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Child psychopathology, parental problem perception, and help-seeking behaviors

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Title:
Child psychopathology, parental problem perception, and help-seeking behaviors
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Book
Language:
English
Creator:
Hankinson, Jessica Curley
Publisher:
University of South Florida
Place of Publication:
Tampa, Fla
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Subjects / Keywords:
Children
Parents
Emotional and behavioral problems
Help-seeking decisions
Dissertations, Academic -- Psychology -- Doctoral -- USF   ( lcsh )
Genre:
non-fiction   ( marcgt )

Notes

Abstract:
ABSTRACT: Service underutilization is a major problem facing children with emotional and behavioral problems. In addition, parents are often the ones most responsible for seeking help for their children. However, many children do not receive adequate help because parents do not perceive a problem or do not recognize that a child is in need. The present study examined parental thresholds for problem perception and subsequent help-seeking decisions based on children's behaviors presented in a vignette. It was hypothesized that the type of child behavior, child and parent gender, and other parental characteristics would be associated with different thresholds for problem perception and seeking professional help. Participants were 160 mothers and 63 fathers recruited via email using the snowball method and a university participant pool. It was found that mothers sought higher levels of services than fathers and that externalizing and comorbid internalizing and externalizing behaviors were rated as more serious and in need of higher levels of services than internalizing behaviors. In addition, exposure to child psychopathology, parenting stress, and tolerance for behavioral problems were associated with different thresholds for problem perception and help-seeking decisions. Treatment acceptability was also found to partially mediate between parental problem perception and seeking mental health services. In addition, parental characteristics were also found to contribute to differential help seeking decisions. These results are discussed in relation to how parents view their child's emotional and behavioral problems and what factors contribute to their decision to seek formal and informal services. Implications for clinical practice, limitations, and future directions of this research are also discussed.
Thesis:
Dissertation (Ph.D.)--University of South Florida, 2009.
Bibliography:
Includes bibliographical references.
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Mode of access: World Wide Web.
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System requirements: World Wide Web browser and PDF reader.
Statement of Responsibility:
by Jessica Curley Hankinson.
General Note:
Title from PDF of title page.
General Note:
Document formatted into pages; contains 87 pages.
General Note:
Includes vita.

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aleph - 002063194
oclc - 555967851
usfldc doi - E14-SFE0002993
usfldc handle - e14.2993
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SFS0027310:00001


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ABSTRACT: Service underutilization is a major problem facing children with emotional and behavioral problems. In addition, parents are often the ones most responsible for seeking help for their children. However, many children do not receive adequate help because parents do not perceive a problem or do not recognize that a child is in need. The present study examined parental thresholds for problem perception and subsequent help-seeking decisions based on children's behaviors presented in a vignette. It was hypothesized that the type of child behavior, child and parent gender, and other parental characteristics would be associated with different thresholds for problem perception and seeking professional help. Participants were 160 mothers and 63 fathers recruited via email using the snowball method and a university participant pool. It was found that mothers sought higher levels of services than fathers and that externalizing and comorbid internalizing and externalizing behaviors were rated as more serious and in need of higher levels of services than internalizing behaviors. In addition, exposure to child psychopathology, parenting stress, and tolerance for behavioral problems were associated with different thresholds for problem perception and help-seeking decisions. Treatment acceptability was also found to partially mediate between parental problem perception and seeking mental health services. In addition, parental characteristics were also found to contribute to differential help seeking decisions. These results are discussed in relation to how parents view their child's emotional and behavioral problems and what factors contribute to their decision to seek formal and informal services. Implications for clinical practice, limitations, and future directions of this research are also discussed.
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Child Psychopathology, Parental Problem Perception, and Help-Seeking Behaviors by Jessica Curley Hankinson A dissertation submitted in partial fulfillment of the requirements for the degree of Doctorate of Philosophy Department of Psychology College of Arts and Sciences University of South Florida Major Professor: Vicky Phares, Ph.D. Tammy Allen, Ph.D. Ellis Gesten, Ph.D. J. Kevin Thompson, Ph.D. Joseph Vandello, Ph.D. Date of Approval: March 13, 2009 Keywords: children, parents, emotional and behavior al problems, help-seeking decisions Copyright 2009, Jessica Curley Hankinson

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i Table of Contents List of Tables .................................... ................................................... .............................. iii List of Figures ................................... ................................................... ................................v Abstract .......................................... ................................................... ................................. vi Introduction ...................................... ................................................... .................................1 Models of Help-Seeking ........................... ................................................... ............2 The Threshold Model .............................. ................................................... ..............4 Factors Associated with Problem Perception and Hel p-Seeking Behaviors ...........7 Problem Type and Severity ....................... ................................................... 7 Child Gender and Age ............................ ................................................... 11 Parental Distress and Psychopathology ........... ..........................................13 Parental Self-Efficacy and Tolerance for Misbehav ior .............................15 Treatment Acceptability, Treatment Type, and Prev ious Experiences ..................................... ...............................................18 The Present Study ................................ ................................................... ...............19 Hypotheses ....................................... ................................................... ...................20 Method ............................................ ................................................... ................................23 Participants ..................................... ................................................... .....................23 Measures ......................................... ................................................... ....................27 Vignette Stimuli ................................ ................................................... ......27 Parental Distress................................ ................................................... ......28 Parental Self-Efficacy .......................... ................................................... ...28 Parental Tolerance .............................. ................................................... ....29 Treatment Acceptability.......................... ................................................... 29 Demographics .................................... ................................................... .....30 Procedures ....................................... ................................................... ....................30 Pilot Studies ................................... ................................................... .........30 Present Study ................................... ................................................... .......31 Results ........................................... ................................................... ..................................33 Discussion ........................................ ................................................... ...............................48 Behavior Type Differences ........................ ................................................... .........49 Child Gender and Parent Gender Differences ....... ................................................51 Parental Factors Related to Problem Perception and Help-Seeking ......................54 Treatment Acceptability as a Mediator ............ ................................................... ...57 Limitations and Future Research .................. ................................................... ......58 Clinical Implications ............................ ................................................... ...............60

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ii List of References ................................ ................................................... ...........................61 Appendices ........................................ ................................................... ..............................73 Appendix A: Survey ............................... ................................................... ............74 Appendix B: Sample Parenting Stress Index-Short Fo rm Items ...........................77 Appendix C: Parenting Sense of Competence Scale .. ...........................................78 Appendix D: Annoying Behavior Inventory Scale .... ............................................82 Appendix E: Inventory of Attitudes Toward Seeking Mental Health Services ........................................ ................................................... ...........83 Appendix F: Parental Demographic Form ............ .................................................85 About the Author .................................. ................................................... .............. End Page

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iii List of Tables Table 1. Participant demographics ................. ................................................... .......25 Table 2. Descriptive statistics for perceived serio usness ratings for each vignette .......................................... ................................................... ..........34 Table 3. Descriptive statistics for number of servi ces selected for each vignette .......................................... ................................................... ..........34 Table 4. Descriptive statistics for number of profe ssional services selected for each vignette ................................. ................................................... .....35 Table 5. Descriptive statistics for number of menta l health services selected for each vignette ................................. ................................................... .....35 Table 6. Mean differences for parent gender and typ e of behaviors on ratings of perceived seriousness and help-seeking d ecisions ....................38 Table 7. Mean differences for types of behaviors on ratings of perceived worry, likelihood to improve, and unusualness ..... ....................................38 Table 8. Parents’ descriptive statistics for Parent ing Stress Index-Short Form (PSI), Parenting Sense of Competence Scale (PS OC), Annoying Behavior Inventory (ABI), Inventory of Att itudes Toward Seeking Mental Health Services’ (IASMSHS) Psychological Openness, Help-Seeking Propensity, an d Indifference to Stigma subscales, and Total scale ....................................40 Table 9. Correlations among select independent vari ables (Parenting Stress Index-Short Form (PSI), Parenting Sense of Competen ce Scale (PSOC), Annoying Behavior Inventory (ABI), Inventor y of Attitudes Toward Seeking Mental Health Services (IA SMSHS)) and dependent variables (perceived seriousness, see king services, professional services, and mental health services) ....................................41 Table 10. Regression analyses of parents’ ratings o f exposure to child behavior problems predicting perceived seriousness, seeking services, professional services, and mental health services .......................42

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iv Table 11. Multiple regression analyses of parents’ ratings on the Parenting Stress Index (PSI), the Parenting Sense of Competen ce (PSOC), and the Annoying Behavior Inventory (ABI) predictin g perceived seriousness, seeking services, professional service s, and mental health services ................................... ................................................... ......43 Table 12. Multiple regression analyses of parents’ ratings on the Parenting Stress Index (PSI), the Parenting Sense of Competen ce (PSOC), and the Annoying Behavior Inventory (ABI) predictin g perceived level of worry, likelihood to improve, and unusualn ess ............................44 Table 13. Mean differences for parent gender on rat ings on the Parenting Sense of Competence (PSOC) total score and Inventor y of Attitudes Toward Seeking Mental Health Services (IA SMSHS) total score ....................................... ................................................... .........44 Table 14. Multiple regression analyses of parents’ years of education and socioeconomic status (SES) predicting perceived ser iousness, seeking services, professional services, and mental health services ..........46

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v List of Figures Figure 1. Partial mediation model of interrelations hip for perceived seriousness, treatment acceptability, and levels of seeking mental health services among parents ..................... ..............................................45

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vi Child Psychopathology, Parental Problem Perception, and Help-Seeking Behaviors Jessica Curley Hankinson ABSTRACT Service underutilization is a major problem facing children with emotional and behavioral problems. In addition, parents are ofte n the ones most responsible for seeking help for their children. However, many children do not receive adequate help because parents do not perceive a problem or do not recogni ze that a child is in need. The present study examined parental thresholds for problem perc eption and subsequent help-seeking decisions based on children’s behaviors presented i n a vignette. It was hypothesized that the type of child behavior, child and parent gender and other parental characteristics would be associated with different thresholds for p roblem perception and seeking professional help. Participants were 160 mothers a nd 63 fathers recruited via email using the snowball method and a university participant po ol. It was found that mothers sought higher levels of services than fathers and that ext ernalizing and comorbid internalizing and externalizing behaviors were rated as more seri ous and in need of higher levels of services than internalizing behaviors. In addition exposure to child psychopathology, parenting stress, and tolerance for behavioral prob lems were associated with different thresholds for problem perception and help-seeking decisions. Treatment acceptability was also found to partially mediate between parenta l problem perception and seeking mental health services. In addition, parental char acteristics were also found to contribute to differential help seeking decisions. These resu lts are discussed in relation to how parents view their child’s emotional and behavioral problems and what factors contribute

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vii to their decision to seek formal and informal servi ces. Implications for clinical practice, limitations, and future directions of this research are also discussed.

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1 Introduction Service underutilization is a major problem facing parents and children with emotional and behavioral problems. Economic disadv antage, poor school grades, parental psychopathology, and parental perceptions of problems have been found to be associated with unmet need (Flisher et al., 1997). In addition, there are racial, ethnic, and cultural differences related to whether or not adul ts and children utilize and receive proper treatment (Chen & Mak, 2008; Leslie et al., 2003). Too often, those children most in need of services do not receive proper treatment Parents and caretakers need to be aware of their children’s problems and seek appropr iate services so that children’s emotional and behavioral needs do not go unmet. Parents are the ones most responsible for seeking help for their children’s emotional and behavioral problems. Some researcher s have called them the “gatekeepers” to professional services for children (Bussing, Koro-Ljungberg, Gary, Mason, & Garvan, 2005). Therefore, they are respon sible for whether a child makes it into treatment or not. In addition, teachers, scho ol personnel, and other professionals also play a major role in recognizing children’s problem s and referring them for treatment (Hartung & Widiger, 1998; Poduska, 2000; Slade, 200 4; Zwaanswijk, Van der Ende, Verhaak, Bensing, & Verhulst, 2007). These profess ionals can provide important information to parents that may ultimately influenc e their recognition of their child’s problem. However, many children do not receive ade quate help because parents or other adults do not perceive a problem or recognize that a child is in need (Slade, 2004). The accuracy with which parents identify their child as needing services and the factors that

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2 may influence parental perception of children’s pro blems are extremely important to study (Poduska, 2000). Therefore, the present stud y evaluated factors associated with parents’ ability to perceive problems in children a nd their subsequent decisions about seeking help. Models of Help-Seeking Several researchers have discussed models of paren ts’ and professionals’ helpseeking decisions. Eiraldi and colleagues (2006) r eviewed several models of helpseeking behavior in their formulation of an appropr iate model for minority children with ADHD. Most models included these four help-seeking stages: problem recognition decision to seek help service selection and service utilization patterns Throughout the development of various help-seeking models, researc hers have assessed how different individual and environmental variables can influenc e this process. These variables included social networks, attitudes toward mental h ealth, and accessibility to treatments. In addition, the role of culture was underscored as influential to the help-seeking process at every stage (Cauce et al., 2002; Eiraldi et al., 2006). For example, parents in different cultures may have different thresholds for recogniz ing a behavior as a problem, different attitudes toward treatment, and different concerns about treatment providers, including perceived discrimination. Also, although some fact ors may be related to problem recognition, they may not necessarily be related to deciding to seek help (Verhulst & Van der Ende, 1997). Therefore, it is important to ide ntify barriers and other variables related to both parents’ perceptions and their decisions to seek help. Other researchers have studied pathways of parenta l help-seeking for their child through consultation with a general practitioner (G P) or pediatrician (Sayal, 2006;

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3 Zwaanswijk, Verhaak, Bensing, van der Ende, & Verhu lst, 2003; Zwaanswijk, Verhaak, van der Ende, Bensing, & Verhulst, 2006; Zwaanswijk et al., 2007). When parents perceive a problem in their child, they tend to con sult their GP. Therefore after parental problem perception, it is up to the GP to correctly identify whether or not the child has mental health problems and provide management and p ossible referrals. Implications of this pathway are that the GP has to be knowledgeabl e about possible mental health problems and the accessibility to other treatments. Yet, as Sayal (2006) mentioned, some parents’ help -seeking behaviors do not take into account primary care and therefore they bypass to more specialized care. In addition, these models may represent an oversimplif ication of the multiple routes that parents take in obtaining specialized services for their child. For instance, parents may not necessarily move uniformly through the proposed stages given that teachers and social service providers may aid in the process or parents may self-refer to professional help. In addition, in families with adolescents, b oth parental and adolescent factors, including adolescent attitudes toward treatment and family history of service use, influenced the parent-mediated help-seeking pathway s (Logan & King, 2001; Zwaanswijk et al., 2007). Also, help-seeking behav iors may differ depending on whether a family lives in urban or rural areas, such that a greater reliance on medical and school services has been shown in rural areas whereas thos e in urban areas tend to use specialized and allied health services (Lyneham & R apee, 2007). Therefore, many factors can hinder or facilitate the help-seeking p athways to service utilization. Overall, however, parental perception of child problems cont inues to play a prominent role in initiating pathways toward help-seeking decisions.

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4 As Douma and colleagues (2006) highlighted, there is an important distinction between parental perception and recognition of a ch ild’s problem. They found that when a parent perceived a problem, these problems were f requently present according to the Child Behavior Checklist (CBCL; Achenbach, 1991) or the Diagnostic Interview Schedule for Children: Version 4 (DISC-IV; Ferdinan d & Van der Ende, 1998). Therefore, they concluded that parental perception of a problem is truly the first step toward help-seeking whether or not the problem is c ompletely recognizable or present. Through deciding to seek help, a parent can obtain a more thorough diagnostic evaluation of impairment to see if there really is a diagnosab le problem. Therefore future research needs to further elucidate the roles of parental pe rceptions in the pathway to help-seeking decisions for children. The Threshold Model As already mentioned, help-seeking decisions begin with parental problem perception. So, what influences whether or not a p arent perceives that a child’s problem is serious and decides to seek help? Important to the study of child psychopathology is not only actual child behavior but the lens in whic h society, including parents and teachers, views the behavior. According to Weisz a nd colleagues (1988), “one effect of culture is to set adult thresholds for distress ove r child problems, thus influencing whether such problems are considered serious and in fluencing which actions will be taken in response” (p. 601). Therefore, individual s in different cultures tend to differ in their threshold for child problems. For instance, in this original study that portrayed child behavior in a vignette, Weisz et al. (1988) found t hat parents in Thailand, in comparison

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5 to parents in America, rated child problems as less serious, less worrisome, and more likely to improve. As mentioned, cultural variables play a role in ad ults’ thresholds for child emotional and behavioral problems (Lambert, Weisz, Knight, Desrosiers, Overly, & Thesiger, 1992; Ramirez & Shapiro, 2005; Shah, Dray cott, Wolpert, Christie, & Stein, 2004; Weisz et al., 1988). In addition, exposure t o child psychopathology also may be associated with different thresholds. It may be th at adults exposed to high levels of child psychopathology may be sensitized to certain proble ms and thus display a lower threshold for problems. Americans tend to be more sensitized to child psychopathology compared to other cultures and that may be one reas on behind a lower tolerance for distress (Weisz et al., 1988). Weisz et al. (1988) also found that the degree of distress faced by the parent, teacher, or mental health prof essional determined whether or not a help-seeking initiative is taken. Based on the threshold model, certain types of beh avior as well as a child’s gender may play a role in different thresholds. Fo r instance, externalizing problems, such as aggression and hyperactivity tend to be more tro ubling to parents and teachers and therefore these adults may be more likely to recogn ize these problems and refer children more quickly for treatment. Also, because boys ten d to have externalizing problems more often than girls, parents may have lower thres holds and refer boys more quickly (Hartung & Widiger, 1998; Keenan & Shaw, 1997). Li kewise, cultural and social values determine levels of acceptability of child behavior s. Parental reports of behavioral problems differed across cultures, such that Thai a dolescents and Embu children in Kenya were more likely to show internalizing proble ms, such as shyness and fearfulness,

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6 compared to American children (Weisz, Sigman, Weiss & Mosk, 1993; Weisz, Suwanlert, Chaiyasit, Weiss, Achenbach, & Eastman, 1993). Therefore, cultural values may interact with expected norms and appear to infl uence thresholds (Weisz et al., 1988). Most studies evaluating the threshold model have u sed experimental methodologies. For instance, Weisz et al. (1988) a nd Lambert et al. (1992) used parallel vignettes of a male and female child showing either externalizing or internalizing behaviors. In these studies, American parents, tea chers, and psychologists were compared to those in Thailand and Jamaica, respecti vely. Results showed that culture had a profound effect on perceived seriousness, wor ry, possible improvement, and typicality of these behaviors. More recently, Rami rez and Shapiro (2005) evaluated the threshold model in Hispanic and White teachers in t he U.S. using standardized videotapes of a Hispanic and a White child. Although results showed that Hispanic teachers had higher ratings of Hyperactive-Impulsivity symptoms than did White teachers, this difference disappeared when acculturation was contr olled for statistically. Therefore, acculturation may play more of a role than race/eth nicity when studying the threshold model in the U.S. Although some studies have focused on parents’ thr eshold for perceiving or recognizing that a child has a problem, other studi es have examined multiple thresholds in the help-seeking pathways. For instance, in a s ample of Latina mothers, Arcia and Fernandez (2003) found that mothers went through se veral thresholds including noting symptoms, becoming concerned, and reaching a “satur ation point” of problem acknowledgment before deciding to seek help. Sever al factors were related to the speed of progression through these stages, including diff icult life events and school reports of

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7 negative behaviors. In addition, other studies ide ntified the need to study two threshold levels, including labeling the problem as problemat ic and seeking professional intervention (Bussing, Zima, Gary, & Garvan, 2003; Shah et al., 2004). Several analogue studies have evaluated the former (e.g. Weisz et al ., 1988; Weisz et al., 1993) but more attention needs to paid to the latter. In addition the inclusion of fathers in such studies is also important and lacking in current research (Sha h et al., 2004). The present study examined parental thresholds for problem perception and subsequent help-seeking behaviors of child behavior s presented in a vignette. In order to increase the ecological validity of the study, pare nts were asked to respond as if the child presented was their own child. Overall, studies ha ve not examined factors that may contribute to different parental thresholds for chi ldren’s problems with differing levels of severity nor have they compared mothers’ and father s’ thresholds for problem perception and help-seeking. The aim of the present study was to evaluate how mothers’ and fathers’ thresholds for perceiving a hypothetical p roblem as serious and seeking help for their child may differ depending on certain factors These factors are now discussed in further depth. Factors Associated with Problem Perception and Help -Seeking Behaviors Problem type and severity. Previous research has found differential rates of perceiving internalizing and externalizing child be haviors as problematic and different patterns of subsequent help-seeking. Externalizing behaviors are described as antisocial, aggressive, hyperactive, assaultive, and sociopathi c whereas internalizing behaviors are described as withdrawn, anxious, depressed, psychos omatic, and fearful (Achenbach, McConaughy, & Howell, 1987).

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8 Several researchers have discussed that externalizi ng behaviors are more distressing to parents and teachers and therefore a re referred for treatment more often than are internalizing problems (Cornelius, Pringle Jernigan, Kirisci, & Clark, 2001; Hartung & Widiger, 1998). These externalizing beha viors have also been described as more observable, objective, socially undesirable, a nd disturbing (Christensen, Margolin, & Sullaway, 1992). In addition, mothers and father s tend to agree more often about externalizing behaviors in contrast to internalizin g behaviors (Duhig, Renk, Epstein, & Phares, 2000). Therefore, parents may be more like ly to recognize externalizing behaviors as a problem and seek treatment. In contrast, internalizing behaviors are not as not iceable and appear to be less distressing to parents and teachers. In a study lo oking at parental perceptions of children’s need, children’s self-ratings of their o wn depressive and anxiety symptoms were not related to parental perceptions of these p roblems (Poduska, 2000). Therefore, parents may not recognize these problems and thus m ay not see that their child is in need. Likewise, their child may not be adequately express ing their feelings of sadness and anxiety. Poduska (2000) advised that parents and t eachers listen closely to children, pay attention to their behaviors, and better incorporat e their child’s feelings into their perceptions of need. In addition, stigmatization m ay play a role in reduced help-seeking for children with depression and internalizing prob lems, particularly in regards to talking with friends and family about a child’s problems (P erry, Pescosolido, Martin, McLeod, & Jensen, 2007). In a review of the literature on children’s pathway to care, Sayal (2006) found that symptom severity and presence of an externalizing p roblem predicted parental perception

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9 of a problem. Other studies found that increasing severity, comorbidity, and persistence of problems increased parental problem recognition and help-seeking behaviors (Zwaanswijk et al., 2003; Zwaanswijk et al., 2007). However, they found conflicting evidence when it came to whether or not the presenc e of an externalizing behavior increased recognition and subsequent help-seeking. In a population-based sample, Teagle (2002) examine d both parental perception of a child’s problems and parental perception of th e impact of suffering caused to others by the child’s problems. The highest reports of pr oblems and impacts were for children with ADHD while the lowest was for children with an xiety problems. Parents’ perceptions were correlated strongly with use of sp ecialty mental health services. Therefore, Teagle (2002) advocated for universal sc reening and multiple informant reports of children’s problems so that children’s a ccess to services would be related to their problem severity and not simply parents’ perc eptions. Parents will often seek treatment for their childre n as a last resort and only after they have exhausted other options. Sometimes paren ts see help-seeking as a threat to their own abilities and self-esteem (Raviv, Raviv, Edelstein-Dolev, & Silberstein, 2003a). Therefore, how parents react to different types of behavior could be related to whether or not they find the behavior distressing enough to se ek help. For example, Schneider, Attili, Vermigli, and Younger (1997) found that mot hers would use moderate to high levels of power assertion in response to aggressive behavior and lower levels in response to social withdrawal. Therefore, given the amount of effort and struggle a parent is likely to put forth and if a reduction in externalizing be haviors is not met with success, parents may be more likely to seek help for these types of behaviors.

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10 Comorbidity of child problems is also related to pa rental problem perception. In a study of referability of internalizing and external izing problems in adolescents, Weiss, Jackson, and Susser (1997) found that the presence of one type of problem decreased the concern about the other type of problem, such that parents were likely to focus on the type of problem of most distress and concern for th em. Another study found that while parents may not be able to identify the presence of any one specific disorder or problem correctly, comorbidity of child problems increases problem recognition and subsequent help-seeking (Logan & King, 2001). Therefore, stud ies should not only look at parental perception of internalizing and externalizing probl ems but also the comorbidity of both. Abidin and Robinson (2002) noted that analogue stud ies tend to construct cases that describe internalizing problems or externalizing pr oblems but not a combination of problems. The present study will further examine t he relationship with comorbid problems and problem perception. In addition, beca use severity of a behavior is linked with increased problem perception, the present stud y will include differing levels of severity of internalizing, externalizing, and comor bid internalizing and externalizing problems in its design. Differing levels of severi ty including more ambiguous stimuli may elucidate the association between parental perc eptions and factors related to helpseeking pathways (Curley, 2006; Hoffman & Levy-Shri ff, 1992). Lastly, mothers and fathers have been found to diff er in their ratings of children’s internalizing and externalizing problems (Duhig et al., 2000). Several explanations have been used to make sense out of this discrepancy, in cluding observability of the behavior, situational specificity, amount of contact, and par ental psychological symptoms (Achenbach, McConaughy, & Howell, 1987; Hankinson & Phares, 2008). Also, because

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11 mothers have more contact and are more distressed b y children’s psychological symptoms, mothers tend to rate their children’s beh avior as more negative than do fathers (Chi & Hinshaw, 2002; Christensen et al., 1992). I n addition, parents differ in their reporting of child internalizing and externalizing behaviors. Therefore, their perception of these problems as problematic and their choice o f help-seeking decisions may also differ. The present study examined this research q uestion further. Child gender and age. Both prevalence studies and analogue studies have found an association with parental problem perception, he lp-seeking decisions, and child gender and age. Zwaanswijk et al. (2003) found that the e ffect of child gender on parental problem recognition and help-seeking was dependent on the age of the child. In childhood, more help is sought for boys whereas in adolescence more help is sought for girls. Perhaps, these findings were related to ext ernalizing problems, which tend to be more prevalent in younger versus older boys in cont rast to internalizing problems, which are more prevalent in older versus younger girls (V erhulst & Van der Ende, 1997). However, Verhulst and Van der Ende (1997) found tha t child age was related to parental perceived service need but not to actual utilizatio n of services. Other prevalence studies have looked at child gende r and differential rates of perceived need and service use. Wu and colleagues (2001) found that girls with depression were more likely to receive professional help whereas boys with depression were more likely to receive anti-depressants. Ther efore, child gender may influence the types of service and treatment that are given. Loo king at externalizing problems and ADHD, Bussing et al. (2003) found that boys were fi ve times more likely than girls to receive an evaluation, treatment, and an ADHD diagn osis. In addition, the odds of a

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12 referral for a boy was twice that of a girl when us ing information obtained from preschool children’s birth records (Delgado & Scott 2006). Lastly, in an epidemiological sample of first graders, boys were perceived as needing educational and mental health services more than girls (Poduska, 20 00). These results may have been related to the younger age of the children studied. However, this is an important issue to be aware of when studying adults’ perceptions of ch ildren’s need. Many analogue studies have focused on teachers’ ref errals associated with child gender. For instance, elementary school teachers w ere more likely to refer boys with ADHD than girls regardless of symptoms type (Sciutt o, Nolfi, & Bluhm, 2004). In addition, Green, Clopton, and Pope (1996) found tha t teachers believed that boys are more in need of referrals for mental health service s than girls because boys tend to have externalizing problems that teachers regard as bein g more severe and more in need of a referral. Teachers were more optimistic that girls with internalizing problems would improve with maturation. However, Cline and Ertube y (1997) used a more realistic rating task with a more full context and descriptio n of child functioning and found no effects of child gender on teachers’ evaluations of need. Raviv et al. (2003a) studied the difference between mothers’ willingness to seek help for their own child versus referring a friend’ s child. It was found that mothers of boys were more willing to refer their own child or another’s child for psychological help more so than mothers of girls. This finding was co nsistent with actual behaviors in which boys get referred for psychological services more o ften than girls. An interesting explanation was that mothers take a greater respons ibility for their daughters’ problems and these problems may threaten mothers’ own self-e steem (Penfold, 1985; Raviv et al.,

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13 2003a). Overall, the issue of gender bias in refer ral of children needs to be further examined in parent analogue studies, particularly w ith fathers. Parental distress and psychopathology. In several review and prevalence studies, parental distress and psychopathology were found to be related to problem recognition and help-seeking behaviors. It was found that the distress level that parents and other adults experience, parenting stress, and parental m ental health problems most likely will determine whether or not child problems are recogni zed and whether child treatment will be considered (Lambert et al., 1992; Sayal, 2006; Z waanswijk et al., 2003). Renk (2005) compared mothers who had contacted a psychology cli nic versus mothers who were college students. It was found that higher parenti ng stress was related to higher rates of referrals to psychological services and mothers who had referred their child also had more negative perceptions of their children, lower levels of support, and lower levels of limit setting. However, other researchers have found conflicting e vidence. Poduska (2000) found parental depressive symptoms were not related to perceptions of their child’s needs for services. In addition, Verhulst and Van der En de (1997) found that parental psychopathology was associated with a greater likel ihood of evaluating their children’s problems as problematic but not with increased serv ice use. Similarly, parental psychopathology and parental substance use have bee n found to act as a barrier to service use (Cornelius et al., 2000). Parental stress anxiety has been shown to influence help-seeking differently for mothers and fathers. For instance, anxiety was neg atively related to support seeking and perceived support showed a stronger relationship fo r mothers than fathers (Norberg,

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14 Lindblad, & Boman, 2006). In addition, mothers hav e been found to be more distressed and anxious about their child’s condition than fath ers (Vrijmoet-Wiersema, van Klink, Kolk, Koopman, Ball, & Egeler, 2008). Pihlakoski a nd colleagues (2004) also found that mothers’ stress was related to help needed but not obtained and fathers’ nervousness was related to help obtained. Using a clinical sample, Duhig and Phares (2003) fo und that mothers and fathers did not differ in their reported distress over thei r adolescents’ internalizing and externalizing behaviors. In addition, they found a strong relationship between adolescents’, mothers’, and fathers’ distress and t he desire to change adolescents’ externalizing behavior. This finding was also evid ent for mothers’ and adolescents’ distress and internalizing behavior. Similarly, Ph ares & Danforth (1994) found that parents were distressed over adolescents’ internali zing behavior more so than were teachers. It is important to recognize the role of bidirectional influences in which child problems may influence parental symptoms at the sam e time that parental distress may influence the exacerbation of child problems (Conne ll & Goodman, 2002; Mash & Johnston, 1990). Therefore, there is a need for fu ture research to further elucidate this association and caution must be taken not to imply causality in these associations. In addition, when it comes to older children and adole scents who are more likely to have insight and discuss how they are feeling, perhaps m utual distress between parents and children would lead to quicker problem recognition and help-seeking than when it is left up to the parents’ perceptions alone. Other studies have evaluated parents’ exposure to c hild psychopathology and its association with problem perception. Verhulst and Van der Ende (1997) found that the

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15 presence of family members who were treated for an emotional/behavioral problem made it more likely for parents to perceive a problem in their child. In addition, through their evaluation of the threshold model cross-culturally, Weisz et al. (1988) found that Americans’ greater exposure to child psychology res ulted in a lower threshold for perceiving a problem as serious or worrisome. The present study attempted to further elucidate th e association between parental distress, exposure to psychopathology, and a lower threshold for perceiving a child’s problems and seeking services by comparing mothers and fathers and examining various degrees of severity in children’s problems. Parental self-efficacy and tolerance for misbehavio r. Parental self-efficacy plays an important role in parental and child adjustment (Jones & Prinz, 2005). Parental selfefficacy is linked to parental competence and psych ological functioning as well as child characteristics, such as emotional adjustment and s chool achievement. Jones and Prinz (2005) also suggested that parental self-efficacy m ay play an important role in prevention and intervention efforts. In a sample of mothers i n a clinic and in the community, it was found that clinic mothers had lower self-efficacy o n multiple parenting tasks, including their child’s refusal to eat, their child’s throwin g a tantrum, and visiting friends or relatives with their child (Sanders & Woolley, 2005 ). Likewise, using the best predictive model of primary service use in a sample of caretak ers, parental distress and self-efficacy accounted for the most variance above the influence of child health status and psychosocial variables (Janicke & Finney, 2003). T herefore, parental self-efficacy and the ability to handle children’s problems appear to be associated with help-seeking behaviors.

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16 In a study of barriers to seeking help, one of the most common barriers parents reported was that they felt that they should be str ong enough to handle their preschooler’s behavior problems on their own (Pavuluri, Luk, & Mc Gee, 1996). Another study looking at the help-seeking process found that when identif ied parents wanted to solve their child’s problems themselves, these beliefs served a s a significant barrier to entering treatment (Douma et al., 2006). This perception i s common amongst parents and it appears to result in reduced self-esteem when paren ts realize they cannot help their children on their own (Raviv et al., 2003a). Howev er, this pattern is not as salient for parents with adopted children. Warren (1992) found that adoptive parents had a lower threshold for referral for psychiatric treatment. This finding may be related to parents seeing the adoptive child as at-risk for more probl ems and their difficulties as more disruptive than if they were biologically related. The relation between self-efficacy and help-seeking may also be related to the severity of the behavior. In a study of mothers of preschoolers, perceived severity of ADHD behaviors presented in a vignette was negative ly correlated with the mothers’ self-efficacy (Maniadaki, Sonuga-Barke, Kakouros, & Karaba, 2005). However, these mothers of “normal” children may have had more nega tive emotions and lower selfefficacy toward the child behaviors due to a lack o f exposure and experience with children with behavioral problems. However, another study including both fathers and m others focused on parent gender differences in their reliance on the self or seeking help from others (Shek, 2001). Although this study was done with Chinese parents, the results are similar in Western societies and adolescent samples as well (SchonertReichl & Muller, 1996; Vingerhoets

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17 & Van Heck, 1990). Results showed that mothers had higher levels of external locus of coping or were more likely to seek help from others whereas fathers were more likely to rely on themselves when facing stress in marital, f amilial, interpersonal, and occupational domains. Therefore, fathers may have higher self-e fficacy when it comes to dealing with child problems. On the contrary, mothers may have lower self-efficacy when dealing with child problems and may be more likely to seek outside help. A recent study found that men were less likely to seek mental health ser vices than women perhaps due to men’s negative attitudes toward psychological openn ess (Mackenzie, Gekoski, & Knox, 2006). In addition, Norberg et al. (2006) found a stronger relationship between perceived support and support-seeking for mothers than father s. Therefore, fathers may be less likely to be open toward others and may be more lik ely to rely on themselves for help than mothers. Few studies have evaluated the diffe rence between maternal and paternal self-efficacy in dealing with child problems. The present study attempted to further evaluate these relationships. Parental tolerance for misbehavior has also been fo und to be associated with parental perceptions of child problems as well as w hether or not a child makes it into treatment (Brestan, Eyberg, Algina, Johnson, & Bogg s, 2003). Some parents may perceive their children’s behavior to be deviant or problematic even when the behavior may be developmentally normal or appropriate. Ther efore, low parental tolerance may lead to a lower threshold of problem perception. I n addition, children whose parents have low tolerance for misbehavior may be referred for t reatment more quickly. Treatment acceptability, treatment type, and previo us experiences. Parents’ acceptability of treatment as well as their previou s treatment experiences may play a role

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18 in their decision to seek help for the children. H aving past negative experiences in treatment were found to be significant barriers for parents seeking professional help for their children with intellectual disabilities (Doum a et al., 2006). In addition, having a positive attitude toward treatment was a significan t determinant of parents’ decision to seek treatment for their children with behavioral d isorders (Gustafson, McNamara, & Jensen, 1994). Likewise, the type of help, either formal or inform al, was associated with parents’ help-seeking decisions for their children. Consult ing natural support systems, like family or friends, not only has lower costs but lower thre at to parental self-esteem. Parents appear to prefer to seek natural supports versus pr ofessional help (Raviv et al., 2003a). However, results have differed when parents were se eking help for children with internalizing problems (Perry et al., 2007). Other studies have found that parents seek informal and community agencies, such as preschool staff and voluntary workers, more often than formal agencies such as, pediatricians a nd general practitioners (Pavuluri et al., 1996) and that parents prefer to seek help from sch ool psychological services more so than from private psychologists (Raviv, Raviv, Prop per, & Fink, 2003b). The latter finding is most likely due to lower costs, more acc essibility, and less stigma. However, researchers have found that when parents perceive a problem as severe enough, then parents will seek professional help at a higher rat e and are more willing to pay the costs (Ho & Chung, 1996). Treatment acceptability has been shown to differ be tween men and women. In a community sample, Mackenzie, Knox, Gekoski, and Mac aulay (2004) found that women had higher (i.e. more positive) scores on the Inven tory of Attitudes Toward Seeking

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19 Mental Health Services scale, including higher scor es of psychological openness, helpseeking propensity, and indifference to stigma than did men. Related to the psychological openness issue, another study discuss ed how mental distress is related to utilization of services. Because women report high er levels of distress, they tend to utilize mental health services at a higher rate (Ko opmans & Lamers, 2007). Similar research needs to be carried out with mothers and f athers to examine if they have differential attitudes toward seeking treatment for their children. Therefore, the present study examined mothers’ and fathers’ level of treat ment acceptability and their decisions to seek treatment for their child. The Present Study Using a quasi-experimental design, we looked at ch ild behavior problems at three points along a continuum (from less severe to moder ate to most severe) and examined parents’ views of severity their decisions to see k help, and what kind of help they sought (e.g. consult with teachers, psychologist, general practitioner). Vignettes included internalizing, externalizing, and comorbid internal izing and externalizing behaviors. Through imagining their own child closest in age to 8 and imagining that child at age 8 with various behavior problems, the study was more ecologically valid than typical analogue studies that present hypothetical children There was a need to look at parental problem perception and help-seeking behaviors beyon d yes/no decisions and to include varying behaviors and severity. In addition, the p resent study further examined the threshold model as it related to both mothers and f athers, varying levels of severity, and both parental perceptions and help-seeking decision s. Previous studies had not explored help-seeking decisions but focused only on adults’ perceptions of severity of a child’s

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20 behavior (Weisz et al., 1988). As Bussing et al. ( 2003) noted, there is a service gap between parental recognition and their attempt to s eek services. Therefore, it was important to study multiple thresholds including id entifying a problem as problematic and deciding to seek help. Also, fathers are often excluded from research on child psychopathology (Phares, Lopez, Fields, Kamboukos, & Duhig, 2005), especially related to parental help-seeking for children as shown in v arious studies mentioned above (e.g. Raviv et al., 2003a; Raviv et al., 2003b; Renk, 20 05). Therefore, it was important to examine fathers’ perceptions of child problems that can ultimately influence their decisions to seek help. The hypotheses for the pre sent study are included below. Hypotheses 1. It was hypothesized that externalizing problem s and comorbid internalizing and externalizing problems would be associated with a lower threshold for problem perception and help-seeking than internalizing beha viors alone (i.e. parents would find the problem to be more serious and seek greater lev els of help). This hypothesis was based on research showing that externalizing and co morbid behaviors were more distressing to parents and that parents tended to s eek help for these problems more often than for internalizing problems (Cornelius et al., 1998; Sayal, 2006). 2. It was hypothesized that parents rating their sons were likely to have a lower threshold for problem perception and for seeking he lp than parents rating their daughters (i.e. parents would find the problem more serious a nd seek greater levels of help). This hypothesis was based on research showing that boys tended to be referred for treatment more often than girls (Verhulst & Van der Ende, 199 7; Zwaanswijk et al., 2003).

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21 3. It was hypothesized that mothers would have lo wer thresholds for problem perception and for seeking help than fathers (i.e. mothers would find the problem more serious and seek greater levels of help than father s). This hypothesis was based on research showing that mothers tended to rate their children’s behavior as more negative than did fathers and tended to seek out help more o ften (Mackenzie et al., 2004; Norberg et al., 2006; Shek, 2001). 4. It was hypothesized that parents’ higher expos ure to child psychopathology would be associated with a lower threshold for prob lem perception and seeking help than parents exposed to less child psychopathology (i.e. parents would find the problem to be more serious and seek greater levels of help). Thi s hypothesis was based on the threshold model that suggested that higher exposure to child psychopathology was related to a lower threshold for problem perception (Weisz et al ., 1988). 5. It was hypothesized that parents’ higher level s of distress, lower levels of tolerance, and lower parental self-efficacy would b e associated with a lower threshold for problem perception and seeking help (i.e. parents w ith these characteristics would find the problem to be more serious and seek greater lev els of help). This hypothesis was based on research showing that more parental distre ss, lower tolerance levels, and lower self-efficacy were related to greater problem perce ption and help-seeking decisions (Brestan et al., 2003; Janicke & Finney, 2003; Renk 2005). 6. (Exploratory) It was hypothesized that parents ’ treatment acceptability would mediate between problem perception and seeking trea tment for their child. This hypothesis was based on research showing that attit udes toward treatment were related to whether or not one is open to seeking treatment (Ma ckenzie et al., 2004).

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22 7. (Exploratory) It was hypothesized that parents with higher education status, higher SES, and non-minority status would be associ ated with a lower threshold for problem perception and seeking help (i.e. parents w ould find the problem more serious and seek greater levels of help). This hypothesis was based on research showing that parents who have these characteristics tended to ha ve fewer barriers and more knowledge about services and child development (Verhulst & Va n der Ende, 1997).

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23 Method Participants Two hundred and thirty three participants (167 mot hers and 66 fathers) were recruited via email using the snowball method and t he University of South Florida’s Participant Pool. A power analysis (with a power o f .80, alpha set at .05, and expecting a medium effect size) showed that a minimum of 64 mot hers and 64 fathers were needed to test for between subjects mean differences adequate ly (Cohen, 1992). Parent participants who were students in the Psychology department were given extra credit points towards one of their psychology courses for partaking in th e study. Parents were invited into the study if they had at least one child who was betwee n 4 and 18 years old. By having a broad range of child ages and therefore parental ag es, results were more generalizable to a larger population. Participants included biolog ical, adoptive, and step parents. A “parent” was defined as an individual who had at le ast monthly face-to-face contact with the child. Although we did not specifically attempt to get pa rental dyads to participate, we kept track of mothers and fathers who were rating t he same child by asking for the child’s birthday and the child’s initials. Due to the low number of parental dyads and the problem with interdependence amongst dyad participa nts, one member of each parental dyad was randomly dropped from analyses (7 mothers and 3 fathers). Thus, the final sample included 223 parents (160 mothers and 63 fat hers) who were not involved with each other. Given that analyses included repeated measures analyses, it was assumed that a reduced sample size would still have enough power to detect significance. See Table 1

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24 for participant demographics. Of the final sample of mothers, 149 were biological mothers (93.1%), 5 were biological mothers and step -mothers (3.1%), 1 was a biological mother and adoptive mother (.6%), and 5 were adopti ve mothers only (3.1%). Of the final sample of fathers, 56 were biological fathers (88.9%), 2 were biological fathers and step-fathers (3.2%), 2 were step-fathers (3.2%), 2 were adoptive fathers (3.2%), and 1 was a biological father and guardian (1.6%). Mothers ranged in age between 21 years old and 56 years old ( M =38.36, SD =7.34). Regarding race and ethnicity, the sample o f mothers was primarily Caucasian (84.8%), with some Black/African American (8.2%), H ispanic/Latino (4.4%), Asian (1.3%), Biracial (.6%), and Other (.6%) ethnicities represented. The majority of the sample of mothers was married (67.3%), while the re mainder were divorced and not remarried (13.2%), divorced and remarried (4.4%), s eparated (1.3%), single with no partner (5.0%), single and living with a partner (6 .9%), and single and not living with a partner (1.9%). Fathers ranged in age between 27 years old and 56 years old ( M =41.00, SD =6.87). Regarding race and ethnicity, the sample of fathers was primarily Caucasian (85.7%), with some Black/African American (4.8%), Hispanic/L atino (6.3%), and Asian (3.2%) ethnicities represented. The majority of the sampl e of fathers was married (84.1%), while the remainder were divorced and not remarried (3.2% ), divorced and remarried (3.2%), separated (3.2%), single with no partner (1.6%), an d single and living with a partner (4.8%).

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25 Table 1. Participant demographics. Standard deviations and percentages are in parentheses. Mothers Fathers Mean Parent Age 38.36 (7.34) 41.00 (6.87) Mean Parent SES 50.93 (9.27) 53.75 (9.50) Parent Type Biological Only Biological and Step-parent Step-parent Only Biological and Adoptive Parent Adoptive Parent Biological Parent and Guardian 149 (93.1%) 5 (3.1%) 0 (0.0%) 1 (0.6%) 5 (3.1%) 0 (0.0%) 56 (88.9%) 2 (3.2%) 2 (3.2%) 0 (0.0%) 2 (3.2%) 1 (1.6%) Race/Ethnicity Caucasian Black/African American Hispanic/Latino Asian Biracial Other 134 (84.8%) 13 (8.2%) 7 (4.4%) 2 (1.3%) 1 (0.6%) 1 (0.6%) 54 (85.7%) 3 (4.8%) 4 (6.3%) 2 (3.2%) 0 (0.0%) 0 (0.0%) Marital Status Married Divorced and Not Remarried Divorced and Remarried Separated Single with No Partner Single and Living with Partner Single and Not Living with Partner 107 (67.3%) 21 (13.2%) 7 (4.4%) 2 (1.3%) 8 (5.0%) 11 (6.9%) 3 (1.9%) 53 (84.1%) 2 (3.2%) 2 (3.2%) 2 (3.2%) 1 (1.6%) 3 (4.8%) 0 (0.0%) The majority of the sample of mothers was employed (71.9%), while the remainder of mothers were unemployed (10.0%), retir ed (.6%), solely a student (8.1%), or other (9.4%). Mean socioeconomic status (SES) w as 50.93 ( SD =9.27; Hollingshead, 1975). Thus, the sample of mothers showed relative ly high SES. A total of 53.2% of the sample of mothers reported that either themselves o r the child’s other parent had received

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26 mental health services in the present or past, whil e 46.8% said they had not. A total of 29.7% of the sample of mothers reported that at lea st one of their children had received mental health services, while 70.3% said they had n ot. The majority of the sample of fathers was employed (90.5%), while the remainder of fathers were retired (1.6%), solely a student (3 .2%), or other (4.8%). Mean socioeconomic status (SES) was 53.75 ( SD =9.50; Hollingshead, 1975). Thus, the sample of fathers showed relatively high SES. A total of 44.4% of the sample of fathers reported that either themselves or the child’s other parent had received mental health services in the present or past, while 55.6% said they had not. A total of 19.0% of the sample of fathers reported that at least one of their childre n had received mental health services, while 81.0% said they had not. The mothers’ mean number of children living in the ir homes was 3.04 ( SD =.97). The mean percentage of mothers who worked professio nally with children was 28.01% ( SD =39.56). The mean number of weekly hours that moth ers spent at work was 31.77 ( SD =19.82). The mean number of hours mothers spent du ring a weekday with their children was 6.89 ( SD =4.25) and the mean number of hours spent during a weekend day with their children was 12.34 ( SD =4.26). Thus, the mothers’ contact with their own children was relatively high. Of the mothers’ chil d closest in age to 8 years old, 78 were sons (48.8%) and 82 were daughters (51.2%). The fathers’ mean number of children living in the ir homes was 3.14 ( SD =.95). The mean percentage of fathers who worked professio nally with children was 6.56% ( SD =21.15). The mean number of weekly hours that fath ers spent at work was 46.16 ( SD =15.90). The mean number of hours fathers spent du ring a weekday with their

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27 children was 4.67 ( SD =4.23) and the mean number of hours spent during a weekend day with their children was 10.25 ( SD =4.53). Thus, the fathers’ contact with their own children was relatively high. Of the fathers’ chil d closest in age to 8 years old, 36 were sons (57.1%) and 27 were daughters (42.9%). Measures Vignette Stimuli. Vignettes were developed using internalizing and externalizing behaviors from the Child Behavior Checklist for Age s 6-18 (CBCL; Achenbach & Rescorla, 2001). Three vignettes described interna lizing behaviors (less severe, moderately severe, most severe), three described ex ternalizing behaviors (less severe, moderately severe, most severe), and three describe d comorbid internalizing and externalizing behaviors (less severe, moderately se vere, and most severe). For the less severe vignettes, CBCL behaviors that were prevalen t in about 50% and higher of the non-referred 8-9 year old girls and boys were used. For the moderately severe vignettes, CBCL behaviors that were prevalent in 20%-50% of th e non-referred 8-9 year old girls and boys were used. For the most severe vignettes, CBCL behaviors that had the largest discrepancies between referred and non-referred 8-9 year old girls and boys were used. The vignettes are included in Appendix A. After reading each vignette, participants were aske d several questions. Based on questions from Weisz et al. (1988) and using a 7-po int Likert scale, questions included: a) If this was your child, how serious are his/her beh aviors described in this vignette? b) If you were this child’s parent, how worried would you be about his/her behavior? c) Do you think his/her behaviors would improve in a year or two? d) Compared to other 8 year olds, how unusual are the behaviors described in this vignette?

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28 In addition, participants were asked to complete th e following: If your 8 year old son/daughter were to show these behaviors, you woul d (check all that apply): a) do nothing, b) talk with your child’s other parent, c) talk with your child, d) talk with your child’s teacher, e) consult with your child’s schoo l guidance counselor or school psychologist, f) talk with friends and family membe rs, g) talk with religious/spiritual leaders, h) talk with other people in the community i) consult your pediatrician or general practitioner (M.D.), j) set up an appointme nt with a counselor or psychologist (M.A., M.S., M.S.W., Ph.D.), k) set up an appointm ent with a psychiatrist (M.D.), i) other? Parental distress. Participants were asked to rate their parental di stress using the Parenting Stress Index-Short Form (PSI-SF; Abidin, 1995; Appendix B). The PSI-SF is a 36-item parent report measure of stress in the pare nt-child system. Four scales were assessed using this measure including Total Stress, Parental Distress (PD), Parent-Child Dysfunctional Interaction (P-CDI), and Difficult Ch ild (DC). For purposes of this study, the Total Stress score was used. Parents whose Tot al Stress score was above a raw score of 90 (or in the 90th percentile) were experiencing significant levels o f stress. The PSI-SF showed strong psychometric properties. The interna l consistency reliability ranged from .80-.91 and the test-retest reliability ranges from .68-.85 across the four scales. In the present sample, the internal consistency reliabilit y for the total scale was .91. Parental self-efficacy. Participants were asked to rate their sense of th eir own parental self-efficacy using the Parenting Sense of Competence (PSOC) scale (Johnston & Mash, 1989; Appendix C). The PSOC is a 17-item p arent report measure used to assess parenting self-esteem. Two factors were ass essed using this measure, including

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29 Satisfaction, reflecting parenting frustration, anx iety, and motivation, and Efficacy, reflecting competence, problem-solving ability, and capability in the parenting role. Higher scores on the PSOC indicated greater self-es teem. The PSOC showed good psychometric properties. Internal consistency reli ability for the total score was .79, for the Satisfaction factor, alpha=.75, and for the Eff icacy factor, alpha=.76. In the present sample, the internal consistency reliability for th e total scale was .81. Parental tolerance. Participants were asked to rate their tolerance f or children’s misbehavior using the Annoying Behavior Inventory ( ABI; Brestan et al., 2003; Appendix D). The ABI is a 36-item parent report me asure of their tolerance for disruptive child behavior in general. Two scales w ere assessed using the ABI including the Total Annoyance Scale, in which higher scores i ndicate greater annoyance, and the Total Punish Scale, in which higher scores indicate a greater propensity to use punishment. For the purposes of this study, the To tal Annoyance score was used. The ABI showed strong psychometric properties. Interna l consistency reliabilities for the ABI Annoyance Scale and Punish Scale were both .93. In the present sample, the internal consistency reliability for the Annoyance scale was .95. Treatment acceptability. Participants were asked to rate their attitudes a bout seeking mental health services using the Inventory of Attitudes Toward Seeking Mental Health Services (IASMHS; Mackenzie et al., 2004; Ap pendix E). The IASMSHS is a 24 item self-report measure based on Fisher and Turner ’s (1970) Attitudes Toward Seeking Professional Psychological Help Scale (ATSPPHS). T hree internally consistent factors were assessed using this scale, including Psycholog ical Openness, Help-Seeking Propensity, and Indifference to Stigma. This scale showed good psychometric properties.

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30 Internal consistency reliabilities ranged from .76.87 for the total score and three factor scores. Test-retest reliabilities ranged from .64.91 across the four scores. In the present sample, the internal consistency reliability for th e total scale was .83. Participants were not asked about their attitudes towards seeking pro fessional help for their children because it was found that child related attitudes w ere not related to future mental health service utilization or the quantity of mental healt h services used (Thurston & Phares, 2008). Demographics. Participants were asked to fill out a basic demog raphic questionnaire including questions about the amount of time spent with their own child(ren), exposure to child psychopathology, past treatment experiences, professional involvement, and general amount of contact with chi ldren. See Appendix F. Procedures Pilot Studies. An initial pilot study was conducted in which ten c linical psychology graduate students and faculty with exper ience in child psychopathology rated each vignette. Vignettes were rated on the content and descriptions of the internalizing, externalizing, and comorbid problems to make sure t he wording was appropriate. In addition, each type of vignette was rated for sever ity and rank ordered from less severe to most severe (within each type of vignette). Result s showed that there was 100% agreement across levels of severity and whether or not the vignette showed internalizing, externalizing, or comorbid behaviors. A second pilot study was conducted in which vignet te wording was adjusted to describe the child behaviors as recent changes or a s being more chronic throughout time. Eight clinical psychology graduate students and fac ulty rated the 9 vignettes describing

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31 behaviors as recent and the 9 vignettes describing behaviors as chronic using the questions given to participants including, how seri ous are the behaviors, how worried would you be about the behaviors, would the behavio rs improve, and how unusual are the behaviors. The vignettes describing behaviors as m ore recent had means closer to the midpoint and larger standard deviations across the four dependent variables, thus they were selected for use in the study. Therefore, whe n the participants read a scenario that implied a relatively recent onset of problems, it w as thought that it would be easier to imagine the participants’ child in that scenario. A final pilot study with eight graduate students a nd faculty was conducted in which these final vignettes describing behaviors as more recent were piloted as described in the initial pilot study. Again, results showed that there was 100% agreement across levels of severity and whether or not the vignette showed internalizing, externalizing, and comorbid behaviors. The final vignettes were prese nted in Appendix A. Present Study. The study was posted on-line through an on-line sur vey program called Survey Monkey. Once mothers and fathers wer e identified who met the criteria to participate (i.e. they had at least one child betwe en the ages of 4 and 18 and had monthly face to face contact with the child), they were ask ed to participate in the study. By agreeing to continue with the study, consent was ob tained. Parents were then asked to give the gender, initials (first, middle, and last) and birthday of their child closest in age to 8. This information was used to match parental dyads while still keeping the identity of the parents anonymous. Mothers and fathers were asked to imagine their child closest in age to 8 and imagine that child at age 8 display ing the behaviors in the vignettes. They were then asked to answer the questions accordingly Using a within subjects design,

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32 parents were presented all nine vignettes and answe red the questions mentioned above. Vignettes were presented in a randomized order acro ss participants. After completing the vignettes and questions paren ts were asked to complete the PSI, the PSOC, the ABI, and the IASMSHS. In additi on, they were asked to fill out a demographic form. Finally participants were debrie fed and thanked for their participation. Participants were also asked to cho ose one of three charities in which a $1 donation was made (up to $50 per charity).

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33 Results Descriptive statistics for the vignettes are displ ayed in Tables 2-5. Recall that seriousness ratings ranged from 1 (Not at all serio us) to 7 (Very Serious) so the means in Table 2 suggest that participants found the vignett es to be moderately to very serious. In Table 3, possible range of services is 10 (i.e. tal k with you child’s other parent, talk with your child, talk with your child’s teacher, consult with your child’s school guidance counselor/school psychologist, talk with friends or family members, talk with religious/spiritual leaders, talk with other people in the community, consult your pediatrician or general practitioner (M.D.), set up an appointment with a counselor or psychologist (M.A., M.S., M.S.W., Ph.D.), and set u p an appointment with a psychiatrist (M.D.)). In Table 4, possible range of services is 5 (i.e. talk with your child’s teacher, consult with your child’s school guidance counselor /school psychologist, consult with your pediatrician or general practitioner, set up a n appointment with a counselor or psychologist (M.A., M.S., M.S.W., Ph.D.), and set u p an appointment with a psychiatrist (M.D.)). In Table 5, possible range of services is 2 (i.e. set up an appointment with a counselor or psychologist (M.A., M.S., M.S.W., Ph.D .) and set up an appointment with a psychiatrist (M.D.)).

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34 Table 2. Descriptive statistics for perceived seriousness r atings for each vignette. Vignette Mean SD Less Severe Internalizing 4.77 1.48 Less Severe Externalizing 5.39 1.32 Less Severe Comorbid 5.05 1.39 Moderate Severe Internalizing 5.99 1.09 Moderate Severe Externalizing 6.45 .75 Moderate Severe Comorbid 6.38 .82 Most Severe Internalizing 6.80 .53 Most Severe Externalizing 6.82 .52 Most Severe Comorbid 6.90 .39 Table 3. Descriptive statistics for number of services selec ted for each vignette. Vignette Mean SD Less Severe Internalizing 3.48 1.69 Less Severe Externalizing 3.70 1.87 Less Severe Comorbid 3.57 1.83 Moderate Severe Internalizing 4.64 1.94 Moderate Severe Externalizing 5.14 1.71 Moderate Severe Comorbid 5.19 1.76 Most Severe Internalizing 5.94 1.99 Most Severe Externalizing 5.87 1.92 Most Severe Comorbid 6.20 1.93

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35 Table 4. Descriptive statistics for number of professional s ervices selected for each vignette. Vignette Mean SD Less Severe Internalizing 1.13 1.69 Less Severe Externalizing 1.09 1.87 Less Severe Comorbid 1.09 1.83 Moderate Severe Internalizing 1.91 1.94 Moderate Severe Externalizing 2.46 1.71 Moderate Severe Comorbid 2.46 1.76 Most Severe Internalizing 3.03 1.99 Most Severe Externalizing 3.00 1.92 Most Severe Comorbid 3.27 1.93 Table 5. Descriptive statistics for number of mental health services selected for each vignette. Vignette Mean SD Less Severe Internalizing .13 .37 Less Severe Externalizing .19 .50 Less Severe Comorbid .16 .43 Moderate Severe Internalizing .40 .61 Moderate Severe Externalizing .53 .67 Moderate Severe Comorbid .52 .64 Most Severe Internalizing .90 .70 Most Severe Externalizing .91 .71 Most Severe Comorbid 1.07 .68

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36 To test the first three hypotheses, a 3x3x2x2 repe ated measures MANOVA was used with perceived seriousness and seeking any ser vice, seeking professional services (including teacher, guidance counselor/school psych ologist, pediatrician/general practitioner, counselor/psychologist, and psychiatr ist), and seeking mental health services (including counselor/psychologist and psychiatrist) as the dependent variables. Factors included problem type (internalizing, externalizing and comorbid internalizing and externalizing), problem severity (less severe, mode rately severe, and most severe), parent gender, and child gender. The first hypothesis stated that externalizing and comorbid internalizing and externalizing problems would be associated with a l ower threshold for problem perception and seeking help than internalizing beha viors alone. Therefore, it was expected that there would be a significant differen ce ( p =.025, Bonferroni corrected for two dependent variables) between internalizing and externalizing vignettes and internalizing and comorbid internalizing and extern alizing vignettes but not between externalizing and comorbid internalizing and extern alizing vignettes. Specifically, parents were expected to find the externalizing and comorbid problems to be more serious and seek greater levels of help (Table 6). The second hypothesis stated that parents rating their sons would be likely to have a lower threshold for problem perception and seeking help than parents rating their daughter s. Therefore it was expected that there would be a significant difference ( p =.025, Bonferroni corrected) between sons and daughters (child gender). Specifically, parents we re expected to find the problem to be more serious and seek greater levels of help for so ns in contrast to daughters. The third hypothesis stated that mothers would have lower thr esholds for problem perception and

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37 seeking help than fathers. Therefore it was expect ed that there would be a significant difference ( p =.025, Bonferroni corrected) between mothers and fa thers (parent gender). Specifically, mothers were expected to find the pro blems more serious and seek greater levels of help than fathers (Table 6). Results showed that there were main effects for ty pe of behavior ( F (8, 212)=10.36, p <.001) and for parent gender ( F (4, 216)=2.87, p =.024). Univariate results are displayed in Table 6. The first hypothesis was supported in which externalizing and comorbid internalizing and externalizing problems w ere associated with a lower threshold for problem perception and seeking help t han internalizing behaviors alone. Parents found externalizing and comorbid problems t o be more serious and seek greater levels of help than internalizing problems alone, t hus the first hypothesis was supported (Table 6). However, results did not support a main effect for child gender ( F (4, 216)=.09, p =.984). Therefore, the second hypothesis was not s upported. Parents rating their sons did not have a lower threshold for probl em perception and seeking professional help than parents rating their daughters. In addit ion, there was no significant child gender by parent gender interaction ( F (4, 216)=.36, p =.840). The third hypothesis was partially supported in which mothers and fathers did differ o n seeking levels of help but did not differ on perceived seriousness of behaviors. Moth ers reported that they would seek greater levels of services in general, greater leve ls of professional services, and greater levels of mental health services for their child th an fathers (Table 6).

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38 Table 6. Mean differences for parent gender and types of beh aviors on ratings of perceived seriousness and help-seeking decisions. Variable Levels Seriousness Services Professional Services Mental Health Services Parent Gender Mother Father 0.00 0.63** 0.45** 0.15* Types of Behavior InternalizingExternalizing InternalizingComorbid -0.38*** -0.27*** -0.23*** -0.27*** -0.17** -0.17** -0.74** -.10*** p <.025 ** p <.01 *** p <.001 Although not specific to any hypotheses, additiona l analyses were conducted examining mean differences for parent gender, child gender, and types of behavior on participants’ rating of worry about the behaviors, likelihood the behaviors would improve, and unusualness of behaviors. Results sho wed that there was a main effect for type of behavior ( F (6, 214)=10.83, p <.001) in which parents found internalizing behaviors to be less worrisome, more likely to impr ove, and less unusual than externalizing or comorbid internalizing and externa lizing behaviors. Univariate results are displayed in Table 7. Table 7. Mean differences for types of behaviors on ratings of perceived worry, likelihood to improve, and unusualness. Variable Levels Worry Likely to Improve Unusualness Types of Behavior InternalizingExternalizing InternalizingComorbid -0.33*** -0.26*** 0.20** 0.26*** -0.20** -0.15* p <.05 ** p <.01 *** p <.001

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39 Descriptive statistics for several variables used in the following analyses are displayed in Table 8. The Parenting Stress Index ( PSI) total mean of 68.39 represents relatively low levels of parenting stress. Parenti ng Sense of Competence (PSOC) total mean of 72.61 represents relatively high levels of parenting competence. Annoying Behavior Inventory (ABI) total mean of 72.03 repres ents relatively average levels of tolerance for annoying behavior. Inventory of Atti tudes Toward Seeking Mental Health Services (IASMSHS) total mean of 69.39 represents r elatively average attitudes toward seeking mental health treatment. Correlations amon gst these variables and select dependent variables are displayed in Table 9.

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40 Table 8. Parents’ descriptive statistics for Parenting Stres s Index-Short Form (PSI), Parenting Sense of Competence Scale (PSOC), Annoyin g Behavior Inventory (ABI), Inventory of Attitudes Toward Seeking Mental Health Services’ (IASMSHS) Psychological Openness, Help-Seeking Propensity, an d Indifference to Stigma subscales, and Total scale. Mean SD Minimum Maximum PSI Total 68.39 16.48 42.00 118.00 PSOC Total 72.61 9.57 42.00 96.00 ABI Total 72.03 16.15 0.00 108.00 IASMSHS -Psychological Openness -Help-Seeking Propensity -Indifference to Stigma -Total Score 22.26 24.32 22.81 69.39 5.31 4.67 6.03 12.56 6.00 9.00 6.00 39.00 32.00 32.00 32.00 96.00

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41 Table 9. Correlations among select independent variables (Pa renting Stress Index-Short Form (PSI), Parenting Sense of Competence Scale (PS OC), Annoying Behavior Inventory (ABI), Inventory of Attitudes Toward Seeking Mental Health Services (IASMSHS)) and dependent variables (perceived seriousness, seeking services, professional services, and mental health services). 1. 2. 3. 4. 5. 6. 7. 8. 1. Seriousness 1 .31** .34** .27** -.25** .19** .16* .11 2. Services .87** .55** -.06 .10 .14* .18* 3. Prof. Services .72** -.07 .14 .17* .72** 4. MH Services .04 -.02 .15* .27** 5. PSI -.68** -.05 -.15* 6. PSOC .02 .16* 7. ABI .04 8. Attitudes 1 p <.05 ** p <.01 The fourth hypothesis stated that parents’ higher exposure to child psychopathology would be associated with a lower th reshold for problem perception and seeking help than parents exposed to less child psy chopathology. Specifically, parents exposed to higher levels would find the problem mor e serious and seek greater levels of help. Four regressional analyses were conducted to see if exposure to child psychopathology predicted perceived seriousness, se eking services, professional services, and mental health services ( p =.0125, Bonferroni corrected for four dependent var iables). Results showed that participants’ exposure to behav ior problems significantly predicted participants’ report of seeking mental health servi ces for their child. Therefore, the fourth hypothesis was partially supported. However exposure to behavioral problems

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42 did not predict perceived seriousness, help-seeking in general, or seeking professional services (Table 10). Table 10. Regression analyses of parents’ ratings of exposure to child behavior problems predicting perceived seriousness, seeking services, professional services, and mental health services. Dependent Variable p Perceived Seriousness .00 .98 Overall Services -.01 .84 Professional Services .10 .14 Mental Health Services .17 .01* *p<.0125 The fifth hypothesis stated that higher levels of parental distress, lower levels of tolerance, and lower parental self-efficacy would b e associated with a lower threshold for problem perception and seeking help. Specifically, parents with these characteristics were expected to find the problem to be more seriou s and seek greater levels of help. Four multiple regression analyses were conducted to see if significant beta weights would identify the unique variance of each variable to pe rceived seriousness ratings, seeking services, seeking professional services, and seekin g mental health services. Bonferroni corrected p-values of .0125 were used to detect sig nificance. Results are shown in Table 11. Results showed that multiple regression analys es were significant for perceived seriousness and seeking professional services. In contrast to the hypothesis, higher levels of parenting stress significantly predicted lower p erceived seriousness. However, a lower tolerance for annoying behaviors predicted higher p erceived seriousness as hypothesized. In addition, a lower tolerance for annoying behavio rs significantly predicted seeking higher levels of professional services.

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43 Table 11. Multiple regression analyses of parents’ ratings on the Parenting Stress Index (PSI), the Parenting Sense of Competence (PSOC), an d the Annoying Behavior Inventory (ABI) predicting perceived seriousness, seeking ser vices, professional services, and mental health services. Dependent Variable F p Perceived Seriousness 6.96 <.001** PSI PSOC ABI -.23 .03 .15 .01** .75 .02* Overall Services 2.24 .08 PSI PSOC ABI .02 .12 .14 .82 .21 .04 Professional Services 2.86 .04* PSI PSOC ABI .00 .09 .17 .97 .31 .01** Mental Health Services 1.71 .17 PSI PSOC ABI .05 .01 .15 .58 .90 .03 *p<.05, **p<.0125 Additional analyses were conducted to examine whet her higher levels of parental stress, lower levels of tolerance, and lower parent al self-efficacy would be associated with higher levels of worry, lower likelihood to im prove, and higher levels of unusualness. Results showed that higher levels of parental stress predicted lower levels of worry regarding a child’s emotional/behavioral p roblems. In addition, a lower tolerance for annoying behavior significantly predi cted higher levels of worry, lower likelihood of improvement, and higher levels of unu sualness. Results are displayed in Table 12.

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44 Table 12. Multiple regression analyses of parents’ ratings on the Parenting Stress Index (PSI), the Parenting Sense of Competence (PSOC), an d the Annoying Behavior Inventory (ABI) predicting perceived level of worry, likeliho od to improve, and unusualness. Dependent Variable F p Worry 7.98 <.001** PSI PSOC ABI -.24 .04 .14 .01** .61 .03* Likelihood to Improve 3.38 .02* PSI PSOC ABI -.03 .13 -.15 .75 .15 .02* Unusualness 5.12 .002** PSI PSOC ABI -.13 .04 .20 .16 .70 .003** *p<.05, **p<.0125 Additional analyses were also conducted to examine whether mothers and fathers differed on self-efficacy and treatment acceptabili ty. Results supported a main effect for parent gender ( F (5, 217)=3.49, p =.005). Univariate results are displayed in Table 13. Mothers showed significantly greater treatment acce ptability than fathers, however no differences were noted for self-efficacy. Table 13. Mean differences for parent gender on ratings on Pa renting Sense of Competence (PSOC) total score and Inventory of Atti tudes Toward Seeking Mental Health Services (IASMSHS) total score. Variable Levels Self-Efficacy Treatment Acceptabili ty Parent Gender Mother Father -2.00 6.16** ** p <.01 The sixth hypothesis stated that parents’ treatme nt acceptability would mediate between problem perception and seeking mental healt h services. Mediational analyses were conducted to see if perceived seriousness stil l predicted seeking mental health

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45 services after controlling for treatment acceptabil ity. Based on Baron and Kenny’s (1986) steps to establishing mediation, participant s’ perceived seriousness ratings significantly predicted ratings of treatment accept ability (using the Help-Seeking Propensity subscale of the IASMSHS; =.14, t (221)=2.03, p =.04). In addition, treatment acceptability ratings significantly predicted highe r levels of seeking mental health services for the vignettes (=.31, t (221)=4.84, p <.001). Perceived seriousness ratings also significantly predicted higher levels of seeki ng mental health services for the vignettes (=.27, t (221)=4.14, p <.001). Results showed that seriousness still sign ificantly predicted higher levels of mental health services e ven after controlling for treatment acceptability (=.23, t (221)=3.67, p <.001). The mediated effect of perceived seriousne ss on seeking mental health services exceeded the dire ct effect and approached significance (Sobel test statistic=1.85, p =.06; Sobel, 1982). However, because the effect of perceived seriousness on seeking mental health services did n ot approach zero after controlling for treatment acceptability, an approach towards partia l mediation can be assumed. .14* .31*** Direct effect .23*** *p<.05, ***p<.001 Figure 1. Partial mediation model of interrelationships for p erceived seriousness, treatment acceptability, and levels of seeking ment al services among parents. The seventh hypothesis stated that parents with hi gher education status, higher SES, and non-minority status would have a lower thr eshold for problem perception and seeking help. Specifically, parents with these cha racteristics would find the problem to Treatment Acceptability Mediated effect .27 *** Perceived Seriousness Seeking Mental Health Services

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46 be more serious and seek greater levels of help. M ultiple regression analyses were conducted to see if significant beta weights would identify the unique variance of years of education and SES to severity ratings and seeking h elp. Bonferroni corrected p-values of .025 were used to detect significance. See Table 1 4 for results. Results showed that multiple regression analyses were significant for y ears of education and SES predicting seeking levels of services overall. However, in co ntrast to the hypothesis, those with higher SES were shown to seek a lower number of ser vices overall. Table 14. Multiple regression analyses of parents’ years of e ducation and socioeconomic status (SES) predicting perceived ser iousness, seeking services, professional services, and mental health services. Dependent Variable F p Perceived Seriousness 1.96 .14 Years of Education SES -.17 -.07 .06 .45 Overall Services 3.88 .02* Years of Education SES .02 -.20 .87 .03* Professional Services 1.22 .30 Years of Education SES -.01 -.10 .92 .27 Mental Health Services 2.73 .07 Years of Education SES -.20 .08 .03 .38 *p<.05 In addition, two one-way ANOVAs were conducted to see if severity ratings and help seeking differ between races. Results showed that perceived seriousness ( F (1, 219)=2.03, p =.16), seeking any service ( F (1, 219)=.04, p =.84), seeking professional

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47 services ( F (1, 219)=.16, p =.69), and seeking mental health services ( F (1, 219)=.31, p =.58) did not differ between minority and non-minor ity races.

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48 Discussion A brief summary of the significant findings of the present study are provided first and then the results are discussed in a more thorou gh manner. Main effects were found for type of behaviors and parent gender in which pa rents found internalizing behaviors to be less serious and sought lower levels of services than externalizing and comorbid internalizing and externalizing behaviors. Parents also found internalizing behaviors to be less worrisome, more likely to improve, and less unusual than externalizing or comorbid internalizing and externalizing behaviors. In addition, mothers were found to seek higher levels of services, including professio nal and mental health services than fathers. Mothers and fathers were also found to si gnificantly differ on treatment acceptability in which mothers showed higher accept ability than fathers. Also, parents’ ratings of treatment acceptability were shown to ap proach partial mediation between their ratings of seriousness and their decisions to seek mental health services. Parents’ higher exposure to child emotional and be havioral problems significantly predicted greater levels of seeking mental health s ervices. However, parents’ higher selfreport of parenting stress predicted lower ratings of seriousness and worry related to child emotional and behavioral problems. In contrast, pa rents’ self-report of lower tolerance for annoying behaviors predicted higher ratings of seriousness, worry, unusualness, and seeking professional services. In addition, lower tolerance predicted lower ratings of likelihood of behaviors improving. Finally, parent s’ socio-economic status was also shown to predict lower levels of seeking services i n general.

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49 Overall, this study adds to the knowledge related to mothers’ and fathers’ perceptions of the severity of children’s emotional and behavioral problems, their subsequent formal and informal help-seeking decisio ns, and the thresholds which determine these steps in the help-seeking process. Unique to this study was the use of a quasi-experimental design rather than correlational and prevalence based designs. In addition, compared to previous analogue studies, th is study focused on both mothers’ and fathers’ ratings and their help-seeking decisions r ather than mothers or parents alone. Mothers’ and fathers’ differences were found relate d to their help-seeking decisions. In addition, mothers and fathers perceived differences in seriousness and subsequent helpseeking decisions based on behavior type. Unique t o this study was the inclusion of internalizing, externalizing, and comorbid internal izing and externalizing behaviors in the vignette stimuli. This study also examined multipl e parental variables such as parenting stress, parental self-efficacy, tolerance for behav ior, and treatment acceptability and the roles these factors played in their perceptions of their children’s problem severity and need for help, which previous research has neglecte d. Lastly, mediational analyses determined that treatment acceptability partially m ediated between perceptions of seriousness and decisions to seek help. Behavior Type Differences The present study’s hypothesis regarding behavior type differences was supported such that externalizing problems and comorbid inter nalizing and externalizing problems were associated with a lower threshold for problem perception and seeking help than internalizing behaviors alone. Parents rated vigne ttes showing internalizing problems as less serious and chose lower levels of services in general, professional services, and

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50 mental health services than externalizing or comorb id internalizing and externalizing problems. In addition, post hoc analyses found tha t internalizing problems were perceived as less worrisome, more likely to improve and less unusual than externalizing and comorbid internalizing and externalizing proble ms. Several studies have supported these findings in which externalizing problems were perceived as more serious because they were more overt, were associated with a higher burden on parents, and were more recognized by outside sources, including teachers ( Abidin & Robinson, 2002; Arcia & Fernandez, 2003; Douma et al. 2006; Sayal, 2006; Te agle 2002). These results have also been upheld across different races and cultures. C hang and Sue (2003) reported that problems such as anxiety, depression, and social wi thdrawal did not receive the same concern from teachers, were perceived as less serio us, and were referred for evaluation less often regardless of the race of the child. In addition, several studies looking at crosscultural differences in parents showed that parents regardless of culture, found internalizing problems to be perceived as less seri ous, would respond less assertively to these problems, and were less likely to seek treatm ent (Lambert et al., 1992; Schneider et al. 1997; Shah et al., 2004; Weisz et al., 1988). However, besides being more noticeable and receivi ng more concern from parents and teachers, other factors could also play a role in why parents seek help less often for children with internalizing problems. For instance Perry et al. (2007) suggested that lower levels of help-seeking, particularly with reg ard to talking with friends and family about child depressive symptoms, could be related t o increased stigmatization. Depression in children has been perceived as more s erious and as having a greater potential for dangerousness than depression in adul ts. Therefore, parents may be less

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51 likely to seek help for their child from informal r esources. In addition, many times parents will not seek help for children with intern alizing problems until the child asks for help, which tends to happen more in adolescence tha n in childhood because adolescents have more insight and can communicate more about th eir emotional problems (Logan & King, 2001; Zwaanswijk et al., 2007). Therefore, i ncreasing parent-child communication is important in order to diminish the gap between r ecognizing and seeking services for children’s internalizing and externalizing problems In addition, Lyneham and Rapee (2007) found that p atterns of help-seeking differed for children with internalizing problems d epending on whether they lived in a rural or urban area. In urban areas, parents were more likely to use specialized clinics while in rural areas parents were more dependent on school and general medical services. However, with limited recognition and perceived ser iousness by teachers and parents, these children could continue to fall through the c racks and not receive proper services regardless of where they live. Child Gender and Parent Gender Differences Results have been mixed regarding child gender and differing perceptions of seriousness and help seeking decisions. In the pre sent study, ratings of seriousness, worry, likelihood to improve, unusualness, and help -seeking behaviors did not differ depending on whether parents were rating their son or their daughter. This finding was supported in previous research that showed no diffe rences in help seeking processes between boys and girls (Cline & Ertubey, 1997; Zwaa nswijk et al., 2007). In addition, in previous research, child gender has been confounded with type of problem and age such that some studies have found that the effect of chi ld gender on parental problem

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52 recognition and help-seeking was dependent on the a ge of the child (Zwaanswijk et al., 2003; Zwaanswijk et al., 2006). Also, externalizin g problems tend to be more prevalent in younger versus older boys and internalizing prob lems are more prevalent in older versus younger girls (Green et al., 1996; Verhulst & Van der Ende, 1997). Therefore, child gender alone may not explain discrepancies. In addition, the experimental design of the present study in which presenting problems were the same regardless of whether the parent was rating their son or daughter could have ruled out any other stereotypical judgments or differing presentation of behaviors th at could contribute to discrepant ratings in population based studies (Bussing et al. 2003; Delgado et al., 2006; Wu et al., 2001). Parental gender differences are frequently found i n the literature with regard to psychological symptoms and help-seeking behaviors. For instance, in pediatric populations, mothers report higher levels of stress and greater support seeking than fathers (Norberg et al., 2006; Vrijmoet-Wiersema et al, 2008). In the present study, differences were also found in which mothers report ed they would seek higher levels of services in general, professional services, and men tal health services than fathers. However, no differences were found between mothers and fathers on ratings of perceived seriousness, worry, likelihood to improve, or unusu alness. Therefore, it appeared that parents tended to agree on degree of seriousness an d worry about a child’s behavior when given the same exact stimuli. In other studies whe re situational specificity and amount of contact played a role, ratings of behaviors have di ffered (Achenbach et al,, 1987; Achenbach, 2006; Chi & Hinshaw, 2002; Duhig et al., 2000). In the present study, support and help-seeking decisions did differ betwe en mothers and fathers and many

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53 studies have discussed factors that could be relate d to this discrepancy. Some research has found that women and mothers are more likely to seek help from others more often than men and fathers when it came to their own copi ng or distress over children’s problems (Koopmans & Lamers, 2007; Norberg et al, 2 006; Shek, 2001). In support of findings by Mackenzie et al. (2004), mothers in the present study were also found to have higher mental health treatment acceptability, psych ological openness, help-seeking propensity, and indifference to stigma than fathers In addition, parents’ self-efficacy has been found to play a role in why mothers and fathers may differ in their help-seeking decisi ons. Johnston and Mash (1990) found that child behavior problems were related to parent ing satisfaction for mothers while child behavior problems were related to parenting s atisfaction and parental efficacy for fathers. In addition, fathers reported higher leve ls of satisfaction than mothers. Therefore, parents may differ in how they handle th eir child problems and may differ in whether they rely on outside support or not (Shek, 2001). Although the present study did not find a significant relationship between parenta l self-efficacy and perceived seriousness and help-seeking decisions, nor did it find that self-efficacy differed between mothers and fathers, these relationships should be explored in future research. In addition, fathers are often excluded from research on parental efficacy and the majority of studies have focused on mothers’ perceived efficacy (Jones & Prinz, 2005; Sanders & Wooley, 2005). Because both mothers and fathers ta ke active roles in making decisions for their families, fathers’ perceptions and help-s eeking decisions need to be explored in further depth. However, the present study did help to further elucidate the help-seeking model in which mothers reported seeking help at gre ater levels for their children than

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54 fathers. Further information on what factors contr ibute significantly to this discrepancy need to be understood. Parental Factors Related to Problem Perception and Help-Seeking Beyond behavior type and gender, several factors w ere shown to be related to whether or not parents perceived children’s problem s as serious and decided to seek help. Parental exposure to behavioral problems has been l inked to increased problem perception but not to help-seeking (Verhulst & Van der Ende, 1997; Weisz et al., 1987). As Sayal (2006) emphasized, it is important to exam ine these two distinct steps in the help-seeking process and to establish how factors m ay differentially influence them. In the present study, it was found that parents’ selfreport of exposure to child psychopathology was related to increased levels of seeking mental health services but not to perceived seriousness of the behaviors. However as Weisz et al. (1988) found in their original exploration of the threshold model, Americ ans tended to be more sensitized to child psychopathology compared to other cultures wh ich could be related to a lower tolerance for distress. Other factors could also b e related to the present study’s findings, including mental health treatment acceptability (Ma ckenzie et al., 2004) and accessibility of services and resources (Lyneham & Rapee, 2007; W illiams, Horvath, Wei, Van Dorn, & Jonston-Reid, 2007). The role of treatment accep tability will be discussed later in further depth. In addition, patterns of service us e due to accessibility and location should be explored in future research. Weisz et al. (1988) also found that the degree of d istress faced by the parent, teacher, or mental health professional determined w hether or not a help-seeking initiative was taken. Research on parental distress has been shown to be related to a lower

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55 threshold for perceiving children’s behavior as pro blematic (Verhulst & Van der Ende, 1997; Teagle, 2002) and higher motivation to change children’s behaviors (Duhig & Phares, 2003). Parental distress over children’s p roblems has also been associated with increased service use (Pihlakoski et al., 2004; Ren k, 2005). In addition, the interaction between parental stress and self-efficacy to cope w ith problems and access services has been linked to use of primary health care services (Janicke & Finney, 2003). However, other researchers have found that parental distress and associated psychological symptoms has led to increased perception of child p roblems but may act as a barrier to actual service use for children (Cornelius et al., 2001). In the present study, it was found that higher levels of parenting stress were related to decreased perceived seriousness and decreased worry. An explanation could be that pare nts experiencing higher levels of stress may have seen the behaviors in the vignettes as less serious compared to their own child or their own symptoms. However, the present sample had much lower scores of total stress compared to other comparison community samples (Haskett, Ahern, Ward, & Allaire, 2006). Therefore, compared to parents exp eriencing more significant levels of stress, the parents’ stress level in the present st udy may not have played a significant role in their perceptions of child problems and decision s to seek help. Interestingly, parenting self-efficacy was not foun d to be related to perception of seriousness and help-seeking decisions. However, a s research suggested, the interaction between self-efficacy and parental distres due to t heir children’s problems and their own psychological functioning should continue to be exp lored in further depth (Janicke & Finney, 2003; Jones & Prinz, 2005). Lower tolerance for annoying behavior was found to be related to greater levels of perceived seriousne ss, worry, likelihood to improve, and

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56 unusualness. In addition, lower tolerance for anno ying behavior was also found to be related to seeking higher levels of professional he lp. These findings are commensurate with what Brestan et al. (2003) discussed in which, parents with low levels of tolerance may view children’s behavior as more problematic an d deviant when their child could be displaying typical behaviors. In addition, parents with low tolerance may be referring their children more often and their perceptions of behavior problems may be discrepant from other observers including teachers and mental health professionals. Consideration of clinical implications of these behaviors is impo rtant such that parents could be provided psychoeducation about typical versus clini cal behaviors and ways they could cope and address these annoying behaviors in their children. Other factors such as socioeconomic status (SES) an d minority status and their association with child problem perception and helpseeking decisions have been explored in past research, such that those with lower SES an d minority status were less likely to perceive child behavior as serious and seek service s (Flisher et al., 1997; Sayal, 2006). However, other studies have not found such a relati onship (Verhulst & Van der ende, 1997; Poduska, 2000). In contrast to the stated hy pothesis in the present study, parents with higher SES selected lower levels of services o verall. However, several factors could be related to these findings. First, the present s ample was comprised of participants of relatively high SES and non-minority status. There fore, range restriction and small minority sample size may not have been adequate to test for differences. In addition, those with higher SES may have the means to access more specific mental health services and may not be as dependent on social supports and community resources as those with lower SES (Poduska, 2000). Because education is a component in calculating SES, those

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57 with higher education may have better coping mechan isms, greater likelihood to recognize a disorder, and better knowledge about ap propriate services (Sayal, 2006). Treatment Acceptability as a Mediator Exploratory analyses revealed that treatment accep tability approached partial mediation between perception of seriousness and see king mental health services. As discussed earlier, recognition or perception of a p roblem, decision to seek help, and actually seeking help are distinct steps in several models of help-seeking behaviors (Douma et al., 2006; Teagle, 2002; Zwaanswijk et al ., 2006; Zwaanswijk et al., 2007). Therefore, what may account for why parents perceiv e that their child has a problem but do not seek help could be treatment acceptability. In the present study and previous research, gender differences have been found in the propensity towards seeking mental health treatment (Mackenzie et al., 2004; Shek et a l., 2001). In addition, stigmatization has been found to be related to seeking help for ch ildren (Perry et al., 2007) as well as wanting to address children’s problems on one’s own (Douma et al., 2006). Also, differences have been found in which parents are mo re likely to seek help for another parents’ child or an adopted child than their own b iological child (Raviv et al., 2003a; Warren, 1992). Therefore, stigmatization may also play a role in seeking help for one’s biological child versus a non-biological child. Gu stafson et al. (1994) used an analogue procedure similar to the one used in the present st udy and found that severity of child problems and attitudes toward treatment were positi vely associated with likelihood of seeking treatment. However as with the present stu dy, the sample was primarily Caucasian and of higher SES. Therefore, future res earch examining the mediating role of

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58 treatment acceptability in the linkage between prob lem perception and help-seeking decisions in minority and lower SES populations is warranted. Limitations and Future Research By using a quasi-experimental design in which pare nts read descriptions of child behavior and rated these descriptions based on thei r own child and parenting, the ecological validity of the results was enhanced. H owever, as with any analogue study, parents’ actual behaviors in the real world were st ill unknown. Yet many researchers use vignettes to investigate perceptions of mental heal th problems because vignettes are comprised of concrete stimuli which are held consta nt across participants (Finch, 1987). Unique to this study was the ability to evaluate th e threshold for parents to seek help for their child by including different types and a rang e of severity of behaviors along a continuum. In addition, by including both mothers and fathers, it was possible to see whether mothers and fathers differed in their thres holds for problem perception and helpseeking decisions. The present study also examined parents reported informal and formal service decisions in order to portray a more realis tic account of parents’ support and helpseeking behaviors. There are, however, additional limitations. Vigne ttes were about an 8 year old child. Parents may have been more or less familiar with this age depending on where their child stands developmentally. The fact that all participants must have had a child between the ages of 4 and 18 controlled for parenta l experiences somewhat. For example, parents whose oldest child is an infant or toddler were not included because their children’s behavior might be too divergent fr om the behavior of an 8 year old. On the other end of the developmental spectrum in adol escence, it was assumed that parents

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59 who had experienced an active role in parenting ove r recent years (even with older adolescent children) would still be familiar enough with an 8 year old’s behavior to provide meaningful ratings of problem perception an d help-seeking decisions. Another concern, though is that the length of the vignettes may not have provided enough information to make a thorough evaluation of the ch ild’s behavior. However, enough detail was provided that participants should have b een able to make decisions on how they perceived the behavior and what they would do if their child exhibited the behaviors in question. Another limitation is that this study did not expl ore some of the factors related to parental problem perception and help-seeking decisi ons. Because the presence of mental health problems in parents has been shown to be ass ociated with increased likelihood of parental perception of problems in children, this f actor will be important to explore in future studies (Sayal, 2006). The present study on ly examined parental stress and not the presence of other psychological symptoms or disorde rs. In addition, the help-seeking process is not stagnant. Many times parents will t ry one avenue of help-seeking initially and then later explore other options if met with li mited success or as problems worsen. In addition, parents may use an avenue of help-seek ing to reach another and may not go through the steps in a uniform manner (Sayal, 2006; Zwaanswijk et al., 2007). Also, greater levels of help may not necessarily be the m ost efficient way to seek help. Therefore, parents may not have chosen multiple inf ormal and formal services but may have chosen one they considered would be most effec tive (i.e. psychologist or psychiatrist). In addition, we did not explore act ual behaviors and whether or not parents would actually follow through with treatment. Alth ough this study did not explore the

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60 multiple pathways in help-seeking decision making, this topic is warranted in future research to elucidate the model of parental help-se eking for child mental health problems. Clinical Implications This study offered several clinical implications. First, within a clinical setting, parents tend to seek services for their children at different times. Sometimes parents will bring a child in for services the moment they notic e a problem. Other parents will wait longer to see if a problem persists or will seek he lp only when it gets very severe. Several factors contribute to when and if help seek ing occurs. Therefore, the present study served to disentangle when parents seek help and what kind of help they seek. Also, mothers and fathers often differ in whether t hey perceive that their child has a problem, what the problem is, and what they should do about the problem. Through a quasi experimental design, this study identified th at mothers and fathers differed in their decision making for their children. Lastly, parent s’ personal factors were related to perceiving problems and help seeking decisions. Cl inicians and other health professionals need to be cognizant of what contribu tes to whether or not a child receives proper services for their emotional and behavioral problems and these professionals should advocate for lessening the service gap in ch ildren’s mental health services.

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61 References Abidin, R.R. (1995). Parenting Stress Index (PSI) manual (3rd ed.). Charlottesville, VA: Pediatric Psychology Press. Abidin, R.R. & Robinson, L.L. (2002). Stress, bias or professionalism: What drives teachers’ referral judgments of students with chall enging behaviors? Journal of Emotional and Behavioral Disorders, 10, 204-212. Achenbach, T.M. (1991). Manual for the Child Behavior Checklist/4-18 and 19 91 Profiles. Burlington: University of Vermont, Department of Psychiatry. Achenbach, T.M. (2006). As others see us: Clinical and research implications of crossinformant correlations for psychopathology. Current Directions in Psychological Science, 15 94-98. Achenbach, T.M., McConaughy, S.H., & Howell, C.T. ( 1987). Child/adolescent behavioral and emotional problems: Implications of cross-informant correlations for situational specificity. Psychological Bulletin, 101, 213-222. Achenbach, T.M. & Rescorla, L.A. (2001). Manual for the ASEBA School-Age Forms & Profiles. Burlington, VT: University of Vermont, Research Cen ter for Children, Youth, & Families. Arcia, E. & Fernandez, M.C. (2003). From awareness to acknowledgment: The development of concern among Latina mothers of chil dren with disruptive behaviors. Journal of Attention Disorders, 6, 163-175.

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66 Hoffman, M.A. & Levy-Shriff, R. (1992). Children’s vulnerability to stressful life events in mothers’ eyes: Effects of gender and parental ex periences. Sex Roles, 27, 3945. Janicke, D.M. & Finney, J.W. (2003). Children’s pr imary health care services: Socialcognitive factors related to utilization. Journal of Pediatric Psychology, 28, 547558. Johnston, C. & Mash, E.J. (1989). A measure of par enting satisfaction and efficacy. Journal of Clinical Child Psychology, 18, 167-175. Jones, T.L. & Prinz, R.J. (2005). Potential roles of parental self-efficacy in parent and child adjustment: A review. Clinical Psychology Review, 25, 341-363. Keenan, K. & Shaw, D. (1997). Developmental and s ocial influences on young girls’ early problem behavior. Psychological Bulletin, 121, 95-113. Koopmans, G.T. & Lamers, L.M. (2007). Gender and h ealth care utilization: The role of mental distress and help-seeking propensity. Social Science & Medicine, 64, 1216-1230. Lambert, M.C., Weisz, J.R., Knight, F., Desrosiers, M., Overly, K., & Thesiger, C. (1992). Jamaican and American adult perspectives o n child psychopathology: Further exploration of the threshold model. Journal of Consulting and Clinical Psychology, 60, 146-149. Leslie, L.K., Weckerly, J., Landsverk, J., Hough, R .L., Hurlburt, M.S., & Wood, P.A. (2003). Racial/ethnic differences in the use of ps ychotropic medication in highrisk children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 1433-1442.

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67 Logan, D.E. & King, C.A. (2001). Parental facilita tion of adolescent mental health service utilization: A conceptual and empirical rev iew. Clinical Psychology: Review and Practice, 8, 319-333. Lyneham, H.J. & Rapee, R.M. (2007). Childhood anxi ety in rural and urban areas: Presentation, impact and help seeking. Australian Journal of Psychology, 59, 108-118. Mackenzie, C.S., Gekoski, W.L., & Knox, V.J. (2006) Age, gender, and the underutilization of mental health services: The inf luence of help-seeking attitudes. Aging and Mental Health, 10, 574-582. Mackenzie, C.S., Knox, V.J., Gekoski, W.L., & Macau lay, H.L. (2004). An adaptation and extension of the Attitudes Toward Seeking Profe ssional Psychological Help Scale. Journal of Applied Social Psychology, 34, 2410-2435. Maniadaki, K., Sonuga-Barke, E., Kakouros, E., & Ka raba, R. (2005). Maternal emotions and self-efficacy beliefs in relation to b oys and girls with AD/HD. Child Psychiatry and Human Development, 35, 245-263. Mash, E.J., & Johnston, C. (1990). Determinants of parenting stress: Illustrations from families of hyperactive children and families of ph ysically abused children. Journal of Clinical Child Psychology, 19, 313-328. Norberg, A.L., Lindblad, F., & Boman, K.K. (2006). Support-seeking, perceived support, and anxiety in mothers and fathers after c hildren’s cancer treatment. Psycho-oncology, 15, 335-343.

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68 Pavuluri, M.N., Luk, S., & McGee, R. (1996). Helpseeking for behavior problems by parents of preschool children: A community sample. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 215-222. Penfold, S.P. (1985). Parents’ perceived responsib ility for children’s problems. Canadian Journal of Psychiatry, 30, 255-258. Perry, B.L., Pescosolido, B.A., Martin, J.K., McLeo d, J.D., & Jensen, P.S. (2007). Comparison of public attributions, attitudes, and s tigma in regard to depression among children and adults. Psychiatric Services, 58, 632-635. Phares, V. & Danforth, J.S. (1994). Adolescents’, parents’, and teachers’ distress over adolescents’ behavior. Journal of Abnormal Child Psychology, 22, 721-732. Phares, V., Lopez, E., Fields, S., Kamboukos, D., & Duhig, A.M. (2005). Are fathers involved in pediatric psychology research and treat ment? Journal of Pediatric Psychology, 30, 631-643. Pihlakoski, L., Aromaa, M., Sourander, A., Rautava, P., Helenius, H., & Sillanpaa, M. (2004). Use of and need for professional help for emotional and behavioral problems among preadolescents: A prospective cohort study of 3to 12-year-old children. Journal of the American Academy of Child and Adoles cent Psychiatry, 43, 974-983. Poduska, J.M. (2000). Parents’ perceptions of thei r first graders’ need for mental health and educational services. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 584-591.

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72 Wu, P., Hoven, C.W., Cohen, P., Liu, X., Moore, R.E ., Tiet, Q., Okezie, N., Wicks, J., & Bird, M.D. (2001). Factors associated with use of mental health services for depression by children and adolescents. Psychiatric Services, 52, 189-195. Zwaanswijk, M., Verhaak, P.F.M., Bensing, J.M., Van der Ende, J., & Verhulst, F.C. (2003). Help-seeking for emotional and behavioural problems in children and adolescents: A review of recent literature. European Child and Adolescent Psychiatry, 12, 153-161. Zwaanswijk, M., Verhaak, P.F.M., Van der Ende, J., Bensing, J.M., & Verhulst, F.C. (2006). Change in children’s emotional and behavio ural problems over a oneyear period: Associations with parental problem rec ognition and service use. European Child and Adolescent Psychiatry, 15, 127-131. Zwaanswijk, M., Van der Ende, J., Verhaak, P.F.M., Bensing, J.M., & Verhulst, F.C. (2007). The different stages and actors involved i n the process leading to the use of adolescent mental health services. Clinical Child Psychology and Psychiatry, 12, 567-582.

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73 Appendices

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74 Appendix A: Survey Thank you for agreeing to participate in this study In order to participate you must be a mother or a father of a child between the ages of 4 and 18 years old. Biological, adoptive, and step-parents are all welcome to parti cipate. You will be asked to read some vignettes, answer questions about the vignettes, an d answer questions about yourself. The study should take about 30 minutes to complete. While reading the vignette below, imagine that your SON/DAUGHTER (closest in age to 8) is showing these behaviors at the age of 8. Not at all Neutral Very Much How serious is his/her behavior? 1 2 3 4 5 6 7 How worried would you be about his/her behavior? 1 2 3 4 5 6 7 Do you think his/her behavior would improve in a year or two? 1 2 3 4 5 6 7 Compared to other 8 year olds, how unusual is his/her behavior? 1 2 3 4 5 6 7 If your 8 year old son/daughter were to show the be haviors mentioned above, you would (check all that apply): € Do nothing € Talk with your child’s other parent € Talk with your child € Talk with your child’s teacher € Consult with your child’s school guidance counselor or school psychologist € Talk with friends and family members € Talk with religious/spiritual leaders € Talk with other people in the community € Consult your pediatrician or general practitioner ( M.D.) € Set up an appointment with a counselor or psycholog ist (M.A., M.S., M.S.W., Ph.D.) € Set up an appointment with a psychiatrist (M.D.) € Other (please specify)

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75 Appendix A: (Continued) Vignettes Less Severe/Internalizing: Imagine that your 8 year old son/daughter has been rather shy. He/She hasn’t liked to play with other kids and would rather just be left alone. Recently, your child has been more self-conscious about what he/she says and does especially in front of other peers. For instance, he/she doesn’t want to wear certain c lothes to school and doesn’t want to try new things for fear of failure. He/she also tends to be perfectionistic and has been getting upset when he/she messes up. Less Severe/Externalizing: Imagine that your 8 year old son/daughter is arguin g with you more. He/she has been stubborn and refusing to follow some of your rules at home. Recently, your child has been demanding more and more of your attention and gets upset when he/she doesn’t get it. He/she would rather hang out with the older ki ds in your neighborhood and has been showing off when he/she is around them. Your child has been more impulsive and often doesn’t think through his/her actions before doing them. Less Severe/Internalizing and Externalizing: Imagine that your 8 year old son/daughter has been rather sullen and stubborn. Your child has recently not wanted to play with other ki ds and is more self-conscious about how kids perceive him/her. When he/she has been pl aying with others, he/she breaks rules that you have set forth. He/she has been sho wing off around other kids and not thinking through his/her actions. However, he/she has been getting upset when he/she messes up and feeling bad about his/her actions. Moderate Severe/Internalizing: Imagine that your 8 year old son/daughter has been worrying a lot. Recently, he/she has become much more secretive with you and you notice he/she is nervous and tense about a lot of things, especially school. In addition, he/ she is crying more easily. He/she is having nightmares and is fearful of things happenin g to you or your family. The other day he/she said that he/she felt unloved after you got upset with him/her. Moderate Severe/Externalizing: Imagine that your 8 year old son/daughter has had a hot temper. His/her mood has been changing frequently throughout the day, one minute he/she is really angry and the next he/she is fine. Also, your child has been teasing others, like his/her siblings and peers. Recently, he/she has been disobeying teachers and o ther adults in school and has been caught lying and cheating. Your child seems to lac k guilt and hasn’t really cared much about the consequences of his/her actions.

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76 Appendix A: (Continued) Moderate Severe/Internalizing and Externalizing: Imagine that your 8 year old son/daughter has been quite moody. Recently, he/she has gotten in trouble for disobeying at school and has been caught for cheating and lying. He/she seems to be quite tense and is crying more e asily. Your child has been teasing others often and seems to lack guilt for hurting ot hers’ feelings. At the same time, he/she has become more fearful and worrisome about bad thi ngs happening to his/her family. Most Severe/Internalizing: Imagine that your 8 year old son/daughter has been very unhappy and sad. He/she has been more nervous and anxious about going to school and participating in activities outside the home. He/she has reported feeling wort hless and would prefer to be left alone. He/she is crying a lot more and has been ve ry secretive about what is bothering him/her. Recently, he/she has said that he/she wis hes he/she would die. Most severe/Externalizing: Imagine that your 8 year old son/daughter has been getting into fights. He/she has been breaking a lot of rules and has been disobedient bo th at home and school. Recently, when he/she gets upset, he/she gets very loud, scre ams, swears, and will often destroy his/her own and others’ belongings. He/she has bee n mean to peers and siblings and has threatened to harm them. The other day he/she atta cked another peer and showed little guilt for it. Most severe/Internalizing and Externalizing: Imagine that your 8 year old son/daughter has been having frequent mood changes. He/she has been sad and unhappy but also screams an d has a hot temper. Your child has been disobeying at school, getting into fights, scr eaming, and swearing. Recently, he/she said that he/she feels worthless and talked about s uicide. When upset he/she has been destroying his/her belongings and that of his/her s iblings.

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77 Appendix B: Sample Parenting Stress Index-Short For m Items (Copyrighted Material) Strongly Agree Agree Not Sure Disagree Strongly Disagree I often have the feeling that I cannot handle things very well. 5 4 3 2 1 There are quite a few things that bother me about my life. 5 4 3 2 1 Sometimes I feel my child doesn’t like me and doesn’t want to be close to me. 5 4 3 2 1 My child gets upset easily over the smallest thing. 5 4 3 2 1 My child makes more demands on me than most children. 5 4 3 2 1

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78 Appendix C: Being A Parent – Mother (Measure: Paren ting Sense of Competence) Name: _____________________________________________ Date: ______________ Listed below are a number of statements. Please res pond to each item, indicating your agreement or disagreement with each statement in th e following manner. If you strongly agree, circle the letters SA If you agree, circle the letter A If you mildly agree, circle the letters MA If you mildly disagree, circle the letter MD If you disagree, circle the letter D If you strongly disagree, circle the letter SD 1. The problems of taking care of a child are eas y SA A MA MD D SD to solve once you know how your actions affect your child, an understanding I have acquired. 2. Even though being a parent could be rewarding, S A A MA MD D SD I am frustrated now while my child is at his/her Present age. 3. I go to bed the same way I wake up in the SA A MA MD D SD morning – feeling I have not accomplished a whole lot. 4. I do not know what it is, but sometimes when S A A MA MD D SD I’m supposed to be in control, I feel more like the one being manipulated. 5. My mother was better prepared to be a good SA A MA MD D SD mother than I am. 6. I would make a fine model for a new mother SA A MA MD D SD to follow in order to learn what she would need to know in order to be a good parent. 7. Being a parent is manageable, and any problems S A A MA MD D SD are easily solved. 8. A difficult problem in being a parent is not SA A MA MD D SD knowing whether you’re doing a good job or a bad one. 9. Sometimes I feel like I’m not getting SA A MA MD D SD anything done.

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79 Appendix C: (Continued) 10. I meet my own personal expectations for SA A MA MD D SD expertise in caring for my child. 11. If anyone can find the answer to what is SA A MA MD D SD troubling my child, I am the one. 12. My talents and interests are in other areas, SA A MA MD D SD not in being a parent. 13. Considering how long I’ve been a mother, SA A MA MD D SD I feel thoroughly familiar with this role. 14. If being a mother of a child were only more SA A MA MD D SD interesting, I would be motivated to do a better job as a parent. 15. I honestly believe I have all the skills necess ary SA A MA MD D SD to be a good mother to my child. 16. Being a parent makes me tense and anxious. SA A MA MD D SD

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80 Appendix C: (Continued) Being A Parent – Father (Measure: Parenting Sense o f Competence) Name: _____________________________________________ Date: ______________ Listed below are a number of statements. Please res pond to each item, indicating your agreement or disagreement with each statement in th e following manner. If you strongly agree, circle the letters SA If you agree, circle the letter A If you mildly agree, circle the letters MA If you mildly disagree, circle the letter MD If you disagree, circle the letter D If you strongly disagree, circle the letter SD 1. The problems of taking care of a child are eas y SA A MA MD D SD to solve once you know how your actions affect your child, an understanding I have acquired. 2. Even though being a parent could be rewarding, S A A MA MD D SD I am frustrated now while my child is at his/her present age. 3. I go to bed the same way I wake up in the SA A MA MD D SD morning – feeling I have not accomplished a whole lot. 4. I do not know what it is, but sometimes when S A A MA MD D SD I’m supposed to be in control, I feel more like the one being manipulated. 5. My father was better prepared to be a good SA A MA MD D SD father than I am. 6. I would make a fine model for a new father SA A MA MD D SD to follow in order to learn what he would need to know in order to be a good parent. 7. Being a parent is manageable, and any problems S A A MA MD D SD are easily solved. 8. A difficult problem in being a parent is not SA A MA MD D SD knowing whether you’re doing a good job or a bad one.

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81 Appendix C: (Continued) 9. Sometimes I feel like I’m not getting SA A MA MD D SD anything done. 10. I meet my own personal expectations for SA A MA MD D SD expertise in caring for my child. 11. If anyone can find the answer to what is SA A MA MD D SD troubling my child, I am the one. 12. My talents and interests are in other areas, SA A MA MD D SD not in being a parent. 13. Considering how long I’ve been a father, SA A MA MD D SD I feel thoroughly familiar with this role. 14. If being a father of a child were only more SA A MA MD D SD interesting, I would be motivated to do a better job as a parent. 15. I honestly believe I have all the skills necess ary SA A MA MD D SD to be a good father to my child. 16. Being a parent makes me tense and anxious. SA A MA MD D SD

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82 Appendix D: Behavior Problem List (Measure: Annoyin g Behavior Inventory) Please read this list of common childhood behavior problems. Give a number from 0 to 3 for how annoying the behavior would be for you if your child acted this way. A rating of 0 would mean that the behavior is not annoying for you. A rating of 3 would mean that the behavior is very annoying to you. How Annoying Is It? Not Annoying Slightly Annoying More Annoying Very A nnoying 0 1 2 3 1. Always wanting their own way 2. Arguing with friends 3. Arguing with brothers or sisters 4. Biting others 5. Crying for no good reason 6. Dawdling/Stalling/Taking too much time to do things 7. Defiance (not wanting to do what they are told) 8. Destructiveness (e.g., destroying property) 9. Fighting with friends 10. Fighting with brothers or sisters 11. Fire-setting 12. Hitting others 13. Hurting pets or other animals 14. Irritability/grouchiness 15. Jumping on furniture 16. Kicking others 17. Lying 18. Nagging 19. Namecalling 20. Noisiness/Being Loud 21. Noncompliance (not doing what you ask) 22. Not eating at meal time 23. Pushing others 24. Pouting 25. Rough play 26. Running away 27. Slamming doors 28. Stealing 29. Talking back or arguing with parents/teachers 30. Talking mean to others (e.g., “you’re stupid”) 31. Teasing 32. Temper tantrums 33. Verbally threatening others (e.g., “I’m going to get you”) 34. Using bad language (cursing or swearing) 35. Whining 36. Yelling

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83 Appendix E: Inventory of Attitudes Toward Seeking M ental Health Services The term professional refers to individuals who have been trained to dea l with mental health problems (e.g., psychologists, psychiatrists social workers, and family physicians). The term psychological problems refers to reasons one might visit a professional. Similar terms include mental health concerns emotional problems mental troubles and personal difficulties For each item, indicate whether you disagree (0), somewhat disagree (1), are undecided (2), somewhat agree (3), or agree (4): Disagree Agree 1. There are certain problems which should not be discussed outside of one’s immediate family. 0 1 2 3 4 2. I would have a very good idea of what to do and who to talk to if I decided to seek professional help for psychological problems. 0 1 2 3 4 3. I would not want my significant other (spouse, partner, etc.) to know if I were suffering from psychologica l problems. 0 1 2 3 4 4. Keeping one’s mind on a job is a good solution for avoiding personal worries and concerns. 0 1 2 3 4 5. If good friends asked my advice about a psychol ogical problem, I might recommend that they see a professi onal. 0 1 2 3 4 6. Having been mentally ill carries with it a burd en of shame. 0 1 2 3 4 7. It is probably best not to know everything about oneself. 0 1 2 3 4 8. If I were experiencing a serious psychological problem at this point in my life, I would be confident that I could find relief in psychotherapy. 0 1 2 3 4 9. People should work out their own problems; gett ing professional help should be a last resort. 0 1 2 3 4 10. If I were to experience psychological problems I could get professional help if I wanted to. 0 1 2 3 4 11. Important people in my life would think less o f me if they were to find out that I was experiencing psychologi cal problems. 0 1 2 3 4

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84 Appendix E: (Continued) 12. Psychological problems, like many things, tend to work out by themselves. 0 1 2 3 4 13. It would be relatively easy for me to find the time to see a professional for psychological problems. 0 1 2 3 4 14. There are experiences in my life I would not d iscuss with anyone. 0 1 2 3 4 15. I would want to get professional help if I wer e worried or upset for a long period of time. 0 1 2 3 4 16. I would be uncomfortable seeking professional help for psychological problems because people in my social or business circles might find out about it. 0 1 2 3 4 17. Having been diagnosed with a mental disorder i s a blot on a person’s life. 0 1 2 3 4 18. There is something admirable in the attitude o f people who are willing to cope with their conflicts and fe ars without resorting to professional help. 0 1 2 3 4 19. If I believed I were having a mental breakdown my first inclination would be to get professional attention. 0 1 2 3 4 20. I would feel uneasy going to a professional be cause of what some people would think. 0 1 2 3 4 21. People with strong characters can get over psy chological problems by themselves and would have little need f or professional help. 0 1 2 3 4 22. I would willingly confide intimate matters to an appropriate person if I thought it might help me or a member of my family. 0 1 2 3 4 23. Had I received treatment for psychological pro blems, I would not feel that it ought to be “covered up.” 0 1 2 3 4 24. I would be embarrassed if my neighbor saw me g oing into the office of a professional who deals with ps ychological problems. 0 1 2 3 4

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85 Appendix F: Parental Demographic Form Please complete the following: 1. This form is being completed by a: ___Mother ___Stepmother ___Adoptive mother ___Father ___Stepfather ___Adoptive father ___Guardian ___Other 2. What is your age? ___ 3. What is your race/ethnicity? ___Caucasian ___Black/African American ___Hispani c ___Asian ___Other (please specify:____________) 4. What is your marital status? ___Married ___Single, living with partner ___Singl e, no partner ___Separated ___Divorced and remarried ___Divorced and not remarried ___Widowed ___Other (please specify:_______________ _) 5. How many children (biological, stepchildren, an d other children) are presently living in your home? ___ 6. List the ages and gender of the children who ar e presently living in your home Child 1: age ____ gender ____ Child 2: age ____ gender ____ Child 3: age ____ gender ____ Child 4: age ____ gender ____ Child 5: age ____ gender ____ 7. In all, how many children (biological, stepchil dren, and others) do you have? ________ 8. List the birth date of your child closest in ag e to 8 years old: __________________ 9. Input the initials of your child closest in age to 8 years old: ___________________ 10. What is the gender of your child closest in ag e to 8 years old? ____ Male ____ Female

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86 Appendix F: (Continued) 11. What is your employment status? ____ Employed ____ Unemployed ____ Retired ____ Student ____ Other 12. If you are employed, please state your occupat ion: ________________________________ 13. What is your spouse’s employment status? ____ Employed ____ Unemployed ____ Retired ____ Student ____ Other 14. If your spouse is employed, please state his/h er occupation: __________________________ 15. Enter your years of education (e.g. High Schoo l = 12 years, Four year college = 16 years, etc): _____________ 16. Enter your spouse’s years of education (e.g. H igh School = 12 years, Four year college = 16 years, etc): ______________ 17. What percentage of your professional involveme nt is spent working with children (0100%)? ______ 18. On a scale of 1-10, where 1=Not at all and 10= A lot, how much experience have you had with children other than your own (either in a work or personal capacity)? ______ 19. On a scale of 1-10, where 1=Not at all and 10= A lot, how much exposure have you had to children (including your own) with emotional or behavioral problems or other psychological, learning, or social problems? ______ 20. What is the average number of hours per week y ou spend at work and/or school, including commuting time? ______ 21. In an average week day, how much time do you s pend with your child(ren) during waking hours? ______

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87 Appendix F: (Continued) 22. In an average weekend day, how much time do yo u spend with your child(ren) during waking hours? ______ 23. Has either of your child(ren)’s parents receiv ed mental health services (such as therapy, counseling, or medication) in order to dea l with something that was psychologically distressing? ______ Yes _______ No If Yes : Please note who received the services, what type of services were received (e.g., psychiatrist, pastoral counseling, etc.), and how l ong ago the services were received. ___________________________________________________ _____________________ ___________________________________________________ _____________________ Evaluate your treatment experiences (i.e. were they positive or negative?) ___________________________________________________ _____________________ ___________________________________________________ _____________________ 24. Have any of your children received mental heal th services in order to deal with something that was psychologically distressing? __ ____ Yes ______ No If Yes : Please note who received the services, what type of services were received, and how long ago the services were received. ___________________________________________________ _____________________ ___________________________________________________ _____________________ Evaluate your treatment experiences (i.e. were th ey positive or negative?) ___________________________________________________ _____________________ ___________________________________________________ _____________________ 25. In lieu of payment or rewards, a donation of $ 1 will be made to one of the below charities for your participation in this study. Please choose which charity you wish a donation to be made to: ____ Judi’s House ( www.judishouse.org ): Helps children and families who are grieving the death of a loved one. ____ Make a Wish Foundation ( www.wish.org ): Grants the wishes of children with life threatening illnesses. ____ World Vision ( www.worldvision.org ): Helps children, families, and communities worldwide suffering from poverty or injustice.

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About the Author Jessica Curley Hankinson received a Bachelor’s Degr ee with High Distinction in Psychology from the University of Virginia in 2001. At the University of Virginia she was named a member of the Phi Beta Kappa Honor Soci ety. She entered the Clinical Psychology Ph.D. program at the University of South Florida in 2003. She received her Master’s Degree in 2006 and her Doctoral Degree in 2009. While in her Ph.D. program, Jessica co-authored several publications and presen ted several poster and paper presentations at regional, national, and internatio nal conferences. Jessica completed her pre-doctoral internship at the Kennedy Krieger Inst itute and the Johns Hopkins School of Medicine and received a post-doctoral fellowship at the same institution.