In contrast to our expectations, both parents and providers rated vignettes that mentioned Latino names to be more impaired and in need of service than the same vignettes with Anglo names. This effect, however, was concentrated in the mild severity condition. In fact, the severity manipulation had little effect on vignettes with Spanish names, whereas it had consistent effects for children with Anglo names in both parent and provider groups. The pattern of results, which was shown in , revealed that parents and providers both perceived Latino and Anglo children with severe problems to be equally impaired. This similarity in perceived impairment among Latinos and Anglos with serious severity was in sharp contrast to perceptions of need for service. Latinos with a more severe condition were judged as less in need of service than identical vignettes with Anglo names and serious severity. This result is congruent with the now well documented underutilization of mental health services for Latino children. By assigning significantly lower need of services to Latinos children in contrast to Anglo children who were previously judged to be equal in impairment, parents and providers show a pattern of judgments that would lead to unmet need.
The overall pattern of results are striking, especially when viewed together: a) Parents and providers view children with mild problems as more impaired if they are Latinos, and b) Latino children with more severe problems are less in need of services if they are impaired. It seems unlikely that our participants would endorse these statements explicitly, since they appear to be inconsistent. One might think that such inconsistent beliefs could be due to unfamiliarity with mental health service systems, but this explanation can not apply here. The providers are clearly experts in mental health, and the parents are all persons who have brought their own children to a mental health treatment center. How is it that they could have these beliefs for generic children described in vignettes?
It is possible that the results arose from implicit forms of prejudice and stereotypes that can operate without conscious intent or awareness (Devine, 2001
; Green et al., 2007
; Greenwald & Banaji, 1995
). Even those who explicitly renounce prejudice can have automatic biases that may be activated spontaneously from memory, without the perceiver’s intent. Given that Latinos are underrepresented and often negatively stereotyped in stories related to crime and violence in the media (Rivadeneyra, Ward, & Gordon, 2007
), the depiction of the Latino child in the vignette could be laden with the unconscious bias of gravity and importance and might therefore influence a higher severity judgment. We did not include measures of implicit biases, such as the IAT (Greenwald, McGhee, & Schwartz, 1998
), in this study but clearly this is a needed future direction.
The fact that Latino parents followed the same pattern as other parents assigning lower need for services to Latino children in the serious condition deserves special consideration. These caregivers, who are already engaged in a treatment plan for their own children, are likely to be aware of children’s psychiatric symptoms. They may, however, be uncertain about the prognosis of treatment, especially for Latinos. Alegría et al. (2004)
identified impairment as a diffuse signal to the caregiver, where they know “something is wrong” but do not know whether treatment would be beneficial. Accordingly, a caregiver’s decision to seek care requires an awareness of the impact of symptoms on the child’s functioning and a perceived benefit of mental health care.
A possible interpretation for provider judgments for impairment ratings might be related to patterns of disparity in service for Latino children. If mostly severe Latino children make it into treatment, this might lead practitioners to believe that Latino patients are generally more severe than Anglo patients, based on their biased sample of patients. Latino parents delay taking their children to services until their symptomatology is more severe. Therefore, providers might be rating Latino children as more impaired based on their own subconscious bias primed by prior clinical practice experience (Cohen & Cohen; 1984
). Subconscious bias occurs when a person’s membership in a target group automatically activates a cultural stereotype in the respondent’s memory regardless of the level of prejudice (Devine, 2001
). Why we would then also observe lower need for services for the Latino versus the Anglo child from providers, is of great importance and will require further investigation.
A result that replicated across all samples indicated that when the child was described as having an internalizing disorder, lower ratings were given for need for mental health services, medication and impairment. These findings emerged despite efforts to have the internalizing and externalizing vignettes balanced in terms of impairment. Our expert research clinicians assigned an average C-GAS of 50.37 to the internalizing vignettes and 50.44 to the externalizing vignettes. We also found an interaction such that Latino parents rated greater need for services and medications, to externalizing symptoms when compared to internalizing symptoms of equal severity. In a prior epidemiological study in Puerto Rico, meeting criteria for a disruptive disorder appeared to be an important factor in predicting caregivers taking their children to mental health services, rather than school services (Alegría et al., 2004
). The key was that the parent could identify behavior problems common to disruptive disorders as problems requiring professional mental health care. Teachers are possibly facilitators in this respect, in that disruptive disorders impact them directly and they might play an important role in informing the problematic behaviors to the parents, and in explaining potential consequences of such behaviors. In another study using race methodology to test teacher evaluations of student behavior, Chang and Sue (2003)
, found that teachers rated externalizing disorders significantly more serious and more likely to result in consultation and referral than internalizing conditions. Internalizing disorders such as depression or anxiety might only be identified by the child and not teachers or parents, explaining observations of lower ratings for these children.
In addition, we also found that parents saw girls as needing fewer medications, and providers assigning girls less need for mental health services than boys; a trend also observed in parents. Previous studies by our group have documented that boys used significantly more mental health services than girls (Cabiya et al., 2006
) and that they also met the criteria for disruptive disorders at a greater rate than girls (Canino et al., 2004
). Several investigators have hypothesized that boys are more likely to be referred for services because they exhibit higher rates of disruptive behavior and such behaviors are viewed as more difficult to manage by parents and teachers (Green, Clopton, & Pope, 1996
; Zwaanswijk, van der Ende, Verhaak, Bensing, & Verhulst, 2003
). Public policies should target the development of community resources such as parent education programs that identify internalizing problems that are more common in girls and difficult for parents, teachers and even providers to identify.
There are several notable limitations to the inferences that can be made from our results. First, we assessed ratings of mental health severity and need using vignette methodology. Rating a vignette and asking about mental health concerns might be quite different than noticing those same symptoms described in everyday life. While this is a limitation, there are several studies that suggest that vignette information may still be valuable. Some reports support the use of case vignettes to assess clinical decision making by physicians (Jones, Gerrity & Earp, 1990
; Schulman, Ohishi, Park, Glick, & Eusenberg, 1999
). In two studies of the external validity of case vignettes, assessments made on the basis of written case descriptions correlated highly with those made on the basis of examinations of patients with equivalent symptoms seen in person (Kirwan et al., 1983a
). Vignettes also offset some other problems in obtaining information, such as social pressure to adjust explicit attitudes to follow norms and conventions. They also allow strict control of the amount and order of information provided about each hypothetical child. Nonetheless, we worried about how artificial the vignettes might seem. To provide an insight into the vignette rating process, we asked a sample of parents to complete open ended questions about what they were thinking when they were rating each vignette. Typically parents reported that the child depicted in the vignette reminded them of their own children or of others they knew.
Related to the possible artificiality of vignettes was a concern expressed by one reviewer that the placement of the child’s name in the first vignette sentence could overstate the importance given to the ethnicity variable. The impact of the placement of ethnic information in the vignette is an empirical question that we can not address here, but we believe that the child’s gender and ethnicity would be among the first bits of information an adult (whether another parent or a provider) would perceive and thus the name conveying this information did have a prominent place in our design.
Another important limitation of the present report is that we collected judgments from a non-probabilistic convenience sample both for parents and providers. The parents had at least one child receiving mental health services. Although this focus assured us that parents would be knowledgeable about mental health symptoms or treatment, it clearly resulted in a sample that is not representative of all parents who might notice symptoms in their own child. While acknowledging that further research is needed with representative samples, we speculate that the ethnic effects observed in these parents who had overcome possible barriers to help seeking would be smaller than those observed with a representative sample of parents. Nevertheless, we recognize that probable differences exist between parents who have had personal knowledge with both the mental health system and with having their own child suffer from a mental illness in comparison to those that have not experienced either situation. Therefore an important extension of this study is to generalize the results to parents in general.
Similarly, the provider sample was not formally representative of all providers. Not only were there selection effects in the group that chose to provide data, the vast majority of our US provider sample provided services to Latinos as part of their practice. Would US providers that do not treat Latino children as part of their practice have the same severity rating for Latino child vignettes? This would be an informative question to pursue.
We also acknowledge as a limitation that Latinos are not a homogeneous group and that extending this study to other Latino nationalities i.e. Mexican-Americans, would be an added contribution. Therefore, future research with a population sample of providers and parents, with attention to demographic characteristics of both groups sampled will help address pending questions.