Mental Health: A Report by the Surgeon General

Although it is clear that an insufficient number of children receive mental health services, it is not clear whether utilization of services varies by race or ethnicity. The majority of studies have found that African Americans tend to use some mental health services, particularly inpatient care, more than would be expected from their proportion in the population. However, research findings are conflicting, probably due to divergent methodological approaches (Attkisson et al., 1995; McCabe et al., 1998; Quinn & Epstein, 1998). Furthermore, as Attkisson and colleagues (1995) point out, consistent with the study by McCabe and colleagues (1998), it is difficult to interpret these findings in the absence of epidemiologic data on the prevalence of a mental disorder in different racial and ethnic groups. Recent reviews of epidemiological findings concluded that present data are inadequate to determine the relationship between race or ethnicity and prevalence of a mental disorder (Friedman et al., 1996b; Roberts et al., 1998).

The task of understanding treatment patterns is made even more difficult because there are racial and ethnic differences in family preferences and family-initiated patterns of help-seeking (see also Culturally Appropriate Social Support Services). For example, parents from various cultural backgrounds have been found to differ in the degree to which they identify child behavioral and emotional problems as disturbed (Weisz & Weiss, 1991). Differences also have been found across cultural groups in their beliefs about whether these child problems are likely to improve in the absence of professional support. Weisz and Weiss (1991) have also identified cultural differences in the power of various children’s behavioral and emotional problems to motivate a parent’s search for professional help.

Differences also arise indirectly from the multiplicity of service systems with authority and responsibility for protecting the well-being of children. These systems have different criteria for initiating treatment and different patterns of utilization. African American children and youth are considerably more likely than those of other ethnic groups to enter the child welfare system (National Research Council, 1993). Their greater chances of having parents compelled to surrender them or of suffering abuse or neglect lead them in greater numbers to be referred to child welfare authorities, to be placed out-of-home, and to be involved with the child welfare system longer. Studies in one California county have found that African American youths are overrepresented in arrests, detention, and incarceration in the juvenile justice system, and in the schools they are overrepresented in educational classes for the severely emotionally disturbed. Hispanic/Latino children and youths are no more likely than whites to come under supervision of the child welfare system but, once involved, remain longer. They are also more likely than whites to be detained in juvenile justice facilities (McCabe et al., 1998).

As a group, Hispanic/Latino and African American children more often leave mental health services prematurely than do Caucasian children (Sue et al., 1991; Bui & Takeuchi, 1992; Takeuchi et al., 1993; Viale-Val et al., 1984). Many factors contribute to premature termination, such as insensitivity of mental health providers to the culture of children and families (Woodward et al., 1992). In general, even after demonstrated success with middle-class Caucasians, mental health treatments should not be applied without culturally appropriate modification to people from other cultures and races (Rosado & Elias, 1993).

Specialized programs and supports linked with the culture of the community being served have been found to be successful in promoting favorable patterns of service utilization for all ages (Snowden & Hu, 1997). It is becoming clear that the children and families served by mental health programs designed to be linked to community cultures are less likely to drop out of treatment compared with similar families in mainstream programs (Takeuchi et al., 1995). For example, Asian American children at an Asian community- or culture-focused program were found to use more services, drop out less often, and improve more than did Asian American children at mainstream programs (Yeh et al., 1994).

In summarizing the relationship between race and ethnicity, need for service, and use of service, Isaacs-Shockley and colleagues (1996) raised the concern that minority children are less likely to receive the care they need than nonminority children—a concern that should energize advocacy for the development of systems of care tailored to the needs of distinct cultures (Cross et al., 1989; Hernandez & Isaacs, 1998).

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