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Confronting barriers

September 1, 2006
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Many factors influence African-American children's involvement in mental health services

One in five U.S. children and adolescents suffers from a mental disorder.1 However, only 21% of U.S. youth identified as needing a mental health evaluation actually receive services from a mental health professional, leaving approximately 7.5 million U.S. children and adolescents with unmet needs for mental health services.

The data are particularly concerning for ethnic minority youth, who comprise a growing percentage of the U.S. population but are most often at risk for unmet mental health service needs.2–4 For example, African-American youth have been found to have a mental disorder prevalence of 21.9%, but only 3.2% of that group actually used specialty mental health services in a three-month period.5

Studies have explored correlates of service use, such as diagnosis, gender, “urbanicity,” and socioeconomic status.6 Other studies have investigated the role of religion and spirituality in mental healthcare service utilization. These constructs may influence parental decisions and actions regarding service utilization and treatment options (e.g., taking medications or utilizing community-based services recommended by a mental healthcare provider).7,8

African-Americans are at greater risk of poor access to treatment and poor care because of a higher likelihood of being without financial resources. The U.S. Surgeon General has indicated that approximately one in four African-Americans is uninsured, and nearly 22% of African-American families are living below the federal poverty level.9 Because of limited financial resources for prescription drug copays, for office visit fees, to compensate for wages lost to attend appointments, etc., many African-American families might find addressing mental healthcare needs to be a low priority when faced with more “immediate” needs.

For many African-American populations (as well as other ethnic minority groups in the United States) interactions with the healthcare system have been scarred by neglect, abuse, misrepresentation, and exploitation (the most famous case being the Tuskegee syphilis study). For many African-Americans it is difficult to trust a system that has failed and taken advantage of them over and over again. It is difficult to forget being treated as if you were less than a human being (such as with the Tuskegee study). From the authors' clinical and research experiences, documentation of African-Americans experiencing these day-to-day abuses in mental healthcare services is limited, but abuse is nonetheless present.

It might be difficult for European-Americans to understand just how wary African-Americans are about healthcare. With historically greater access to healthcare services, many European-Americans automatically trust the system and providers, which is not the case for African-Americans. And discrimination does not have to be overt; subtle service inequities based on socioeconomic and educational status also act as barriers to healthcare utilization.

As the research focus across the United States increasingly becomes more community-based, more researchers are interested in elucidating the barriers to mental health research and clinical care participation. However, this can be a catch-22, as the culturally diverse often have an appropriate level of skepticism about the provider's/system's intentions, ability, and motivation to respect their boundaries. They often ask, “Why are you now interested in working with me?” Although many clinicians/researchers genuinely may be interested in serving these populations, many African-Americans wonder if the driving force is money, since federal funding stipulates the inclusion of minority groups in research studies.

The impact of these negative past experiences with the healthcare system further affect today's African-American youth because parents with knowledge of misguided and abusive clinical research undertakings are reluctant to allow their youth to participate in clinical research trials.10 Stigma and lack of knowledge regarding the significance of mental healthcare likely solidify negative views.

The Christian church historically has served not only as a place of worship but also as a place to receive support, education, and direction regarding various facets of life, including healthcare decisions. Empirical research indicates that religious faith and the church community have a large effect on African-Americans’ perceptions of the mental healthcare system and service utilization.11,12

The church has provided counseling in a variety of circumstances to its parishioners (e.g., regarding domestic violence, drug abuse, and childhood disorders). This counseling traditionally has been based on spiritual health and religious faith as the means to a healthy mind, body, and spirit. In fact, more research is needed to investigate the role of religion as a source of social support in families of children with mental disabilities. This would assist both the mental healthcare and faith-based communities.