The authors examined
racial/ethnic differences in pathways from maltreatment exposure to specialty
mental health service use for youth in contact with the Child Welfare system.
Participants included 1600 non-Hispanic White, African American, and Latino youth
(age 4–14) who were the subjects of investigations for alleged maltreatment and
participated in the National Survey of Child and Adolescent Well-Being.
Maltreatment exposure, internalizing, and externalizing problems were assessed
at baseline and subsequent specialty mental health service use was assessed one
year later. Maltreatment exposure predicted both internalizing and
externalizing problems across all racial/ethnic groups, but non-Hispanic White
youth were the only group for whom maltreatment exposure was linked with
subsequent service use via both internalizing and externalizing problem
severity. Only externalizing problems predicted subsequent service use for
African American youth and this association was significantly stronger relative
to non-Hispanic White youth. Neither problem type predicted service use for
Latinos. It is likely that individual, family, and system-level factors
converge to link African American youth with externalizing problems to
services, but not as responsive in linking African American and Latino youth
with internalizing problems to services...
For all racial/ethnic groups, we hypothesized that
maltreatment exposure would be a strong predictor of both internalizing and
externalizing problems, which was supported by our findings. We also expected
that there would be a strong correlation between internalizing and
externalizing problem severity in this high-risk population, which was also
supported by our data. While our model considered the potential direct
association between maltreatment exposure and MHS use, we predicted that
maltreatment exposure would be indirectly linked to MHS via child
emotional/behavior problems. Given the foregoing evidence suggesting
racial/ethnic disparities in MHS use as a function of problem type for youth in
contact with CW, we further hypothesized that these indirect pathways to care
would differ for racial/ethnic minority youth, which also supported by our
data. Specifically, although maltreatment exposure significantly predicted both
internalizing and externalizing problem severity across all racial/ethnic
groups, non-Hispanic White youth were the only group for whom both types of
problems significantly predicted subsequent specialty MHS use. Only
externalizing problems predicted subsequent specialty MHS use for African
American youth and neither type of MH problem predicted service use for
Latinos. Thus, we found evidence of disparities in pathways from maltreatment
exposure to mental health service use that varied by problem-type and youth
race/ethnicity. Furthermore, while externalizing problem severity was a predictor
of specialty MHS use for both non-Hispanic White and African American youth, it
was a much stronger predictor for African American compared to non-Hispanic
White youth. Conversely, internalizing problem severity was a stronger
predictor of specialty MHS use for non-Hispanic White youth compared to African
American and Latino youth.
Taken together, these findings suggest a more
complicated association between race/ethnicity and MHS use than what is
suggested by research examining disparities without considering the type of MH
problem in question. These differential patterns may be explained by
individual, family, and system-level factors that lead to the particular
visibility of racial/ethnic minority youth with disruptive behavior as compared
to internalizing problems. However, the data and design of the current study
does not enable us to discern whether these racial/ethnic disparities are due
to differences in responsiveness on the part of the CW system in linking
certain youth with certain needs to specialty MHS, or whether individual and
family factors deter families from following through with MHS receipt.
It is likely that individual, family, and system-level
factors converge to influence problem-specific disparities in pathways from
maltreatment exposure to MH care for different racial/ethnic groups. Ethnic
minority youth are overrepresented in CW and juvenile justice (Crane & Ellis, 2004; Morton, 1999), where externalizing problems
are closely scrutinized. Disruptive behavior is also a robust predictor of
placement instability in CW (James, Landsverk, & Slymen, 2004), thus
more resources may be directed towards youths with externalizing problems to
support placement stability. CW workers may attend particularly to addressing
the externalizing behaviors of African American youth who, in general, are at
greater risk of placement instability and other negative CW outcomes. Data from
NSCAW I suggest that externalizing problems are systematically associated with
placement disruption for African American children but not for non-Hispanic
White children (Foster, Hillemeier & Bai, 2011). Perhaps
stronger linkages to effective care for disruptive behavior problems are all
the more important for African American children who are more vulnerable to
adverse system outcomes.
Yet, it may also be the case that individual and
family factors work to amplify system-level determinants of MHS use. Even if a
referral for MHS is made on the part of the CW system, racial/ethnic minority
parents may hold culturally-influenced perceptions of child MH problems (e.g.,
beliefs about causes) and MHS (e.g., mistrust, stigma,) that may dissuade or
encourage help-seeking (Cauce et al., 2002). These barriers may be
more pronounced in the identification of and help-seeking for internalizing
problems compared to externalizing problems in ethnic minority families (Gudiño et al., 2009). While child behavior
that is disruptive, oppositional, or defiant may run counter to cultural values
that emphasize respect, obedience, and deference to adults, internalizing
problems may not necessarily be at odds with such cultural values. The adult
distress threshold model of cultural influence (Weisz et al., 1988)
suggests that culture may influence perceptions of how serious a problem is and
decisions about what should be done. Because internalizing problems are already
less likely to lead to MHS use, relative to externalizing problems (Wu et al., 1999), the
presence of internalizing problems in racial/ethnic minority children may not
lead to sufficient distress to overcome a higher threshold for concern and the
aforementioned barriers to accessing mental health services.
Examining specialty MHS use prospectively, use of a
nationally representative sample of children in contact with the CW, and the
application of analytic methods to examine moderation and indirect effects are
notable strengths of this study. However, our results should be interpreted in
light of study limitations. First, we relied on parent-report for all study
variables and it would be important to replicate these results with
multi-informant methods. Second, while the use of a general maltreatment latent
variable is a strength in that it accounts for the complexity of exposure to
such adversity, the current study does not examine potential differences
related to specific forms of maltreatment. Third, although paths from
internalizing and externalizing problems to MHS use were in the predicted
direction, they were not statistically significant predictor of MHS use for
Latino youth. Despite the large nationally representative sample, uneven group
sizes could have impacted significance levels. For example, the relatively
smaller sample of Latino youth and the resulting larger standard errors for
estimates may have limited our ability to identify significant effects. Additional
research examining specific determinants of MHS use for Latino youth in contact
with child welfare is warranted. Fourth, we were unable to verify the Missing
at Random (MAR) assumption from our missing data estimation used in Mplus.
However, this concern is mitigated by the fact that there were few missing
data. Fifth, we defined service use as any contact with an outpatient specialty
MH provider and cannot comment on the effectiveness or quality of services.
Furthermore, although we assessed child behavior problems, we are unable to
specify the reasons families sought services. Lastly, while we examined overall
racial/ethnic group disparities in specialty MHS use, we were unable to examine
more proximal indicators of culture in our model due to limitations of the
NSCAW data set. Research is needed to refine our understanding of
enthnocultural factors impacting MHS use. Despite these limitations, these
results highlight concerning patterns of disparities that require further
study.
Gatekeepers of MHS, including those within the family
and the broader CW system, may be more likely to direct attention to
racial/ethnic minority youth with externalizing problems who are also at risk
of having poor CW system outcomes. Yet, this greater responsiveness to disruptive
behavior among African American children occurs in the context of disparities
whereby racial/ethnic minorities are less likely to receive services overall.
It stands to reason that racial/ethnic minority youth with clinical need that
does not include disruptive behavior may be driving the overall pattern of
disparities (Gudiño et al., 2012). Increased awareness of
these disparities as a function of problem type and increased awareness of the
negative impact of untreated internalizing problems is needed within CW. While
information provided to CW staff and families of children who come into the
system may be one important avenue for targeting disparities, efforts must also
focus on improving methods for identifying need and facilitating referral to
MHS. Efforts to support the implementation of evidence-based MH assessment
within CW and to examine the impact of these methods on disparities may help
ensure equitable linkage of vulnerable youths to MHS.
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