 DAYS INCLUDING TODAY Circle only one number for each problem and do not skip any items. If you change your mind, erase your first mark carefully. 0 = NOT AT ALL 1 = A LITTLE BIT 2 = MODERATELY 3 = QUITE A BIT 4 = EXTREMELY HOW MUCH WERE YOU DISTRESSED BY: 1. Nervousness or shakiness inside 0 1 2 3 4 2. Faintness or dizziness 0 1 2 3 4 3. The idea that someone else can control your thoughts 0 1 2 3 4 4. Feeling others are to blame for most of your troubles 0 1 2 3 4 5. Trouble remembering things 0 1 2 3 4 6. Feeling easily annoyed or irritated 0 1 2 3 4 7. Pains in heart or chest 0 1 2 3 4 8. Feeling afraid in open spaces 0 1 2 3 4 9. Thoughts of ending your life 0 1 2 3 4 10. Feeling that most people cannot be trusted 0 1 2 3 4 11. Poor appetite 0 1 2 3 4 12. Suddenly scared for no reason 0 1 2 3 4 13. Temper outbursts that you could not control 0 1 2 3 4 14. Feeling lonely even when you are with people 0 1 2 3 4 15. Feeling blocked in getting things done 0 1 2 3 4 16. Feeling lonely 0 1 2 3 4 17. Feeling blue 0 1 2 3 4 18. Feeling no interest in things 0 1 2 3 4 19. Feeling fearful 0 1 2 3 4

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96 Appendix H (Continued) 20. Your feeling being easily hurt 0 1 2 3 4 21. Feeling that people ar e unfriendly or dislike you 0 1 2 3 4 22. Feeling inferior to others 0 1 2 3 4 23. Nausea or upset stomach 0 1 2 3 4 24. Feeling that you are watc hed or talked about by others 0 1 2 3 4 25. Trouble falling asleep 0 1 2 3 4 26. Having to check and double check what you do 0 1 2 3 4 27. Difficulty making decisions 0 1 2 3 4 28. Feeling afraid to trav el on buses, subways, or trains 0 1 2 3 4 29. Trouble getting your breath 0 1 2 3 4 30. Hot or cold spells 0 1 2 3 4 31. Having to avoid certain things, places, or activities because they frighten you 0 1 2 3 4 32. Your mind going blank 0 1 2 3 4 33. Numbness or tingling in parts of your body 0 1 2 3 4 34. The idea that you should be punished for your sins 0 1 2 3 4 35. Feeling hopeless about the future 0 1 2 3 4 36. Trouble concentrating 0 1 2 3 4 37. Feeling weak in parts of your body 0 1 2 3 4 38. Feeling tense or keyed up 0 1 2 3 4 39. Thoughts of death or dying 0 1 2 3 4 40. Having urges to beat, injure, or harm someone 0 1 2 3 4 41. Having urges to break or smash things 0 1 2 3 4 42. Feeling very self-conscious with others 0 1 2 3 4 43. Feeling uneasy in crowds 0 1 2 3 4 44. Never feeling close to another person 0 1 2 3 4 45. Spells of terror or panic 0 1 2 3 4 46. Getting into frequent arguments 0 1 2 3 4 47. Feeling nervous when you are left alone 0 1 2 3 4 48. Others not giving you proper credit for your achievements 0 1 2 3 4 49. Feeling so restless you c ouldn’t sit still 0 1 2 3 4 50. Feelings of worthlessness 0 1 2 3 4 51. Feeling that people will take advantage of you if you let them 0 1 2 3 4 52. Feeling of guilt 0 1 2 3 4 53. The idea that something is wrong with your mind 0 1 2 3 4

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97 Appendix I Dear Sir/Madam, Thank you for participating in this research study. As you recall, this study was about understanding how typical parent s and their children use mental health services and the reasons why they use mental health services Since some people wonder about where to receive services, this letter is being sent out to all particip ants regardless of their answers to the survey. In case you are interested in seeking mental health services, we wanted you to know that most health insurance companies cover some t ype of mental health service. Therefore, you should first check with your insurance comp any to see what type of mental health services are covered, if a ny. Many insurance companies have a list of “preferred providers” from whom you should seek treatm ent. Sometimes they have certain rules that you need to follow (for example: they wi ll pay for 70% of services from a licensed psychologist but not pay for a li censed mental health worker). Please get this information clarified with your insurance company if you are concerned about payment for mental health services. If you do not have health insurance or if your health insurance does not cover mental health services, you may want to consider one of the following f acilities in the Tampa Bay area (all of which have either lo w-fees or fees on a sliding scale): Mental Health Care (813) 272-2244 Near Hillsborough and 22nd Northside Mental Health Center (813) 977-8700 On Bruce B. Downs, near USF USF Psychological Services Center (813) 974-2496 At USF in the Psychology Department Child and Family Counseling (813) 744-5953 Hillsborough County If you do not live in the Tampa Bay area, consider using the “Find a Psychologist” referral service that is run through the American Psychologi cal Association. This service can be accessed on-line ( http://locator.apahelpcenter.org ) or through a toll-free phone call (1-800-964-2000). In addition, most comm unities throughout the United States and Canada have a Community Mental Health Cent er, so a quick call to the local information center might help you gain access to the services in your community, if you are interested.

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98 If you have any questions about this rese arch study, please cont act Idia Binitie, Department of Psychology, University of S outh Florida, 4202 E. Fowler Avenue., PCD 4118G, Tampa, FL 33620, 813-974-9222, ibinitie@mail.usf.edu Thank you. Sincerely, Idia Binitie Graduate Student


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Breaking down the wall :
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ABSTRACT: This study investigated the influence of parents' gender, race, and psychopathology on barriers and attitudes to mental health utilization for themselves and for their children. It was hypothesized that mothers and Caucasian¨ parents would have more positive attitudes and would perceive fewer barriers to mental health services than fathers and African American¨§ parents. A total of 194 African American and Caucasian parents were recruited from the community to participate in this study. Parents completed measures on barriers and attitudes toward treatment for themselves and their children, utilization of mental health services for themselves and their children, and their own current psychological symptoms. Results indicated that 36.3% and 19.4% of parents and children, respectively, had used mental health services during their lifetime. Parents perceived fewer barriers and had more positive attitudes toward seeking services for their children than for themselves. Race and gender differences were found in parental perceptions of barriers and attitudes toward treatment. Furthermore, barriers, attitudes, and psychopathology predicted parents' plan for future utilization of professionals for mental health services. The clinical implications of this study and directions for future research were discussed.
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