ABSTRACT Title of Thesis: ASIAN-AMERICAN IMMIGRANT PARENTS’ BELIEFS ABOUT HELPFUL STRATEGIES FOR ADDRESSING ADOLESCENT MENTAL HEALTH CONCERNS Kristen Marie Frese, Master of Arts, 2018 Thesis Directed By: Assistant Professor Cixin Wang, Department of Counseling, Higher Education, and Special Education The present exploratory, mixed-methods study explores Asian-American immigrant parents’ beliefs about helpful strategies for addressing youth mental illness (i.e., depression and eating disorders). Nineteen Asian-American immigrant parents (M=46.1 years, SD=3.9) completed closed-ended surveys and semi-structured interviews. Frequency counts were collected from the surveys on parents’ attitudes toward mental health services, products, and providers for the prevention and intervention of adolescent mental illnesses. The interviews were coded for themes using thematic analysis in order to explore parents’ beliefs about helpful strategies for addressing youth mental illness. Five primary strategies for addressing youth mental health concerns emerged: Providing social support; providing strategies to improve mental health; teaching adolescents about mental health; seeking help from professionals; and identifying the cause or diagnosing the problem. The roles that the school and culture play in each of those strategies is discussed. Implications are given for school-based mental health providers. ASIAN-AMERICAN IMMIGRANT PARENTS’ BELIEFS ABOUT HELPFUL STRATEGIES FOR ADDRESSING ADOLESCENT MENTAL HEALTH CONCERNS by Kristen Marie Frese Thesis submitted to the Faculty of the Graduate School of the University of Maryland, College Park, in partial fulfillment of the requirements for the degree of Master of Arts 2018 Advisory Committee: Assistant Professor Cixin Wang, Chair Associate Professor Matthew Miller Associate Professor Richard Shin © Copyright by Kristen Marie Frese 2018 Table of Contents Table of Contents .......................................................................................................... ii List of Tables ............................................................................................................... iii Chapter 1: Introduction ................................................................................................. 1 Guiding Theory ......................................................................................................... 3 Chapter 2: Literature Review ........................................................................................ 6 Mental Health Disparities in Asian-Americans ........................................................ 7 Mental Health Disparities in Immigrant Families ................................................ 8 Factors that Influence Mental Health Disparities ................................................. 9 Mental Health Literacy and Help-Seeking in Parents ............................................. 12 MHL and Help-Seeking in Asian-American Parents .......................................... 13 School-Based Mental Health Services for CLD Youth .......................................... 25 Asian-American Parent Perceptions of School-Based Mental Health Services . 27 Present Study .......................................................................................................... 27 Quantitative (Descriptive) Research Questions .................................................. 29 Qualitative Research Question ............................................................................ 29 Chapter 3: Methods ..................................................................................................... 30 Participants .............................................................................................................. 30 Quantitative Procedure........................................................................................ 31 Qualitative Procedure.......................................................................................... 31 Measures ................................................................................................................. 33 Demographics. .................................................................................................... 33 Mental Health Literacy (MHL). .......................................................................... 33 Attitudes Toward Help-Seeking. ........................................................................ 33 Data Analysis .......................................................................................................... 35 Quantitative Analysis. ......................................................................................... 35 Qualitative Analysis. ........................................................................................... 35 Chapter 4: Results ....................................................................................................... 38 Quantitative Results ................................................................................................ 38 Qualitative Results .................................................................................................. 39 Chapter 5: Discussion ................................................................................................ 64 Limitations and Future Directions .......................................................................... 78 Conclusions ............................................................................................................. 80 Tables .......................................................................................................................... 83 Appendices .................................................................................................................. 84 References ................................................................................................................... 93 ii List of Tables Table 1. Themes and Subthemes iii Chapter 1: Introduction Estimates show that 20% to 40% of youth experience psychiatric disorders and could benefit from mental health services; however, as many as 75% of youths do not have their mental health needs met (Becker, Buckingham, & Evangelista Brandt, 2015). Rates of unmet mental health needs and barriers to mental health care may be even higher among culturally and linguistically diverse (CLD) individuals (Garland et al., 2005; Yeh, McCabe, Hough, Dupuis, & Hazen, 2003). Asian-Americans are one of the largest and fastest-growing racial groups in the U.S. (Huang, Calzada, Cheng, & Brotman, 2012), yet are underrepresented in both mental health care (Gudino, Lau, & Hough, 2008) and the literature regarding it (Miranda, Nakamura, & Bernal, 2003; Office of the Surgeon General, 2001). However, this research is imperative, as studies indicate that Asian-Americans experience high rates of mental illness but are less likely to have their mental health needs met compared to White youth (Gudino et al., 2008; McCabe et al., 1999). A large contributor to racial disparities in mental health care is different rates of help- seeking in CLD groups compared to Whites, with CLD youth demonstrating significantly lower rates of help-seeking (Guo, Nguyen, Weiss, Ngo, & Lau, 2015). Help-seeking for psychological needs by CLD individuals can be impeded due to a variety of linguistic and cultural barriers, such as limited English proficiency and lack of understanding of the U.S. health care system (Coffman & Norton, 2010). Additionally, Asian-American adolescents may be less likely to communicate problems with their parents due to hierarchical family structure; They report more difficulty sharing personal problems with their parents, which may deter them from asking their parents for help with mental health challenges (Guo, Kataoka, Bear, & Lau 2014). This may prevent adolescents from seeking informal help from their parents or using their parents as a resource to seek more formal supports, such as from a psychologist or counselor. 1 Parent involvement in the help-seeking process is important, as adolescents may be hesitant or unable to seek help for themselves, and thus may rely on adults to seek appropriate services (Gudino, Lau, Yeh, McCabe, & Hough, 2009). Parents and caregivers play a vital role in recognizing signs of mental illness in their children and accessing treatment for their children, yet a substantial number of parents lack knowledge about mental illness and treatment options (Frauenholtz, Conrad-Hiebner, & Mendenhall, 2015). Mental health literacy (MHL), or knowing how, when, and from where to seek formal help from professionals, is particularly important for caregivers because when adolescents do seek help, they typically first reach out to members of their social network, such as friends or family (Gulliver, Griffiths & Christensen, 2010). Thus, parents may serve as gatekeepers to formal sources of help, including psychologists, psychiatrists, and general doctors. Other factors such as cultural views of mental illness, stigma related to mental illness and seeking treatment, and parent perceptions of mental health services influence whether a parent seeks help for their child. In particular, parents’ perceptions of activities and service providers that are helpful for treating or preventing mental illness in youth may influence the activities and services a parent promotes or utilizes for youth who are experiencing mental health challenges. However, there is limited research regarding immigrant or CLD parents’ perceptions of mental health services. The present work seeks to explore parental perceptions and attitudes toward mental health services for their adolescents, and how they think mental illness can be prevented. Of particular interest is Asian-American immigrant parents’ perceptions of school-based mental health services for their children, which is a topic that has received minimal attention in existing literature. The present exploratory study will add to the literature by exploring Asian-American immigrant parent MHL, specifically the components of symptom recognition, knowledge of and 2 attitudes toward providers/services, and knowledge regarding prevention of mental illness. Extant data from a mixed-methods study will be utilized to explore these areas of MHL. Guiding Theory The present study is guided by two primary theories: Cauce et al.’s (2003) help-seeking framework and the theory of MHL, a term coined by Jorm et al. (1997) to refer to one’s “knowledge and beliefs about mental disorders which aid their recognition, management, or prevention” (p. 182). The help-seeking framework includes three interconnected steps: recognizing the problem, deciding to seek help, and selecting the appropriate service (Cauce et al., 2002). This model emphasizes how culture impacts each step, which is important to consider as the present study utilizes a sample of CLD parents. In particular, this study utilizes Cauce et al’s (2002) model to consider how culture impacts the services that Asian-American parents would utilize for mental health concerns experienced by their children. MHL has been broken down into five components: knowledge of how to prevent mental disorders; recognition of the development of mental disorders; knowledge of help-seeking options and treatments; knowledge of self-help strategies for milder mental health problems; and skills to support others who are developing a mental disorder or are experiencing a mental health crisis (Jorm, 2012). An important component of MHL is having knowledge “that is linked to the possibility of action” (Jorm, 2012). Similarly, Kutcher, Wei, and Coniglio (2016) have expanded upon the definition of MHL to include “decreasing stigma related to mental disorders” and “enhancing help-seeking efficacy (knowing when and where to seek help and developing competencies designed to improve one’s mental health care and self-management capabilities)” ( p.155). MHL has been linked to positive attitudes towards seeking mental health services 3 (Cheng, Wang, McDermott, Kriedel, & Rislin, in press) and actual help seeking behavior (Bonabi et al., 2016) among adults, although less research has focused specifically on parents. Culturally responsive MHL. Culture plays an important role in MHL and can impact all of its components. Specifically, Asian-American immigrant parents’ culture can impact what mental health symptoms they find concerning in their children, from whom and where they seek support for their children’s mental health challenges, and their beliefs regarding prevention of the development of mental illness (Cauce et al., 2002). However, MHL typically adopts a “one-size- fits-all” approach, which assumes that the needs, experiences, and modes of service reception are similar for all individuals, regardless of race or ethnicity (Na, Ryder, & Kirmayer, 2016). In fact, Jorm (2012) acknowledges that MHL is a Western framework that utilizes an understanding of mental illness that may conflict with other cultures’ views of mental health. Thus, while prior studies have found Asian-American participants to have low MHL, these findings may simply demonstrate that individuals in these groups have different views and perceptions of mental health symptoms and appropriate treatment than those of Western ideals. For example, some Eastern Asian immigrants view mental health services as less relevant to their concerns because Western treatment focuses on symptom relief, rather than a holistic perspective that integrates social, emotional, and spiritual well-being (Kwong, Chung, Cheal, Chou & Chen, 2012). Similarly, mental health concerns such as depression and anxiety may be regarded as moral or personal problems which should be addressed by a family member, elder, or spiritual leader (Abe-Kim, Gong & Takeuchi, 2004). For these reasons, an Eastern Asian participant may say that meeting with a psychologist, participating in a support group, or taking antidepressants would not be helpful for an individual with depression. While the traditional MHL framework would state that this is incorrect or demonstrative of low MHL, a culturally responsive MHL 4 framework would posit that these beliefs are representative of the way in which Eastern Asian immigrants may seek help based on their perceptions of the problem, and thus are reflective of high MHL. Recent literature seeks to integrate knowledge of ethnocultural variations in symptom recognition or attribution and help-seeking into the MHL framework. Additionally, stigma related to mental illness is often highest in ethnically diverse groups (Clement et al., 2015) due to their distinct cultural beliefs and values. A culturally responsive MHL framework seeks to better understand the impact of culturally-based beliefs about mental illness that may be associated with increased stigma and decreased help-seeking of all forms (Na et al., 2016). The present study will explore MHL from a culturally responsive framework, rather than from a deficit-based approach which assumes that beliefs that are not consistent with Western ideals are incorrect or indicative of low MHL, to understand how a group of Asian-American immigrant parents view symptoms of mental illness and how or from where they would seek help if their children exhibited these symptoms. 5 Chapter 2: Literature Review Parents’ Role in Seeking Mental Health Treatment for Their Children Adolescence is a developmental stage which focuses on individuation and separation from one’s primary caregivers, as he or she forms close relationships with other adults and youth outside the family (Logan & King, 2001). However, this period is also significant for the marked increase in the prevalence of mental disorders (Kelly, Jorm, & Wright, 2007). The identification of psychopathologies in youth is crucial as treatment during adolescence can reduce instances of recurrent or persistent mental illness in adulthood (Logan & King, 2001). However, adolescents typically do not seek services or treatment on their own, and instead tend to be directed to services by their parents or other adults (Stiffman, Pescosolido, & Cabassa, 2004). One reason adolescents typically do not seek services for themselves is that they face many challenges in seeking help, including perceptual and pragmatic barriers. Many adolescents experience self- stigma related to experiencing mental health problems and fear lack of privacy or confidentiality (Lindsey, Chambers, Pohle, Beall, & Lucksted, 2012). These concerns can prevent adolescents from seeking help for themselves, but advice, encouragement, and guidance from an adolescent’s social network, including parents, can help promote the seeking of services (Stiffman et al., 2004). Practical barriers also prevent adolescents from seeking services and resources on their own. For example, seeking and receiving private sector mental health services often requires parent permission to access services and insurance (Stiffman et al., 2004), as well as parent coverage of transportation and cost of treatment. Considering the barriers adolescents face in seeking mental health services, parents play important roles in seeking mental health services for their adolescents. These roles include recognizing that there is a problem, identifying their child’s mental health need, deciding to seek 6 help for the youth, and seeking out the appropriate services or resources (Stiffman et al., 2004). Parent involvement is crucial, as youth mental health problems that are not detected or considered “serious enough” are unlikely to receive attention from parents, and hence, delay seeking treatment from professionals, such as mental health providers (Gudino et al., 2008). Parents may also play a role in treatment, including practicing learned skills at home, participating in the treatment, or working on their own mental health challenges to support the needs of their children (Stiffman et al., 2004). Parent involvement is one aspect that affects if, and from where, adolescents receive mental health services. In addition, race and ethnicity seems to play an important role in help-seeking and service utilization among both adolescents with mental health needs and their parents. Mental Health Disparities in Asian-Americans The mental health needs of Asian-American adolescents are often unmet, and mental health service utilization is not reflective of the prevalence of mental illness in this populations. McCabe et al. (1999) found that Asian/Pacific Islander Americans were underrepresented in community mental health services by approximately one half, compared to the size of the population. Overall, Asian-American youth with significant mental health challenges are less likely than White children to receive needed mental health services (Gudino et al., 2008), with 72% having unmet mental health needs (Yeh et al., 2003). Additionally, it is important to understand that immigrant children and U.S.-born children of immigrant parents may face different, or additional, mental health needs than their U.S.-born peers with U.S.-born parents. 7 Mental Health Disparities in Immigrant Families Existing literature suggests that immigrant parents may face additional challenges in regard to seeking mental health services for their children. Gudino et al. (2008) indicate that children of immigrant parents experience additional barriers to mental health services due to their parents’ increased likelihood of limited English proficiency, lower levels of formal education, lack of insurance, and poorer access to health providers. Due to these barriers, immigrant parents and their children may be less likely to receive the mental health care they need. Immigrant parents may also face challenges such as economic hardship and discrimination inherent in the acculturation process (The Urban Institute, 2006). Acculturation, or the process of adapting to new languages, customs, and social norms, is a large source of stress for immigrants, with implications for mental health (Choi, Miller, & Willbur, 2007). For example, a study by Li and Li (2017) found that Chinese immigrant parents most frequently perceived “acculturative stress” as a stressor in their children’s lives, such as having different cultural practices at home and school. One parent reported that youth may be “stuck in the middle” and confused by the different expectations and cultural practices between home, school and society (Li & Li, 2017). In addition, Asian immigrant parents and their children experience different rates of acculturation (Li & Li, 2017), and one study found that mothers who perceived a larger acculturation gap with their children reported having greater difficulty communicating with their youth than mothers who perceived a smaller acculturation gap (Buki, Ma, Strom, & Strom, 2003). Communication challenges between parents and their children may make identifying mental health challenges more difficult, as better communication increases parental identification of mental illnesses (Logan and King, 2002). Thus, the challenges that some immigrant parents 8 and adolescents in particular face may make recognizing mental illness and seeking appropriate treatment even more difficult than it is for families who are living in their country of origin. However, it is important to note that immigrant parents are extremely heterogeneous, and their experiences may be very different based on a number of circumstances, including the reason for immigration, how long the individual has been living in the United States, English proficiency, acculturation, and a variety of others. Thus, the experiences described in some of the studies above cannot be generalized to all immigrant parents. Rather, these experiences simply guide one’s thinking regarding immigrant parents’ experiences and attitudes, such that it is important to consider how immigration status is one factor that can influence mental health and the help-seeking process. Factors that Influence Mental Health Disparities Many factors influence mental health service utilization in Asian-American immigrants. According to Li and Seidman (2010), the disparities in mental health service engagement in Asian-American families compared to White families can be attributed to three main factors: different explanatory models for mental illness, stigma, and logistic and perceived barriers. These factors can help explain why Asian-American adolescents and parents are less likely to seek and utilize mental health services. The following sections will review how Asian- Americans may view mental illness, including cultural understanding and explanatory models of mental illness, and the associated stigma attached to these views. MHL also influences disparities in mental health service engagement and utilization, and this area will be further explored in later sections. Cultural understanding of mental illness. The ways in which a cultural group understands mental illness can impact if, and from where, members of the group seek help for 9 mental health challenges. Researchers have suggested that mental health is a culturally- constructed concept (Li, Friedman-Yakoobian, Min, Granato, & Seidman, 2013). Both cultural values and explanatory models of mental illness impact help-seeking decisions (Gudino et al., 2008; Li & Seidman, 2010). First, family structure and values in Asian-American culture seem to play an important role in adolescents’ and adults’ recognition and response to mental health challenges. Many Asian-American families can be classified as interdependent, which often means these families promote hierarchical family relations over individual autonomy (Gudino et al., 2008). Symptoms such as impulsivity, aggression, and noncompliance violate interdependent cultural expectations and are more easily identified than internalizing symptoms, such as withdrawal and depressed affect. Internalizing symptoms may not cause concern among familial elders, as characteristics such as quietness and deference are expected and sometimes valued in children (Gudino et al., 2008). In one study, CLD parents reported that they perceived themselves as placing more emphasis on their children having self-control and achieving academic success than did European American parents (Jambunathan, Burts, & Pierce, 2000). These expectations may make CLD parents less concerned by internalizing symptoms, and less likely to seek services for their children when they display these symptoms. Additionally, externalizing symptoms are more disruptive to the family unit and could be seen as shameful, leading adults to seek treatment and change for these behaviors. However, among Asian- American youth, rates of internalizing disorders are significantly higher than externalizing disorders (Huang et al., 2012), resulting in high levels of unmet need for Asian-American adolescents with internalizing problems (Gudino et al., 2008). Thus, the high levels of unmet psychological need in Asian-American youth, specifically in regard to internalizing disorders, 10 may stem from low rates of recognition or concern by parents and relatives, who may not recognize symptoms or know where to turn for help. A cultural group’s values regarding from whom they seek advice and guidance can influence rates of professional help-seeking. For example, when Asian-Americans do seek help, they typically report using self-help strategies, such as exercising or talking to friends, and prefer to seek help from friends and family or religious leaders rather than physicians or psychologists (Na et al., 2016). Similarly, Lin, Inui, Kleinman, and Womack (1982) found that Asian- American parents utilize formal mental treatment only as a last resort, and every attempt is made to deal with the problem within the family before seeking outside help. These cultural values may help to explain why fewer Asian-American adolescents seek and utilize professional mental health services compared to White adolescents. Explanatory models of mental illness. In addition to cultural values and expectations of youths’ behavior, explanatory models of mental illness influence whether people seek mental health treatment. Explanatory models of illness encompass a person’s beliefs about the nature, cause, severity, prognosis, and treatment preferences regarding a health problem (Kleinman, 1980). A commonly-held Westernized explanatory model of mental illness is the biomedical model, which posits that mental illnesses are brain diseases that can be treated pharmacologically (Deacon, 2013). In contrast, McCabe and Priebe (2004) found that ethnic minorities were more likely to cite supernatural causes of mental illness and were less willing to seek help than were White participants. Religious and spiritual beliefs held by Asian-American parents can greatly influence whether they seek help for their child’s mental illness, and from where they seek help (Wynaden et al., 2005). In particular, Asian-Americans may believe in Karma – the notion that every action has a consequence (Li & Seidman, 2010). Some Asian-American parents may 11 believe that the reason their child has a mental illness is because they or the grandparents have committed an unforgivable sin (Li & Seidman, 2010). Asian-American parents may also believe that “bad blood” from the mother can be blamed for the child’s mental illness (Wynaden et al., 2005). These ideas may make the holders of these beliefs more likely to seek help from sources such as religious and spiritual figures than from psychologists or doctors. These explanatory models of mental illness may also lead to more stigma and shame related to one’s child having a mental illness, and can help explain why Asian-Americans are more likely to seek informal help from their community, rather than from professionals, for mental health challenges (Wynaden et al., 2015; Miskimen, 2012). Community members may be more likely to share the same beliefs regarding the cause and treatment of mental illness, and parents may believe that mental health professionals are unable to help or understand the child’s and family’s struggles (Li & Seidman, 2010), perhaps due to cultural differences and different explanatory models of mental illness. There may be a lack of trust towards providers or individuals outside of the ethnic/racial community. These “outside” mental health providers may also overlook culture-specific psychological and behavioral factors among CLD adolescents due to their negative perception or lack of understanding of the community. Many of the beliefs and values described in the preceding sections are components of MHL, which plays an important role in parental help-seeking for adolescent mental health challenges. Mental Health Literacy and Help-Seeking in Parents Although studies suggest that parental factors strongly affect children’s access to mental health services, few have examined parents’ mental health literacy (MHL). MHL is defined as the “knowledge and beliefs about mental disorders which aid their recognition, management or prevention” (Jorm et al., 1997, p. 182). MHL has also been broken down into five components: 12 knowledge of how to prevent mental disorders; recognition of the development of mental disorders; knowledge of help-seeking options and treatments; knowledge of self-help strategies for milder mental health problems; and skills to support others who are developing a mental disorder or are experiencing a mental health crisis (Jorm, 2012). Kutcher et al. (2016) added stigma as an additional component to MHL. MHL is an important construct to study, as higher levels of MHL have been found to significantly predict increased likelihood of accessing services and using psychotherapy (Bonabi et al., 2016; Gulliver, Griffiths, & Christensen, 2010; Teagle, 2002). Furthermore, treatment retention is higher among children of all races whose parents identify the problem as mental health-related and recognize a need for help (Kazdin & Wassell, 2000). However, in the studies that specifically examine MHL in parents and caregivers, results suggest that parental MHL is low (Teagle, 2002; Moses, 2011), and may be even lower in CLD parents (Mendenhall & Frauenhlotz, 2013), which may contribute to lower help seeking rates for CLD youth. MHL and Help-Seeking in Asian-American Parents Research suggests that there are ethnic/racial differences in the levels of MHL. For example, Mendenhall and Frauenholtz (2013) found that MHL is lower among CLD adults, and MHL appears to be lower among CLD parents compared to their White counterparts. CLD parents are also reported to be less likely to expect mental health services to be helpful and more concerned about potential negative effects of these services compared to White parents (Gudino et al., 2009). However, these types of comparisons between Western and Asian groups may be culturally insensitive and are often based on the utilization of measures which are developed based on Western epidemiological definitions of mental health disorders, including symptoms rooted in the DSM paradigm (Cheng et al., 2018). Symptoms which are typically seen as 13 indicative of mental health disorders in the DSM may be perceived differently by other cultures, as mental health concerns are influenced by values and experiences of cultural groups. This concern regarding the cultural competency of the MHL framework is more salient in adults with limited English proficiency, as studies may report limited MHL in participants that stems from limited understanding of the language, rather than a lack of knowledge about the topic. Unfortunately, no MHL measures have been specifically developed for CLD individuals in the U.S. Despite these limitations, the following sections examine the existing literature regarding the components of MHL, with a focus on Asian-American adults. However, it is important to note that the existing literature regarding MHL among Asian-Americans is extremely limited, specifically in regard to Asian-American parents. Because most studies do not utilize a culturally-responsive model of MHL, there are important implications for the findings they present. These implications and limitations will be discussed. Recognition of the symptoms and development of mental disorders. Symptom recognition is one of the most researched components of MHL, and most studies have found that parents have a hard time recognizing symptoms of mental illness in their own children or in adolescent vignette characters. For instance, Teagle (2002) found that only 39% of parents of children with a diagnosed mental illness recognized the problem, and parents were more likely to recognize Attention Deficit Hyperactivity Disorder (ADHD) than other psychopathologies. In a similar study, Moses (2011) interviewed 70 parents of children receiving wrap-around services for mental health challenges and found that over a third of all parents were “uncertain” about recognizing symptoms of mental illness in their children. These parents directly and indirectly expressed uncertainty regarding the extent to which their child’s problems were indicative of 14 mental illness (Moses, 2011). Parents specifically have trouble identifying symptoms of internalizing mental disorders, such as depression, in their children. In fact, Logan and King (2002) found that 79% of parents with adolescents diagnosed with depression did not endorse a single symptom of depression in their children on the Diagnostic Interview Schedule for Children. These data support the role of parental identification of depression as a mediator between parent and adolescent characteristics and reports of mental health service use. Overall, the existing MHL literature suggests that many parents and caregivers lack the ability to recognize mental health disorders in their children and seek appropriate treatment. Prior research has found that CLD adults often do not recognize or report symptoms of mental illness (Coffman & Norton, 2010). In a study by Moses (2011), “minority” parents were less likely to use psychiatric terms when describing their children’s problems, indicating a lack of knowledge regarding mental illness and its associated symptoms. Parents may also struggle to identify symptoms of mental illness. For example, in a study of Chinese adults, only 30.2% and 25.5% of participants were able to identify child depression and adult depression, respectively, from vignettes (Gong & Furnham, 2014). Studies have also compared Asian and White participants’ ability to identify the main problem of characters in vignettes. Loo, Wong, and Furnham (2012) presented a variety of vignettes to participants from Britain, Hong Kong, and Malaysia. These authors found that, overall, the British participants were able to correctly label more psychiatric disorders from vignettes than participants from Hong Kong and Malaysia. Two thirds of British participants correctly identified depression from a vignette, followed by 65.7% of participants from Hong Kong, and 39.3% of participants from Malaysia. Adults with limited English proficiency may face additional challenges in regard to recognizing symptoms of mental illness and understanding how such disorders develop. One 15 study compared English proficient and limited English proficiency Asian-Americans with mental disorders and found that those with limited English proficiency were significantly less likely to identify a need for mental health care services (Bauer, Chen, & Alegria, 2010). This finding may reflect a lack of knowledge of the vocabulary related to mental illness and seeking services. For example, not all languages have words that mean “psychiatrist” or “schizophrenia,” thus making it challenging for someone who natively speaks a language that does not have words for these topics to be able to comprehend English vignettes and questions related to seeking mental health care services. Although the studies mentioned in this section examined Asian and Asian-American adults’ ability to recognize symptoms of mental disorders, the majority of studies do not classify adults as parents or non-parents, prohibiting us from fully understanding CLD parents’ ability to identify symptoms of mental disorders in youth. Knowledge of treatment options and perceptions of health providers’ helpfulness. Several existing studies have explored parents’ attitudes toward help-seeking for mental health challenges in their children, including parents’ perceptions regarding helpful resources, products, and service providers. Knowledge of and attitudes toward formal sources of help are important factors that contribute to if, and from where, people seek help for mental disorders (Jorm, 2012). Among the general public, many adults view informal sources of support, such as friends as family, more positively than formal sources of support, such as general doctors or psychologists (Jorm, 2012). Additionally, adults are more likely to view general professional help more positively than specialized mental health providers (Jorm, 2012). This may be related to stigmatized beliefs about mental health disorders and seeking treatment for psychological concerns. Adults may feel less stigmatized or embarrassed to see a provider who treats physical 16 problems than a provider who treats mental health problems. Additionally, in some cultures, there may be a lack of trust for mental health providers, leading adults to turn to informal sources of support or to well-known general doctors for mental health concerns. Although many adults prefer informal sources of support to formal sources of mental health treatment, previous studies have found that parents frequently endorse getting professional help for youth with mental illnesses. For example, Jorm, Wright, and Morgan (2007) read parents vignettes about adolescents with various mental illnesses and asked them to classify several options for help-seeking as helpful or harmful. These authors found that parents most frequently classified getting professional help for the youth and listening to/talking with/supporting the youth as helpful. When asked how they would help the vignette character if it were their child, 55 parents said they would encourage professional help from a doctor or physician, while only 3 parents said they would encourage professional help from a psychiatrist and a psychologist, respectively. This result is not surprising, given that many parents lack knowledge about mental health providers (Jorm, 2012). In a similar study by Jorm, Morgan, and Wright (2008), parents frequently expressed that talking to the youth firmly about “getting their act together”, as well as suggesting having a few alcoholic drinks, would be harmful for the youth in the vignettes. In both studies, parents were more likely than their adolescents to believe that seeking professional help and asking the youth if they were feeling suicidal would be helpful (Jorm et al., 2007; Jorm et al., 2008). Knowledge and attitudes regarding mental health treatment vary across age groups and cultures. Previous studies have found that particularly among CLD parents, mental health knowledge is low. For example, Mendenhall and Frauenholtz (2013) found that White caregivers had higher levels of knowledge regarding mental health treatment than did non-White caregivers. 17 Focus groups with Chinese-American women illuminated that participants had insufficient knowledge about the availability of mental health services in general (Tabora & Flaskerud, 1997). In addition to lack of knowledge, many CLD adults have negative attitudes toward seeking formal sources of help (Gong & Furnham, 2014). Kung (2004) surveyed 1700 Chinese American immigrants and found that half of the participants did not know where to seek help for mental health problems and 25% indicated skepticism regarding the credibility of mental health treatment. Existing studies have also compared participants from Western countries, such as the United States and Australia, to participants from Asian countries, including Japan, China, and Malaysia, in regard to their attitudes toward sources of help for mental disorders. One such study conducted by Jorm et al. (2005) compared Japanese and Australian adults and found that Australians were more likely to believe that a general practitioner would be helpful for someone with a mental illness, while Japanese participants were more likely to believe in getting help from informal sources of support, including family members. Similarly, Loo et al. (2012) found that for seven different mental illnesses, British participants were more likely than participants from Hong Kong and Malaysia to recommend professional help and were less likely to recommend social support or self-help strategies. These cultural differences may be explained in part by factors such as explanatory models of mental illness and cultural beliefs regarding mental illness and the best sources of help and support. For example, more collectivistic cultures may emphasize seeking help from family and friends over perceived strangers (i.e., unknown professionals). However, it is important to reiterate that these studies utilize Western measures to examine participants’ beliefs and fail to take into account the impact of differences in values, knowledge, and experiences between Western (predominantly White) and Asian participants. These results should not lead to conclusions that the White participants had correct views while 18 the Asian participants were incorrect. Rather, these results should be used to highlight differences in cultural values pertaining to the help-seeking process. Studies conducted in a variety of countries have found that many adults, regardless of race or ethnicity, have pessimistic beliefs about treatments from mental health professionals, including that services will not be helpful or effective (e.g., Burns & Rapee, 2006; Jorm & Wright, 2007), and have particularly negative attitudes towards psychiatric medication (Kovess- Masfety et al., 2007). These negative attitudes toward mental health treatment options are concerning, as ten Have et al. (2010) found higher perceived effectiveness of mental health care was associated with utilization of mental health services. However, mental health treatment that is rooted in Western psychology and philosophy may not be perceived as effective or valuable to individuals from different cultures, so it is important to also examine parents’ perceptions of informal sources of support, such as talking to religious leaders or participating in preferred activities, or sources of support commonly found in an individual’s culture or country or origin. While the literature suggests that Asian-American adults know fewer mental health providers and have more pessimistic views about them, this viewpoint fails to take into account that the studies ask participants about Westernized mental health providers. Based on my knowledge, no study asked participants about providers or services that are frequently used in the cultures of the participants. For example, when Chinese individuals experience symptoms of depression or anxiety, they may visit an elder or spiritual healer to discuss the problem and find ways to feel better (Abe-Kim, Gong & Takeuchi, 2004). The providers that are listed in these studies are almost always exclusively Western providers. Consequently, findings tend to show individuals from diverse background as having less knowledge and more negative beliefs about mental health providers. To better understand knowledge of treatment options and perceptions of 19 health providers’ helpfulness in Asian-American participants, it is important to either include traditional helpers from both cultures in the list of providers, or to ask open-ended questions such as “Who would you go to if you experienced the symptoms in the story?” Knowledge regarding how to prevent mental disorders. Much of the existing research regarding parent involvement in their children’s mental health revolves around identifying existing problems and seeking appropriate help. However, a less researched aspect of parent MHL is knowledge of actions that can prevent the development of mental disorders. Very few studies have asked participants to identify ways that mental illness can be prevented, and studies that have asked this question have revolved primarily around youth in countries outside the U.S. (e.g., Jorm, Morgan, & Wright, 2010). For example, Yap, Reavley, and Jorm (2014) asked adolescents and young adults in Australia to select from a list of seven activities that could prevent different mental illnesses ranging from depression to social phobia. The participants in this study most frequently endorsed “regular contact with family/friends” and “staying physically active” as activities that could prevent mental illness (Yap et al., 2014). In a similar study, Jorm et al. (2010) found that Australian youth were most likely to believe keeping regular contact with family and friends, making regular time for relaxing activities, and avoiding marijuana would be helpful in preventing depression. In a replication of this study, Jorm et al. (2012) found similar results, with youth focusing on the importance of family, friends, and relaxation. While the aforementioned studies focused on youth beliefs, Schomerus et al. (2008) conducted interviews with Germans of all ages to ask their beliefs about prevention of depression. These authors found that participants were most likely to believe stable friendships, participating in enjoyable leisure activities, and having family support could prevent depression (Schomerus et al., 2008). While some studies have examined parents’ beliefs regarding 20 prevention of adolescent mental illness (Yap & Jorm, 2012; Yap et al., 2014), they tend to focus on parenting strategies, rather than actions the adolescent can take. More research is needed to understand parent beliefs regarding prevention of mental illnesses, and specifically Asian- American parent beliefs. Knowledge of self-help strategies for mental health problems. Related to perceptions regarding helpful sources of support, many people view self-help strategies positively, and often as more helpful than psychotherapy (Jorm, 2012). Self-help strategies are “actions that a person can take on his or her own to deal with a mental disorder” (Jorm, 2012, p. 234) and include actions such as exercising, taking vitamins, talking to family and friends, or meditating. Parental knowledge of self-help strategies is important for adolescents with mental disorders, as they can encourage their children to partake in these activities, particularly if there are barriers to utilizing formal sources of support. Based on my knowledge, no studies have explored parental knowledge of self-help strategies for their adolescents. While there is a lack of literature addressing parental knowledge of self-help strategies that their adolescents can use, there is literature regarding knowledge of self-help strategies among adults in general. Studies have examined adult beliefs regarding self-help strategies for both clinical and sub-clinical mental health challenges. For example, Morgan, Jorm, and Mackinnon (2012) surveyed adults with sub-threshold depression from Australia, New Zealand, England, Ireland, Canada, and the United States and asked them to rate their frequency of usage and perceived helpfulness of 26 self-help strategies. Participants ranked getting out of the house, eating a healthy diet, and doing something enjoyable as their most frequently used self-help strategies (Morgan et al., 2012). The self-help strategies with the highest level of perceived helpfulness were exercising, engaging in an activity that gives a feeling of achievement, and doing 21 something enjoyable (Morgan et al., 2012). Similarly, studies of Australian and Canadian adults found that the general public in both countries believe that clinical depression can be helped by many self-help strategies, such as taking vitamins, participating in a physical activity, or doing courses in relaxation, stress management, or yoga (Jorm et al., 2005). Jorm et al. (2000) also found that Australians commonly used activities such as getting help from family and friends, taking time off work, and engaging in physical activity to deal with high levels of anxiety and depression. Mental health professionals and the general public often endorse similar self-help strategies, including activities such as maintaining a regular sleep schedule, doing something you enjoy, and eating a healthy diet (Morgan & Jorm, 2009; Jorm, 2012)). While the strategies from the aforementioned studies have focused on self-reported self-help strategies that would be helpful for participants, parents can also teach their children these strategies and promote the use of them. It is important to note that parents should suggest that their children engage in these types of activities when mental health symptoms are mild; Parents should also recognize when adolescent mental health challenges require treatment beyond self-help strategies, including professional, formal treatment (Kitchener & Jorm, 2002). Skills to support others who are experiencing mental health challenges. While some mental disorders are mild and can be treated through self-help strategies and informal sources of support, other disorders may require formal treatment to lessen symptomology and prevent worsening of the illness. A crucial component of MHL is a person’s ability to support others who are experiencing mental health challenges or crises. Providing this assistance to others has been termed “mental health first aid” (Kitchener & Jorm, 2002). Mental health first aid can be broken down into five key elements, ranging from listening nonjudgmentally to encouraging the person 22 to get professional help or utilize social supports and self-help strategies (Mental Health First Aid, 2016). Studies that have examined this component of MHL have presented different mental health scenarios and asked participants what they would do if the character was someone they knew and cared about (Jorm, 2012). In one such study, Jorm et al. (2005) found that the most common responses from adults were to encourage professional help-seeking and to listen to and support the person. These responses showed high levels of MHL and good knowledge of mental health first aid. However, participants also failed to mention other important aspects of mental health first aid, including assessing risk for an individual with suicidal ideation (Jorm et al., 2005). In a similar study, Jorm et al. (2008) found that parents and adolescents believed that it would be harmful to ask a young person with a mental illness if they were feeling suicidal. However, assessing risk of suicidality is an important element of mental health first aid (Kitchener et al., 2010). While few studies have specifically examined parental knowledge of mental health first aid, many studies of adolescents and young people have illuminated the importance of parent involvement in recognizing mental health concerns and seeking help for the youth. For example, Dunham (2004) asked adolescents in the United States to read a vignette about a student who was having suicidal ideation and asked what the student would do if the character was their friend. Responding to a vignette where the character explicitly stated that she wanted to die, only 62% of students said they would tell an authority figure (Dunham, 2004). This study reveals the importance of parent and adult MHL, as adolescents may not have the skills and knowledge to appropriately respond to mental health crises in their peers. Parents play an important role in recognizing signs of mental distress, including suicidality. Many factors influence one’s mental health first aid skills and knowledge, including knowledge of mental disorders and their 23 accompanying symptoms (Jorm et al, 2005) and prior experience with mental illness (Dunham, 2004). Additionally, in the study by Jorm et al. (2005), first aid responses were most appropriate in adults with less stigmatizing attitudes. Mental health stigma. An important component of MHL is low levels of stigma related to mental illness and receiving mental health treatment. Mental health stigma can be defined as “objectifying and dehumanizing a person known to have or appearing to have a mental disorder” (Mendoza, Masuda, & Swartout, 2015, p. 206). Self-stigma may influence one’s decision to seek help for themselves or for others (Cauce et al., 2002). Stigma not only may deter parents from seeking help for their children, but can decrease their involvement in the treatment process. Butler (2014) examined the correlation between shared decision-making and stigma and found that higher parent stigma significantly correlated with decreased shared decision-making, which is a parent’s involvement in making treatment decisions alongside the provider. Shared-decision making between a parent and a provider has been found to correlate with lower mental health impairment in children (Butler, 2014). Furthermore, there is an association between parent and adolescent stigma: High parental stigma regarding mental illness is associated with high stigma in their adolescents (Jorm & Wright, 2008). Thus, parental stigma not only inhibits the help- seeking process for youth mental health issues, but may also contribute to high stigma in children. Asian-American adults in particular report high levels of stigma regarding mental illness and seeing a psychologist, and this stigma serves as a deterrent from seeking help (Clement et al., 2015; U.S. Department of Health and Human Services, 2001). Asian-Americans frequently view mental illness as shameful and do not seek treatment to “save face” and avoid the associated stigma (Lee et al., 2008). In some Asian cultures, mental illness is thought to reflect 24 poorly on one’s family lineage and can negatively influence others’ beliefs regarding the stability and healthiness of the family (Office of the Surgeon General, 2001). A mixed-methods study of 701 young Asian women with a history of depression and suicidality found that both family stigma and community stigma led to underutilization of mental health services (Augsberger, Yeung, Dougher, & Hahm, 2015). Participants of this study stated that despite having mental health concerns about themselves, they did not seek help due to the perceived stigma in their culture, and would only seek help if it was kept confidential from their family and friends (Augsberger et al., 2015). Thus, it appears that low MHL and high rates of stigma both deter Asian-American parents from seeking help for their children and actively participating in treatment if it is sought. However, prior research has found that seeking mental health services at school may decrease the stigma that students and families feel when going to an unfamiliar setting for treatment (American Academy of Pediatrics, 2004). The following section will further explore school- based mental health services for Asian-American students, and the potential for these services to decrease racial disparities in help-seeking and service utilization. School-Based Mental Health Services for CLD Youth Prior research has shown that students with mental health needs who attend schools with school-based mental health services are more likely to be identified and to access mental health treatment than youths at schools without these programs (Juszczak, Melinkovich, & Kaplan, 2003; Leaf et al., 1996). One reason for this is that parents are not the sole gatekeepers to school- based mental health services, and children’s mental health issues can be identified early by school personnel who are able to make quick, efficient referrals to school-based services (Becker et al., 2015). Other factors, including ease of access to treatment and cost-free services, can help 25 explain why adolescents are more likely to utilize school-based services than community-based services (American Academy of Pediatrics, 2004). Additionally, students may feel less stigmatized seeking treatment at school rather than in the community (American Academy of Pediatrics, 2004), and some school-based programs actively work to decrease the stigma attached to seeking and utilizing mental health services (Schachter et al., 2008). By decreasing the barriers to accessing mental health services, “hard-to-reach” populations such as CLD students may specifically benefit from in-school services, as they are more likely to receive mental health services at school-based health centers than in community clinics (Farmer, Burns, Phillips, Angold, & Costello, 2003). Lyon et al. (2013) found that students and parents both reported that, regardless of race, youth utilized school-based mental health services more frequently than specialty or primary mental health services. School-based services can thus reach students who would otherwise not receive mental health care. Furthermore, once referred for school-based services, most Asian-American students accept the school-based mental health services provided to them, and appear to face few barriers in receiving care (Guo et al., 2014). Therefore, it appears that mental health services offered in schools may help increase service utilization in ethnic minority students. Because school-based mental health services can benefit CLD students and reach students who would not otherwise receive services, it is important that parents see these services as helpful and allow their children to participate in these services, as well as refer their children to school-based providers when problems arise. Parent perceptions of school-based services can greatly influence their decision to allow or prohibit their children from participating in these services. As such, the following section will explore the literature regarding parent perceptions of formal mental health services. 26 Asian-American Parent Perceptions of School-Based Mental Health Services Based on my knowledge, very few studies have specifically examined CLD parents’ perceptions of school-based mental health services. More research is needed to explore Asian- American parents’ perceptions of barriers to mental-health services, specifically within schools. In fact, existing literature suggests that Asian-American parents may be unaware that school- based mental health services exist, and parents who are aware may be hesitant to allow their children to utilize these services (Li & Li, 2017). For example, in Li and Li’s (2017) study, very few Chinese immigrant parents named psychologists as a source of support, and a few parents noted that they were unaware that mental health services were available at school. One parent who was aware of school-based mental health services stated that she would not want her child to use these services because she was concerned that her child would “lose face” if the counselor shared the matter with teachers or students (Li & Li, 2017). In addition, parent involvement in school-based mental health services may be hindered by unique factors, such as previous lack of involvement or connectedness with the school (Becker et al., 2015; Wang, Do, Frese, & Zheng, in press). Overall, Li and Li (2017) report that Chinese immigrant parents may not fully understand what psychologists do in school settings and how these services can help their children. In general, more research is needed regarding parents’ knowledge of school-based mental health services. Based on my knowledge, Li and Li’s (2017) study is the first to specifically ask parents about their perceptions of school-based mental health services. Present Study Most existing studies have examined MHL measured by symptom recognition (e.g., Cheng, Wang, McDermott, Kriedel, & Rislin, 2018), but very few studies explore other components of MHL, including knowledge of professional service providers, perception of 27 health providers’ helpfulness, and knowledge regarding prevention. Additionally, MHL related to eating disorders has not been well studied (Mond, Bentley, Harrison, Gratwick-Sarll, & Lewis, 2014), leaving gaps in our knowledge regarding parents’ knowledge, beliefs, and stigma towards eating disorder development, treatment, and prevention for their adolescents. The present study adds to the literature by exploring multiple components of parental MHL, specifically in regard to their knowledge and beliefs related to adolescent mental illness and related services among Asian-American immigrant parents. The joint focus of the present study on both depression and eating disorder knowledge will help fill gaps in the existing literature. Further, most of the existing literature regarding MHL in adults does not identify whether participants are parents, and studies that do provide this information typically do not examine parents’ race or ethnicity. It is important to study parent MHL because youth are unlikely to seek help for their own mental health challenges, making parents gatekeepers for problem identification and referral to proper services. While school-based mental health services can decrease barriers that both parents and adolescents face in seeking support for adolescent mental health challenges, few studies examine parents’ knowledge and beliefs about school-based services. Furthermore, studies that do identify participants as parents or by race have typically been conducted outside of the United States. Although Jorm and his colleagues have studied Australian parents’ attitudes toward help-seeking, little research has studied American parents’ attitudes, and even less literature exists exploring the attitudes of Asian-American parents. Because attitudes and experiences of parents in the U.S. may differ from parents in Australia, the existing literature may not be generalizable to parents living in the U.S. Further, prior research has shown that CLD parents have different attitudes than White parents regarding mental illness and help-seeking for adolescent mental health challenges (Li & Seidman, 2010). Relatedly, 28 researchers have argued that commonly used measures of MHL were developed based on Westernized epidemiological definitions of mental disorder symptoms, which may be perceived or evaluated differently by other cultures (Cheng et al., 2018). To my knowledge, no mental health literacy measures have been specifically developed for CLD individuals in the U.S. Thus, an important area for future research is the development and cross-cultural validation of mental health literacy measures (Cheng et al., 2018). The present study is the first step towards understanding MHL in Asian-American immigrant parents, particularly from a culturally sensitive MHL framework. The current work seeks to answer the following research questions. Quantitative (Descriptive) Research Questions 1. How do parents believe mental illness can be prevented? 2. What sources of support do parents believe are most helpful in the treatment of eating disorders and depression? Qualitative Research Question 1. What strategies do Asian-American immigrant parents think help to address mental illness in adolescents? 29 Chapter 3: Methods The current exploratory study utilized extant data from a mixed- methods study conducted in 2014-2015 to examine Asian-American immigrant parents’ perception of mental health providers and activities for youth with eating disorders and depression, and how they think mental illness can be prevented. Participants Participants included 19 Asian-American immigrant parents living in California who had at least one adolescent. The majority of the participants were mothers (n = 17, 89.5%). The parents ranged in age from 38 to 51 years (M = 46.1 years, SD = 3.9), and their adolescents ranged from 11 to 18 (M=14.6 years, SD=2.8). All participants were born outside of the U.S., in countries including China (n = 16), Taiwan (n = 2), and the Philippines (n = 1), and have been living in the United States between one and 40 years, with an average of 16.8 years (SD=11.1). Fourteen of the parents had been living in the U.S. for at least ten years. The participants were highly educated, with over half (n = 12, 66.7%) holding an advanced degree (master’s degree or higher). Nine parents shared that they had experienced mental health concerns in the past, and nine parents shared that their children had experienced mental health concerns. Seven parents stated that their children had received school-based mental health treatment. Procedure Data for this study came from a larger project which examined mental health literacy of youth, parents, and school personnel. Participants were recruited using convenience and snowball sampling methods. Recruitment fliers were posted in stores, restaurants, clinics, and at a large public university in California and were distributed through the university’s email listserv. Participants received a $10 gift card for participating in this study. 30 This study utilized a mixed-methods design including a survey and a semi-structured interview. Participants were first asked to fill out a survey either in person or online, and then participated in in-depth, semi-structured interviews to elaborate on their answers. The survey and interview will be further described in the following sections. The survey data allowed for a descriptive examination of parents’ ability to identify mental illness based on symptoms, attitudes toward helpful providers and services, and beliefs about the prevention of mental illness, and the interviews provided an opportunity for parents to discuss these areas of MHL in a more open-ended manner and to elaborate on their responses. Quantitative Procedure. Participants first completed a survey, which was administered by trained research assistants. The survey contained demographic questions and questionnaires to assess MHL, stigma, attitudes regarding help-seeking, and personal depression symptomology (see Appendix A). The survey also presented parents with two vignettes, with one describing an adolescent who exhibited symptoms of bulimia, and another describing an adolescent who exhibited symptoms of depression. These measures will be discussed in further detail in the “Measures” section. Qualitative Procedure. Following the completion of the survey, semi-structured interviews were conducted in person, over the phone, or via the web camera function in a popular software among Chinese Americans, to allow parents to elaborate on their responses and to answer open-ended questions. Interview questions were developed based on the MHL framework (Jorm et al., 2010; Yap & Jorm, 2012) and research on treatment engagement (Breland-Noble et al., 2010). The interviews 31 were conducted by trained research assistants and were audio-recorded and later transcribed and coded. Parents chose the language in which they were comfortable being interviewed. Of the 19 interviews, 13 were done in Mandarin, and six were conducted in English. Interviews conducted in Mandarin were transcribed and then translated into English by two native Mandarin speakers on the research team. They discussed the translation to ensure that it captured the essence of the original meaning. The interviews included questions regarding parents’ knowledge of symptoms related to eating disorders, depression, or anxiety, and how to help someone with these disorders (including their adolescents in a hypothetical situation). Participants were also asked to elaborate on and explain their reasoning behind their survey responses regarding which professionals (i.e. psychologist, teacher, religious leader) or activities (i.e. exercising more, smoking cigarettes) would be helpful, harmful, or neither for an adolescent with a mental illness. After re-reading the vignettes, parents were asked what activities, services, or providers would be helpful for the character, as well as what they would do if their child exhibited the symptoms from the vignettes. This allowed participants to mention options that were not included in the survey, such as individuals or services that are commonly utilized in participants’ native cultures or countries of origin. Finally, they were asked open-ended questions regarding what they thought could be done to prevent mental illness, and what they would do if their child had depression or an eating disorder. See Appendix B for the interview protocol. 32 Measures Demographics. The demographic questionnaire included in the survey asked questions regarding participants’ age, relationship to child (i.e. mother or father), highest level of education, race/ethnicity, country of origin, and number of years living in the United States. Mental Health Literacy (MHL). To assess parent MHL, participants read two case vignettes, which depicted one adolescent who exhibited symptoms of bulimia nervosa (e.g., LinLin; Hart, 2010) and one adolescent who exhibited symptoms of depression (e.g., WenWen; Jorm et al., 2010; Olsson & Kennedy, 2010; Yap & Jorm, 2012). After reading the vignettes, participants were asked to identify what they thought the character’s “main problem” was from a list of 14 problems. Participants were allowed to choose more than one correct answer. Answers were marked as correctly identifying the problem only if they selected “bulimia nervosa” and “depression” from the list of options for each respective vignette. Attitudes Toward Help-Seeking. Participants’ attitudes toward help-seeking were assessed by asking participants to rate whether they believed various people (i.e. psychiatrist, minister, family member), products (i.e. antidepressants, vitamins), and activities (i.e. psychotherapy, trying to deal with the problem alone, admission to a psychiatric ward) would be helpful, harmful, neither, or “I don’t know” for each vignette character. This measure was adapted from Jorm et al. (1997). 33 To expand upon their survey selections, participants were also asked open-ended questions to explore their attitudes toward help-seeking during the interview. Questions such as “If someone is struggling with an eating disorder/depression, what do you think are some appropriate forms of support or services for them?” and “Why do you think that provider/service would be helpful?” were asked so that parents could discuss help-seeking options that may not have been on the list of options on the survey and to provide an opportunity to explain why different sources of support would be helpful. Participants were also asked “What would you do if [the character from the vignette] was your child?” The answers to these interview questions contributed to the exploration of parental attitudes toward help-seeking. Participants were also asked in the survey to select from a list of options regarding ways in which they believe mental illness can be prevented (i.e. making regular time for relaxing activities, not using drugs). The present study adapted Jorm et al’s. (2010) and Yap and Jorm’s (2012) questionnaire by removing two of the original “distractor” items (i.e. avoiding sugary foods) and emphasizing school-based providers (i.e., school psychologist instead of community- based psychologist). During the interviews, participants were asked “How can eating disorders/depression be prevented? What can teachers or schools do to prevent eating disorder/depression?” These open-ended questions gave participants an opportunity to discuss preventative measures that may be common in their cultures or country of origins but were not listed in the survey, and to explain why these measures would be helpful in preventing the development of mental illness. 34 Data Analysis Quantitative Analysis. Descriptive statistics were used to examine the quantitative research questions. Parent responses to the survey questions regarding which activities and service providers would be helpful for an adolescent with depression or an eating disorder were counted for frequency. Frequency counts for parents’ perceptions of activities that can prevent mental illness were also collected. Qualitative Analysis. The present study utilized a thematic analysis procedure outlined by Braun and Clarke (2006) to investigate the qualitative research question. The research team which analyzed the data for the present study consisted of two PhD-level researchers who have conducted qualitative research and five graduate assistants. Three of the team members are Asian-American, including two Chinese-Americans, who helped to ensure that the interview data was analyzed and interpreted through an appropriate cultural lens. The coding process included two stages. In the first stage, a coding framework was determined, in which a priori categories were established based on three broad research questions: 1) What are the signs, symptoms, and causes of mental disorders that immigrant parents identified? 2) What are helpful strategies or ways of seeking help for mental disorders, as described by immigrant parents? and 3) What barriers to help-seeking do immigrant parents report? These three questions guided the three a priori codes that were used to initial coding (definition and contributing factors of mental health issues, helpful strategies or ways of seeking help, and barriers preventing help-seeking). 35 To ensure the coders understood the coding categories, the coders received training using a sample transcript. First, a list of coding rules with specific definitions was created and distributed to the coders. All members of the team coded the sample transcript by highlighting text segments that represented the three a priori codes. Intercoder reliability and agreement was calculated using Campbell, Quincy, Osserman, and Pedersen’s (2013) procedure, where percent agreement was made up of the number of matched lines divided by the total numbers of lines coded. After the team members independently coded the transcript, reliability was calculated to assess the effectiveness of the coding procedure and to identify areas which required additional training. The coders then met to discuss the transcript, including areas of disagreement and challenges that arose during the coding process. The coding rules were then revised to make them clearer, and the coders re-coded the sample transcript. Following the training, four coders began coding the English interviews and two coders who were fluent in Mandarin and English coded the Chinese interviews. In the first stage, 20% (n = 5) of the interviews were randomly selected and coded independently for the three a priori categories. After coding each transcript, the coders discussed areas of disagreement, attempted to reach a consensus, and recoded the transcripts. The final cumulative intercoder agreement across the five interviews was 86.3%. The remaining 13 transcripts were coded by two coders for the English interviews and two coders for the translated interviews using the same negotiated agreement process described above. If no consensus could be reached, an additional coder was involved in the discussion to settle disagreement. In the second stage, after all of the interviews had been coded for the three a priori categories, two coders returned to the interviews to examine lines coded as helpful strategies or ways of seeking help (including preventative efforts) and assign code labels that described or 36 captured the meaning of that segment. The English interviews were coded by two English- speaking coders, and the Chinese interviews were translated and then coded by one bilingual coder and one English-speaking coder to ensure that the meaning of the text segments were accurately captured. The labels were then extracted with the sample text segments and organized into an Excel file with broad themes and smaller subthemes that represent participants’ ideas about prevention and intervention for adolescent mental illness. Participants were assigned pseudonyms to protect confidentiality. To ensure that the themes accurately reflect parents’ beliefs about strategies for addressing youth mental health concerns, a member check was conducted with two parents. Both parents reviewed the themes and subthemes electronically and said that they capture their true beliefs. 37 Chapter 4: Results Quantitative Results Regarding parents’ ability to correctly identify mental illness based on symptoms described in the vignettes, less than one third (26.3%) of parents correctly identified bulimia, while three quarters (73.7%) of parents correctly identified depression from the case vignettes. Frequency counts were collected to examine what providers and activities parents thought would be most helpful in the treatment of eating disorders in adolescents. Participants reported that the most helpful providers would be a close friend (93.75%), a school psychologist (87.50%), and a family member (87.50%). The activities that parents thought would be most helpful for adolescents with eating disorders are getting advice about diet or nutrition (93.75%), getting information about problem eating and available services (93.75%) and receiving counseling (87.50%). To examine what sources of support parents believe are helpful for adolescents with depression, frequency counts for helpful providers, products, activities, and parent actions were collected. Participants were most likely to report that close friends (100%), school psychologists (92.86%), and teachers (71.43%) would be helpful providers. The most frequently reported helpful products were vitamins (57.14%) and antidepressants (50.00%). Participants reported that activities such as getting relaxation training (100%), reading a self-help book on the problem (92.86%), receiving therapy from a specialized professional (85.71%), and joining a support group of people with similar problems (85.71%) would be most helpful for an adolescent with depression. Lastly, when asked what actions they would take if their own children exhibited the symptoms from the depression vignette, participants reported that helpful actions would include encouraging the child to become more physically active (92.86%), suggesting the child get 38 professional help (85.71%), and making an appointment for the child to see a general doctor (71.43%). Finally, participants were asked to select which activities would be helpful for preventing mental illness. The three most common answers, which were all reported by 92.86% of participants, were keeping regular contact with friends, keeping regular contact with family, and making regular time for relaxing activities. Full results regarding frequency of helpful ratings for sources of support can be found in Appendix C. Qualitative Results Interview questions focused on what parents think would be helpful for adolescents with eating disorders or depression, what parents would do if their own child exhibited symptoms of eating disorders or depression, and how parents believe mental illness can be prevented. Five themes emerged from the analysis, and will be discussed below in order of the percentage of participants who mentioned each strategy at least once (see Table 1 for a full list of themes). The themes regarding what parents believe is helpful for addressing mental illness during adolescence include: Providing social support (94.7%); providing specific strategies to improve mental health (89.5%); teaching adolescents about mental health (63.2%); seeking help from professionals (63.2%); and identifying the cause or diagnosing the problem (57.9%). Each main theme also subsumes smaller, relevant sub-themes, which will be described in detail in the following sections to highlight the various ways in which these strategies can be helpful in both treating and preventing mental illness in adolescents. Percentages listed for each subtheme indicate the percentage of participants who mentioned each sub-theme at least once during the interview. Additionally, under each main theme I will explore how culture influences the 39 strategy suggested by parents, as well as the role of the school in utilizing these strategies to address adolescent mental health concerns. 1. Providing social support. Throughout the interviews, many parents talked about the importance of providing social support to adolescents, both to prevent mental illnesses from developing and to help individuals who are currently experiencing mental illness. Participants talked about a variety of forms of social support and many different individuals who could provide this social support to adolescents. Overall, parents mentioned strategies such as communicating about the problem (73.7%), paying attention to the adolescent’s mood or behavior (36.8%), providing a sense of belonging or security (31.6%), spending time with the adolescent (26.1%), sharing one’s own experiences (21.1%), and reducing stigma (5.3%). For each theme, the roles of culture and the school context will be discussed. Communicating about the problem. Almost all parents talked about the importance of communicating with youth, particularly about mental illness and problems that adolescents face. Parents discussed ways in which it would be helpful for individuals such as family members, friends, and professionals to talk to the adolescent about their problems. For example, one parent talked about how friends can be helpful: Sometimes close friends see there’s something wrong and help, [they] can say, ‘You’re not your normal self.’ So they can also influence or identify that, you know, there’s something wrong with them or also be there to have someone to talk to (Wendy). Parents also reported that talking to the youth about their experiences and concerns can provide an opportunity for expression of emotions, which can be cathartic. One mother, whose son would cry in the morning because he did not want to go to school, said “My son, he has a channel to express his emotions. He can talk to his mom. It is very dangerous if he feels that he 40 can talk to no one...After he talked about his feelings, he felt better” (Tiffany). Thus, having an outlet to express his feelings and talk about his concerns helped improve his mood. Additionally, parents talked about how communicating about the issue could lead to an open conversation about seeking help. When asked how to help an adolescent with depression or anxiety, one mother said: I think talking about it. I think addressing the issue is good, bringing it out in the light, in the open. Let’s talk about it in a loving and supportive way. And it’s important to not be judgmental and just lend a hand. ‘Do you want me to go to counseling with you?’ ‘Do you want me to find someone that you can talk to about it?’ Yeah, I think to offer assistance, to offer there’s a way out, that you’re not alone in this, to partner up with them to get some help (Michael). Thus, participants believe that communicating with adolescents about their experiences and concerns is an important aspect of providing social support as it allows the teenager to express his/her emotions and provides an opportunity to talk about ways to seek help. Paying attention. A common strategy that participants believe is helpful for addressing mental illness in adolescence is to pay closer attention to adolescents’ moods and actions. Specifically, when discussing what would be helpful in treating or preventing eating disorders, many participants talked about the importance of paying close attention to what their child is eating. One mother discussed ensuring her children are healthy by monitoring their food intake, stating “If parents pay attention to the food you eat, the kids will eat healthy, which decreases the chance that she is unhealthy...I think it has to be a balanced meal. You cannot go too extreme” (Lynn). A father echoed this sentiment, saying, “Parents usually care about their kids very much. They will notice the abnormality in diet very quickly” (Kevin). Thus, parents felt that by paying 41 close attention to their children’s diet, they could detect signs that the adolescent might be struggling with an eating disorder or a mental illness where appetite is affected, such as depression. In addition to paying attention to what their children eat, participants talked about the importance of paying attention to their children’s mood or behavior. One parent said, “I am that kind of person that pays a lot of attention [to my children]. I know when my daughter has mood swings or big changes in her mood” (Tina). Another parent talked about paying more attention to her own children after an increase in teenage suicide: “Recently there are news about teen suicide every year. I do not know the details. Maybe family and friend factors contribute to it. So I always carefully monitor my own children” (Kelly). This type of monitoring allows many parents to feel confident that they will notice when changes in mood and behavior arise and will be able to determine if the child needs help. For example, a father said, “I will notice her situation right away. I will ask family members including myself to pay more attention to this issue and think of ways to address her situation” (Kevin). Providing a sense of belonging/security. Next, some participants discussed how providing a sense of belonging or security is an important aspect of social support which is helpful for addressing mental illness. One parent talked about the importance of friendship, suggesting that parents should “Encourage people to make friends and to communicate with each other…[if] you have friends in [the] U.S., that makes you feel secure” (Hannah). This parent believed that having friends makes youth feel less isolated, which can decrease negative feelings which may be associated with mental illness. This is particularly important for immigrant families, who may know very few people in their new country. Thus, parents feel that in order 42 for their children to adjust to the U.S. environment and be healthy, they must make friends and feel like they belong. Participants also talked about how religious institutions can provide a sense of belonging: “Also attending religious group or churches is a good way too. They have their small group and meetings. They can resolve helpless feelings, empower each other and create good environment. I think all these things can be helpful” (Hannah). In particular, many parents felt that attending a Chinese church provides an opportunity for immigrants to socialize and make friends in a new country. Forming a social network with individuals from one’s home country was important to parents, and several discussed the positive influence that other immigrant families have on one another as they provide a sense of belonging and can support each other. Parents felt that this social support can help teenagers feel happier and healthier. Spending time together. Some parents talked about the importance of spending time with their adolescents as a strategy for providing social support. Participants talked about the ways in which spending time together can improve adolescents’ moods, parent-child connections, and adolescents’ mental states. One parent discussed how spending time as a family helps her son feel less worried about stressful situations, such as waiting to find out about college acceptances. She said, “When my son is very unhappy, we play cards together as a whole family. He laughs and feels better” (Hannah). Another participant talked about how he would want to spend more time with his child if he discovered they were experiencing symptoms of a mental illness because this would allow him to help the adolescent adjust their state of mind: After I find out this issue, [I would] need to spend more time with him. I mean, I have to find ways to help him deal with or resolve his mental ideation. Friends and family can spend more time with him and talk to him more to help him adjust his thoughts or mental 43 state (Kevin). Sharing experiences. Similarly to communicating about the problem, parents believe that sharing experiences with adolescents is a valuable form of social support which can be helpful in preventing and addressing mental illness. Some participants felt that when other people share their experiences of mental illness or specific concerns with an adolescent, he or she will feel less isolated and will be able to learn about resources or activities that have been helpful for other people. When talking about what would be helpful for a vignette character with bulimia, one parent said: Well, knowing what’s out there can help you. She might be surprised that there are other girls that have the same problem. So a group, I think, could be helpful…just knowing the resources out there, and I think at that age, you want to know that you’re not alone. So I think it’s more important for them to have a group that has similar problems, than it is for probably the one-on-one. So it’s better to understand, to know what’s out there, and then figure out what’s gonna work for you (Wendy). Sharing one’s own experiences with mental illness can also decrease stigma and normalize both seeking help and discussing one’s mental health. Reducing stigma. Stigma is an important factor that can decrease the likelihood that an individual seeks help for mental illness. High stigma is particularly prevalent among adolescents, who do not want to appear different from their peers. One parent talked about the importance of reducing the stigma around mental illness. She felt that it was important for parents and children to understand that mental illness is similar to physical illness in that an individual does not have 44 control over its development. She stated that parents and children need to understand that mental illness is not a sign of weakness and is not something to be ashamed of. This parent said: I will tell kid[s] that depression is nothing to feel shamed about. Don’t see it as a negative thing. When my kid has some issues, I bought some books for him and told him do not view it negatively. It is just like having cold. You have no control over that. It happens and it happens, the key is how to handle it (Tiffany). Tiffany talked about how parents who do not understand mental illness or believe it is shameful may yell at their children, which could worsen the child’s symptoms. She said, “Parents need to accept that depression is an illness,” and they should not be mad at their children for experiencing symptoms of depression. Culture. Culture plays an important role in the strategy of providing social support for youth. It can affect both how and from where/whom parents believe social support should be sought and provided. Some parents talked about the ways in which living in the U.S. can be isolating for themselves and their children, and discussed ways that the Asian community can provide support during challenging times. For example, Cynthia said, “The entire societal environment is different. Certain Asian small groups, such as church, could provide space for them to talk about their struggles.” Similarly, parents talked about the ways in which their communities provide a sense of belonging for immigrant youth. In [the] U.S., in college dorms, usually one person has his own room, or two people sharing one room. This is different from China, several people share a dorm room together. Everyone knows each other quickly and help each other. Here, the environment is different. People have to go through a lot. It is hard work. Now, we have Wechat, and we have small Chinese groups where people help each other out, which create a sense of 45 belonging. For this parent, structural and contextual differences between her home country and the U.S. affect interpersonal relationships in negative ways, including making youth feel more isolated. One strategy for addressing this challenge is by using Wechat (a popular Chinese app that allows users to message and video call each other), which allows immigrant youth to stay in contact with their friends and family who may be far away geographically. Additionally, small social groups of Chinese individuals provide a space for immigrant children to help one another and foster a sense of belonging. Thus, parents believe that one of the ways to provide social support for youth is to utilize one’s community and to stay connected with family and friends from one’s country of origin in person (e.g., through church) or online (e.g., by using apps such as Wechat). The role of the school. Many parents highlighted the differences between schools in their home countries and schools in the United States. Some participants who were knowledgeable about school-based mental health services were surprised by how many resources were available in American schools, and talked about the ways that various school staff members could provide social support for students in order to improve mental health. One parent highlighted how school staff can foster a sense of belonging for students experiencing depression: I think American schools are really good because they have school psychologists or school counselors...There are counselors in school. Also, kids can have their friends together as their support team. Counselors can help to build these friendship team[s] to support the kids who are depressed. If my kids were in this situation, I would ask [the] school to take these steps (Elaine). 46 However, other parents expressed that it is the role of parents to provide support for their children and ensure they are healthy. One mother believed that schools could not provide social support because staff members are too busy. She said, “American teachers cannot pay attention to every [child]. Parents need to pay more attention to their children” (Tina). Thus, parents had varying views about how schools could play a role in providing social support for students in order to help foster mental health. One factor that could influence parents’ differing views and opinions about school-based mental health services (SBMHS) is their level of knowledge about available mental health services and the roles of school staff. 2. Providing strategies for improving mental health/alleviating concerns. Many participants were concerned about the health and wellbeing of their adolescents, and suggested that a helpful way to address adolescent mental illness would be to provide strategies that improve mental health. These strategies include teaching youth strategies to reduce or address existing symptoms (78.9%). Participants also talked about strategies which were geared toward parents or caregivers, including changing their own actions (i.e., lowering expectations, altering the youth’s environment; 57.9%), encouraging help-seeking (47.2%) and learning strategies for helping their children (15.8%). This section highlights parental beliefs about the ways in which providers, activities, and parents themselves can provide strategies for improving adolescent mental health. Teaching strategies for reducing/addressing symptoms. The majority of parents discussed the importance of providing youth with strategies for reducing existing symptoms of mental illness and increasing overall wellbeing. Specifically, parents talked about the ways in which different activities could reduce symptoms, as well as the way professionals and family or friends could help adolescents find solutions to their problems. For example, one parent said that 47 for an individual experiencing mental health symptoms, “Counselors may talk to him, and give him methods to think about the problem and to solve problem” (Hannah). This participant expressed the idea that professionals can be helpful to adolescents by teaching them strategies for solving their problems and reducing their symptoms. This sentiment was echoed by other participants regarding a variety of providers; For example, one parent noted that for a youth with depression, a nurse could give her advice on how to relax. Additionally, participants talked about strategies adolescents could utilize to address their own symptoms. One father talked about how an adolescent could learn relaxation techniques to address their symptoms. He said, “The relaxation [techniques] are helpful and will help you adjust your nerves. It teaches you how to adjust your nerves. I think they are helpful” (Kevin). In addition to targeting specific symptoms, parents also talked about strategies for improving youths’ mood and overall wellbeing. Parents most frequently talked about the ways in which medication (i.e., antidepressants), exercise, and family/friend interactions can help improve adolescents’ mood and promote healthiness. Exercise was the most frequently mentioned strategy for increasing positive feelings, and parents voiced opinions such as: It’s the endorphins that are released, you know. It makes you happier. Exercise makes you happier. People don’t realize that. You have to enjoy it though. Exercise is anything. I mean it could be just walking the dog. I think it makes you happier” (Wendy). Participants also talked about a variety of other strategies for increasing positive feelings and promoting healthiness. Many suggested that providing adolescents with opportunities to engage in positive activities may make them feel good about themselves, and could take their mind off their struggles. One parent said: Engage the students with activities so that the student would not keep on thinking about 48 food or food related issues. Or if they interact with different people of different weight, maybe they will not be as self-conscious about their weight. Even if they volunteer in some organizations like, you know, food pantry or nursing home. Then they, maybe they will gain [a] different perspective in life. Maybe either the food or weight gain or weight loss is not, would not be as much of an issue as what they have been thinking of. Well it also, it puts the current issue into different perspective (Kim). The participants talked about ways that they would engage their adolescent in such activities. Several parents gave anecdotal examples about how they or their family members have reduced symptoms of mental illness by engaging in positive activities, such as taking family trips or having game nights at home. Parents making accommodations/change expectations for children. Parents felt that they were responsible for their children’s wellbeing and talked about specific actions they could take to improve their children’s mental health. Participants talked about accommodations or changes they could make to the home environment, as well as ways they could change their expectations for their children to decrease stress and improve mental health. Parents shared stories of how they altered their home environments based on their children’s needs. For example, one parent talked about her son, who had very high expectations for himself and experienced high stress. This parent, along with her husband, tried to “create more positivity” in their son’s life and encouraged him to eat healthy and get enough sleep (Ann). Several participants talked about identifying sources of stress in their adolescent children’s lives, including determining if their own parental expectations were causing stress or mental health symptoms in their children, and then adjusting these expectations. Cynthia stated, “Parents have to see their kids’ limits and have to make a judgment whether the challenges were 49 beyond the kids’ ability to cope. If the problem needs more time and process to overcome, they need to make appropriate arrangements.” Parents talked at length about the importance of not placing too much pressure on their children, both because of the stress it causes for youth and because children might begin to have unrealistic expectations for themselves. Parents felt that it is important to “encourage kids to broaden their views, adjust their expectations and let certain things go...Anxiety comes from high expectation for grades. Thus, lowering your expectation will work well” (Cynthia). These examples highlight the high level of responsibility participants took for their children’s mental health and wellbeing, and the strategies they have employed in the past or would use if they noticed their children were experiencing high levels of stress, pressure, or symptoms of mental illness. Encouraging help-seeking. While participants talked about the many ways in which they could serve as a helpful resource if their children experienced symptoms of mental illness, they also felt that they played an important role in seeking professional help for their children or encouraging youth to seek help themselves. Parents felt that by seeking help from a professional, they could learn more about their child’s problem, and the adolescent’s symptoms could decrease. Lynn said: First, I think you have to find some professionals…I may consult with him/her myself about the reasons that lead to this [disorder] and solutions. When I knew [more], I think I will take my kids to seek out help from the professional. This mother felt that a professional could serve as a resource to both her and her child. In addition to finding help for the child, many participants discussed how they would encourage their children to seek out professional help. For example, one parent said that if she noticed her 50 child was exhibiting symptoms of a mental illness, she would “take the initiative to talk to them and encourage them to seek out counselor” (Kelly). Parents learning strategies for helping their children. Many participants talked about what they could do as parents to help improve their children’s mental health. In particular, four parents talked about how they could learn strategies that would be helpful for their children. Participants mentioned how parents could seek help from counselors and psychologists to learn strategies to implement at home. One parent said, “Not only kids, parents should also seek out help from psychologists. Let psychologists suggest what they should do” to help the child (Kevin). Similarly, participant Kim talked about how parents could go with their children to therapy. She said, “If family go occasionally with the child for therapy service, maybe family can learn how they can help.” Thus, parents expressed a sense of responsibility for helping improve their children’s mental health and talked about strategies they would take to become more informed about ways to help their children. Culture. Participants talked about the ways in which culture and the experiences of immigration affect their children’s mental health and the strategies they use to help their children alleviate mental health concerns or stress. For example, some parents allow their children to engage in activities that they do not necessarily approve of (i.e., playing lots of video games) because they understand that the immigration experience is hard on their children. Hannah said: My son plays more video game right before [an] exam. He needs this to relax [himself] and balance. I have no choice but let him play. I think adults are anxious too. They cannot adjust to life here [in U.S.] easily after immigration. It is hard both on adults and children. So I do not blame him. 51 Hannah recognized that adjusting to life in a new country is hard on both her as a parent and for her adolescent son, and changed her expectations and beliefs about her son playing video games because she realized that this activity increases his positive feelings and decreases stress and anxiety. Another important way in which culture influenced parents’ beliefs about improving mental health or alleviating concerns is that many parents talked about how cultural standards and expectations can lead to mental health concerns, and that parent should change their expectations to improve adolescent mental health. Several parents talked about how in Asian communities, parents often compare their children to other highly successful children and set extremely high expectations for their children. In particular, many parents discussed high academic expectations, including pushing their children to earn straight A’s and very high test scores. One parent shared that in her opinion, Asian-American immigrant parents place too much emphasis on their children getting excellent scores and being accepted to prestigious universities, and this puts too much stress on youth. She said: We discussed this at the Chinese parent association. Decreasing the focus on college admission has been discussed by parent association. The most important thing is not about whether you make it to a good college, but about cultivating a kid’s interests and overall health. You have to have a right judgment about your kids. Don’t care too much about which school they go to...It is about their physical and mental health. It is not being excel in all aspects. They are not almighty. There are other important things besides study. Accepting them as who they are and do not pull the plant to make it grow (Tiffany). 52 One parent even felt that the best way to support her child’s mental health was to stop going to places where other Chinese immigrant parents would be talking about their children’s accomplishments, as this leads to competition and comparison. She said: [I] don’t go to the place where there are lot of Chinese. My child scored 25 on a scale of 36, and I felt bad after I compared with other Asian friends. My friend’s child scored 30. After I saw that, I was very upset for a long time after I got home. So in our head, it is hard to [not] compare or compete with others… Do not go to places where there are many comparisons. Otherwise you feel bad; then you blame your kids (Kelly). Thus, in order to help promote positive mental health among their children, many parents felt that it was important for parents to change their expectations for their children, including setting more realistic goals and not overemphasizing grades and test scores. However, parents also stated that these values are deeply engrained in some Asian-American immigrant communities, and it is not always easy to change one’s values or expectations. The role of the school. In addition to the accommodations parents could make for their children to improve youth mental health and alleviate concerns, participants also mentioned accommodations that teachers and schools could make. One parent shared a story about a teacher at one of her children’s schools who helped a child with special needs immensely by encouraging other children to be nice and helpful. Lynn said: [The] teacher told all students to be nice to the child with special needs. Do not do mean things towards that child, not say bad words towards him, and be extra nice. I want to say that the teacher reminded classmates to give the kid extra help. The teacher helped the kid get used to school and help him/her achieve [a] relatively relaxing state. 53 Parents also felt that schools provide a good opportunity for youth to be exposed to positive peers. In order to increase positive feelings and promote healthiness, one parent suggested that parents and teachers should place the adolescent with peers who are going to be positive influences. She said, “Classmates will have great impact on him/her. Let him/her be with classmates or friends who are healthy, strong, and graceful… Teachers could guide students towards more positive directions” (Cynthia). This parent felt that classmates and teachers are influential on children’s mental health and can help promote healthiness. 3. Teaching adolescents about mental health. Lack of knowledge about mental health is a pervasive issue that impedes help-seeking and can promote unhealthy behaviors. In particular, individuals may be unaware of symptoms of mental illnesses, which can prevent one from seeking help for oneself or for others. Youth in particular may not know what habits and behaviors are healthy or unhealthy, and so may not be concerned about symptoms such as restricting calories, isolating oneself, or exhibiting other behaviors associated with mental health disorders such as anorexia and depression. Thus, many participants felt that adolescents would benefit from learning more about mental health. Parents shared that youth should be taught about healthy habits (57.9%) as well as signs and symptoms of mental illness (21.1%). This section highlights how parents believe lack of knowledge in these areas can be addressed to improve adolescent mental health. Teaching adolescents healthy habits. Over half of the participants talked about the importance of teaching adolescents about healthiness, both mental and physical. One parent shared that in her opinion, one must first teach children to have a healthy mindset, followed by how to have a healthy body. She said: You want to teach them, you have to know what is healthy mindset first of all. You have 54 to have a right understanding for what is true definition for healthy beauty. After that understanding, you will take a second step on this basis. How do you understand what is healthy food? (Lynn). In addition to teaching adolescents about healthy ways of thinking and behaving, many parents felt that it was their duty to provide guidance toward healthiness. Some parents shared that the best way to improve their children’s mental and physical health is for adults to model healthy habits. One mother shared: Parents have to cultivate a healthy lifestyle and influence children constantly and gradually. It is not about one day or two’s work. Parents influence children imperceptibly through words and behaviors. They have to cultivate children to have healthy mindset. They have to instill accurate concept through daily life. Parents’ each language and each behavior has a large impact on kids. It is hard to change things around after there is already an issue. Little by little, children will know what [the] parents’ values are. The children may not listen on surface but actually they will absorb gradually. (Tiffany) For this parent, helping adolescents develop healthy thoughts and habits is a long-term process that may include both explicit comments and lessons as well as subtle behaviors that model a healthy lifestyle. Participants also talked about the importance of professionals teaching adolescents what is healthy or unhealthy habits. One parent said, “From a doctor’s perspective, they educate children what are the benefits for healthy diet, direct his/her attention to other things. Proper guidance will have good impact” (Cynthia). Some parents felt that a doctor could provide education and guidance about healthy habits while family members could demonstrate what a healthy lifestyle looks like. 55 Teaching adolescents about signs and symptoms of mental illness. In addition to teaching adolescents about mental and physical health, participants shared that many adolescents need to learn more about the signs and symptoms of mental illness. Parents talked about the ways in which schools could provide information about mental illness as well as raise awareness about mental health concerns in adolescence. One parent, Tiffany, shared “I think it is important for schools to talk to parents and children through seminar and workshops so that they can be aware of the [mental health] issue.” Another participant discussed ways in which schools could incorporate information and awareness of mental illness into the curriculum. She felt that providing a class that covered topics such as mental health and physical appearance could be helpful for youth. Culture. Culture greatly influences what values and behaviors parents believe are important to teach their children. It is important to consider that many parents’ beliefs and values are guided by their own culture, even if they do not explicitly talk about how culture impacts what they think children should be taught in regard to mental health. For example, many parents talked about the importance of cultivating a healthy lifestyle for their children, building their children’s confidence, and modeling healthy behaviors. While most participants did not talk about how they came to value these actions, culture underlies the development of individuals’ belief systems and values. Some participants discussed how professionals with similar ethnic backgrounds could provide appropriate guidance for children. For example, one parent shared, “My son has anxiety and depression. He went to a family doctor when he [was] in 6 grade. The doctor is Taiwanese and is very good at guidance” (Sue). This mother felt that because her son’s doctor shared the same ethnicity/cultural background and understood the family’s background, he could guide the youth toward healthiness. 56 The role of the school. As described earlier in this section, many parents felt that schools should take responsibility for teaching students and parents about the symptoms of mental illness as well as strategies for prompting mental health. Parents did not discuss the role of the school in teaching youth healthy habits. 4. The benefits of seeking help from professionals. The majority of helpful strategies participants shared for addressing adolescent mental health concerns revolved around what parents themselves could do to help their children. However, parents also discussed ways in which they could not help their children and the reasons why professional help should be sought. This section highlights participants’ beliefs about the benefits of seeking help from professionals. Parents believe that professional help is important because professionals have training or expertise in mental health (52.6%), will keep confidentiality (21.1%), and because teens may listen to professionals more than they listen to their parents (15.8%). It is important to note that all participants talked about professionals providing important, helpful services throughout their interviews. However, only 63.2% of participants mentioned the subthemes listed below. Many quotes revolving around professional help fall under the other primary themes and subthemes. Professionals have training/expertise in mental health. Half of the participants shared that seeking professional help would be helpful for adolescents experiencing mental health concerns because of the professional’s training and expertise. Many parents said that service providers such as doctors, psychologists, and nutritionists have years of experience working with individuals with mental illnesses, so they are more knowledgeable than parents or friends. Additionally, some parents worried that they could harm their children by not having the proper knowledge about mental illness – they would seek help from a professional because he or she has both training and experience and could be more helpful. 57 Although parents talked throughout the interviews about the ways in which family and friends can be most helpful to adolescents with mental health concerns, some mentioned that these sources of support may be biased and cannot provide an outside opinion, as a professional can. One parent summed it up by saying: I think if you can find a good psychologist or counselor who can click with you, it will be a great professional help for people who are depressed. Your family and friends are biased, but the counseling psychologists, he or she has received professional training and knows how to guide you. Psychologists can be really helpful (Elaine). Because professionals have received training, they can provide guidance and advice based on their education, whereas parents and friends could give advice that would actually harm the child. Professionals will keep confidentiality. Adolescence is often a period of increased privacy, where youth seek to keep their problems and experiences to themselves. Teens often only share information with individuals who they deem trustworthy, and many parents said that professional help allows an adolescent to share their experiences and seek help from an individual who would maintain confidentiality. Some parents thought it would actually be easier for an adolescent to talk with a professional than with a family member or friend. A father shared an experience with a psychologist who operated a mental health hotline. This provider said that adolescents would often call to talk to someone who didn’t know them personally and could keep their information private and confidential. The parent said: When my kid was in middle school, a psychologist, an expert from outside of the school, was invited to talk to parents. She mentioned that she often received calls when she was on duty for a mental health hotline in China. I think it is helpful. She said that some kids 58 often call her and tell her things that they do not want to share with parents and friends. She would suggest them on how to deal with the situation (Kevin). Thus, because professionals do not know the youth well, there is less stigma and judgment about sharing one’s personal experiences, and there is a guarantee of confidentiality. In regard to the type of professional that would be most helpful for an adolescent experiencing symptoms of a mental illness, some parents mentioned that what matters most is that the adolescent trusts the professional. Teens will listen to professionals. Although parents felt they could be helpful sources of support for their children, they also worried that their children would not want to listen to their parents. For this reason, professionals were viewed as a helpful source of support because teens may be more likely to listen to what a professional has to say. Participants also shared that their children may not believe that they have a problem if this information comes from a parent, but that they might listen if a professional says the same thing. Wendy said: Maybe that person, because of being a doctor, can help her see that she has an issue. She has a problem. Sometimes, you know, kids don’t take it from parents. We’re not smart enough. They need it, they need a professional to tell them...So sometimes it takes a professional to tell a person, if they respect that, if that person has enough education or experience. Culture. Some participants shared that despite seeking professional help being an important strategy for addressing adolescent mental health concerns, culture can sometimes impede the help-seeking process. Some parents felt that parents may be hesitant to seek help from a professional who is not Asian, as the professional may not be culturally competent and 59 may not understand the client’s culture. One mother shared some beliefs among parents in her parenting group: A lot of people in the group are very Chinese. For those people, it is better to have a therapist who is Asian. Asian therapist with a similar cultural background can understand the roots of my problem. White therapist and traditional Chinese clients, I think it will be very difficult (Elaine). Although parents raised concerns about seeking help from professionals who are not from the same cultural and ethnic background as the client, they also emphasized training and expertise over ethnicity. For example, Elaine said, “Chinese need to embrace this idea of psychology since psychologists receive professional training. As long as they are well trained, no matter they are Asian or not, you have to go to them to communicate with them to see whether they can help you.” Other parents discussed how the idea of seeking help from professionals is not always embraced by individuals from their cultural background. Thus, although many parents feel it is important to seek professional help for their children when they experience symptoms of mental illnesses, they also acknowledge the cultural specific barriers (e.g., stigma, lack of same-ethnicity providers) that can prevent help-seeking. The role of the school. Participants often talked about school-based mental health providers being the first referral they would make. Some parents shared that they would go to the school counselor and see if they could help the youth and, if not, provide a referral to another provider. Michael said, “I would first suggest someone at school level or church or personally who may have some experience and then ask for their opinion. Someone who’s really, like a school counselor. Someone who knows what they’re dealing with and a counselor, the school counselor can talk to the girl and go from there first.” While many parents felt that a psychologist 60 could ensure confidentiality, few parents specifically mentioned a school psychologist being able to keep a child’s information private. In fact, several parents discussed concerns that information shared to a SBMH provider could be added to the student’s school record, which could negatively affect their chances of being accepted to a prestigious university. Parents may not understand the process of seeking and utilizing SBMH services, including that mental health records would not be shared with college admissions counselors. 5. Identifying the cause/diagnosing the problem. Over half of participants felt that an important aspect of helping children who experience mental health concerns is to identify the cause of the problem, and to label or diagnose the problem. Many parents felt that it was their duty to find out from where the mental health concern stemmed. One mother, Grace, said: Parents need to ask questions. Ask where is the problem? Children may have some ideas. Is it because children did not do well at school, and then they have mental health problems? Is it because of friendship problems? Is it because [the] parents did not pay enough attention to the children? Is it because there is a lack of communication? Parents need to help children – Ask children to say what is the problem. Participants noted that by determining the cause of the problem, parents and children could better address it. For example, if a child is depressed because of social concerns at schools, parents would know to focus their attention on addressing this specific area of concern. Participants also felt that it would be helpful for a professional to diagnose the problem. In particular, many parents thought that a diagnosis would better inform treatment. One parent, Lynn, shared her experience of taking a family member in order to get a diagnosis of her mental health concerns: We went to see a doctor in hospital and got the diagnosis of depression. We lived in a small city. We went to the psychiatry department, not normal psychology. They saw 61 some symptoms [in her] and diagnosed her with depression and prescribed medication. Lynn shared that after being diagnosed with depression and put on antidepressants, her relative’s symptoms drastically decreased, and her mental health improved. For many parents, labeling the problem allows the family to better understand what the child is experiencing and to take more specific steps to address the concerns. Culture and the role of the school. In many ways, parents saw culture and the role of the school in identifying or diagnosing the mental health concern as intertwined. Participants talked about the ways in which U.S. schools are different from the schools in their home countries, and how this impacts the ability of school staff to identify the causes of students’ mental health problems. Specifically, Lynn discussed the importance of parents communicating with school staff, and particularly counselors, to determine if something happened to the youth at school. This mother felt that because there is not one lead or homeroom teacher in U.S. middle schools, students’ problems may not be identified because teachers don’t always know their students well and may be too focused on academics to notice mental health and behavioral concerns. For this reason, she felt school counselors play an important role in being aware of what’s going on with their students, which allows them to recognize the problem and identify the cause. Parents also talked about the ways in which school stress can lead to mental health problems in adolescents. When talking about how she would identify the cause of a mental health problem in her teens, one parent said she would ask, “Is it because children did not do well at school, and then they have mental health problems?” (Julie). Participants shared that because many issues arise at school, school staff are more aware of what’s going on in a child’s life and are thus in a better position to help identify the cause of problems than parents might be. Lynn said, “School counselor is responsible to figure out whether significant things happened to 62 the student at school” and if no significant events took place, she would know to take her child to a doctor who could examine biological and physical changes. Parents felt that it was their duty to reach out to school staff to determine if any changes or problems had arisen, and this notion highlights parents’ desire to communicate with school staff and work together to identify and treat youth mental health concerns. The role of culture also influences from which providers parents take their children for a diagnosis. For example, one parent who is a doctor in the U.S. said that she would first try to determine the cause of her child’s mental illness, and if she was unable to find the cause, she would take her child to “a traditional Chinese medicine doctor.” While parents were not specifically asked if they would take their children to a professional from the same ethnic background as the family, it is important to consider how factors such as race and ethnicity influence from where a family seeks help. 63 Chapter 5: Discussion The present mixed-methods study explored Asian-American immigrant parents’ beliefs about strategies that are helpful for addressing adolescent mental health concerns, including strategies for both prevention and intervention. Descriptive statistics were utilized to examine participants’ ability to recognize bulimia and depression from case vignettes, as well as to determine which providers and strategies parents were most likely to recommend for adolescents with these mental illnesses. While there have been a variety of studies on MHL, the majority of these have examined only symptom recognition and have utilized White participants. These studies typically do not indicate whether the participants are parents, and often categorize participants as White or minority/non-White. This study extends the current literature on the help-seeking process and MHL among CLD parents by utilizing both surveys and interviews to better understand what strategies Asian-American immigrant parents believe are helpful for addressing youth mental illness. Additionally, while schools are the most common setting for youth to receive mental health services (Wood et al., 2005), very few studies have explored parent perceptions of school- based services and providers. To extend this literature, the present study explored parents’ view of the role of the school in addressing youth mental illness. It is important to design programs that are appropriate for Asian-American students, as these youth are less likely to seek help from SBMH services than their peers (Anyon et al. 2014; Gudino et al. 2009; Guo et al. 2015). In order for school-based mental health (SBMH) providers to design programs that engage Asian- American youth and are supported by their parents, we must first understand what strategies Asian-American parents believe are most helpful in addressing mental health concerns. SBMH services should be culturally responsive and teens and parents alike should feel comfortable seeking out these services for youth mental health concerns. 64 Strategies for Addressing Youth Mental Illness The use of semi-structured interviews in this study allowed for deeper exploration of parental beliefs about how to address youth mental illness. Overall, the interviews revealed that parents believed a variety of formal and informal strategies could be helpful for preventing and treating adolescent mental illness. Parents viewed themselves as responsible for addressing mental health concerns in their children, and discussed strategies that they would implement to help their children. However, they also shared a number of concerns they had regarding their knowledge and skillsets, and discussed the importance of seeking professional help for their adolescents. In particular, parents discussed a need for increased communication and collaboration between parents and school staff, including counselors, teachers, and psychologists. The most common strategy that parents discussed for addressing adolescent mental health concerns was providing social support (94.7%). Throughout the interviews, parents talked about the importance of supporting youth both before and during experiences of mental illness. For example, parents felt that by paying close attention to children’s mood and behavior, they would notice changes and know to seek help. Importantly, the majority of the quotes under this theme revolved around what parents and family members could do to support their children. Social support is critical not only to the youth who are experiencing a mental illness but also to the family. For immigrants who have lost their family network and cultural roots as a result of migration to the U.S., rebuilding the support system is critical to their adaptation and successful coping with a mental illness. Social support may be particularly valuable for families from collectivistic cultures who highly value family cohesion and social connectedness. This theme highlights an important cultural value of Asian-American immigrant parents, and should inform 65 clinical practice. Practitioners who adopt a family-system approach to treatment based on their client’s cultural values will likely receive more buy-in and be more effective than practitioners who utilize an individual treatment approach. Individuals may prefer to seek help from family and friends because they see it as less shameful than seeking help from a professional. Asian-American immigrant parents may want to “save face” and avoid the stigma associated with seeking help and having their child labeled as mentally ill (Wang et al., in press). For many parents, seeking formal help is associated with shame and fear, whereas seeking informal help (i.e., from family) can feel like a safer choice. Some parents explicitly talked about addressing this shame, and shared that reducing stigma is an important component of providing social support. This theme is supported by the descriptive results, which showed that parents were most likely to report that close friends and family members would be helpful sources of support for youth experiencing mental illness. Additionally, in regard to preventing mental illnesses from developing, parents felt that two of the most important strategies are keeping regular contact with friends (92.86%) and keeping regular contact with family (92.86%). SBMH providers should not assume that this means parents do not value professional help, but rather should use this information to engage family and friends in SBMH services. Including members of a youth’s social network in services can help build rapport and promote positive perceptions of SBMH services among immigrant communities. Additionally, parents do value professional help, which was made clear both in the themes that emerged from the interviews as well as the survey results. Parents frequently discussed providing strategies for improving mental health for their children. Specifically, parents felt that it would be helpful to reduce or address existing symptoms of mental health disorders while making changes that promote mental health. Many 66 parents discussed targeting the cause of the mental health concern, when possible. For example, many participants shared how their own actions can negatively affect their children’s mental health, including setting unrealistic expectations and comparing their children to other youth. They discussed the importance of changing these expectations to be more realistic in order to reduce youth stress and anxiety. The Chinese immigrant parents in Li and Li’s (2017) study also reported that their children experience stress caused from high parental expectations. The participants in this study discussed youth stress caused by both parental expectations and self- expectations in regard to academic performance. Other research has also found that cultural values and the “model minority” stereotype can lead to unrealistic expectations which can cause stress and mental health concerns (Wong & Halgin, 2006; Wang et al., in press). For example, Asian-American families and communities might expect students to excel academically but ignore their mental health needs (Wang et al., in press). However, the parents in the present study were aware of these high expectations placed on Asian-American youth, and said that it was important for parents to lower their expectations and make accommodations for their children to ensure their happiness and healthiness. Parents felt that taking actions such as attending parenting workshops to work on setting realistic expectations or even avoiding situations where parents are likely to compare their children could help decrease stress for their children. SBMH providers could use their expertise in education and academic outcomes to help parents set realistic expectations and could help immigrant parents better understand the school system in the U.S., which was a barrier many parents discussed (Wang et al., in press). In addition to making changes to parenting style, parents felt that it would be helpful to encourage their children to participate in activities that promote physical and mental health (i.e., team sports). This finding can also be seen in the descriptive results, which show that parents 67 value activities such as “getting out more/finding new hobbies” (81.25%) and “getting relaxation training” (100%) for addressing eating disorders and depression in adolescents. These results are consistent with Jorm’s (2012) list of self-help strategies that have been endorsed by mental health professionals. This list includes tips such as “make sure you get out of the house for at least a short time each day” and “learn relaxation methods.” These types of self-help strategies are often easy to access, and individuals tend to view these strategies more positively than formal help-seeking strategies (Jorm, 2012). It is important that parents are aware of self-help strategies as well as formal help-seeking strategies so that they can promote and encourage a variety of methods in order to find what is most effective for youth experiencing mental health concerns. Despite having many suggestions for improving youth mental health, parents expressed concerns that children and parents alike do not have sufficient knowledge in general about mental health. Lack of knowledge about mental disorders is a common barrier to help-seeking, and has been reported in Asian-American immigrant parents (Wang et al., in press). Although 73.7% of parents correctly identified depression, only 26.3% correctly identified bulimia from the vignettes. This finding suggests that parents may have a difficult time recognizing mental illnesses based on symptoms, particularly eating disorders. Throughout the interviews, many parents also said that they were unsure if they knew anyone who had experienced an eating disorder, and shared that it is often difficult to discern if an individual has an eating disorder. While most participants said that they knew someone who had experienced depression, very few parents said that they knew someone who had experienced an eating disorder. Many parents said they did not pay attention to the eating habits of the people around them (excluding their children), but also acknowledged a lack of knowledge about eating disorders. 68 It is important that parents first recognize the lack of knowledge, but then must also seek out information and resources to increase knowledge about mental health among themselves and their children. The third most frequently suggested strategy for addressing mental health concerns in youth was teaching adolescents about mental health, including information about mental illnesses and about healthiness. Ninety three percent of parents believed that an adolescent experiencing symptoms of bulimia would benefit from getting advice about diet or nutrition, and 93.75% would recommend the adolescent get information and problem eating and available services. During the interviews, parents shared that both family members and professionals should provide information about healthiness and should provide guidance toward healthy lifestyles. Mental health providers should make this information readily accessible, and available in a variety of languages. Information about symptomology and disorders should be provided, as well as information about what behaviors are healthy versus unhealthy. School- based mental health providers are well-positioned to share this information with parents through school websites, resources, and events. Additionally, they can work with parents to not only teach families about mental illness, but to give parents suggestions for serving as positive role models for their children. This would allow parents to feel more confident in their knowledge and ability to guide their children in healthy directions while strengthening the relationship between parents and service providers. Collaborating with families can help SBMH providers build upon parents’ existing knowledge and skillset, which may be particularly important for immigrant families who may face additional stressors that make it challenging for them to cope with and address youth mental health concerns. For example, one parent in the present study allowed her son to play copious amounts of video games to relax because she knew that he faced many stressors, including the family’s migration. SBMH providers could work with parents like 69 this mother to find additional ways to help their children alleviate stress. This could help improve children’s mental health while empowering parents to help their adolescents. As mentioned previously, many parents talked about the importance of seeking help from professionals. Parents shared that professionals can be helpful for youth with mental illnesses because youth may be more likely to listen to a professional than to a parent, professionals do not know the youth and will maintain confidentiality, and because professionals have both training and experience working with individuals with mental illnesses. Parents seemed to prefer to provide help and support for their children themselves, but recognized their own limitations. In some cases, participants discussed how their lack of knowledge and training could actually harm their children. Thus, parents valued professional help and discussed how they would encourage their children to seek professional services. For example, the descriptive results revealed that the majority of parents believed activities such as attending counseling (87.50%) and joining a support group of people with similar problems (85.71%) would be helpful for adolescents experiencing mental health concerns. These results are inconsistent with the existing literature, which typically suggests that Asian-American adults do not believe professionals are helpful for addressing mental health concerns (Li & Li, 2017; Kung, 2004; Loo et al., 2012). One explanation for this difference is that the parents who volunteered to be part of this study likely had an interest in mental health, and may have more positive attitudes toward mental health and the help-seeking process than the general public. Another possible explanation is that the parents in this study understand the value of professional help and believe it can be helpful, but may face challenges and barriers in their own lives when deciding from where to seek help. For example, while parents shared in both the interviews and the survey that a variety of professionals would be helpful for addressing youth 70 mental health concerns, they also reported a variety of barriers to seeking these services, which have been explored by Wang et al. (in press). Importantly, parents in this study stated that providers often give “common sense” advice that parents could easily obtain from their social networks (Wang et al., in press). Parents might also view their own children’s mental health concerns as less severe than the situations described in the vignettes. Li and Li (2017) noted that Asian-American immigrant parents tend to rely on family, friends, and community support first, and only employ professional services when the situation becomes too severe for the parents to address. Lastly, individuals who have sought mental health services in the past may be more likely to endorse these services as helpful. While the present study did not explicitly ask parents if they had sought professional help for mental health concerns in themselves or in their children, nine parents mentioned mental health concerns for their children, and seven parents shared that their children had utilized school-based mental health services in the past. Thus, the parents in the present study may be more likely than Asian-American immigrant parents in general to view professional services as helpful because they have already had positive experiences using these services. Finally, a little over half of parents (57.9%) discussed that an important strategy for addressing youth mental illness is identifying the cause of or diagnosing the problem. Participants shared that in order to properly support the adolescent, they would need to understand what caused the problem. This would allow parents to address or remove the problem if possible, and prevent similar problems from causing mental health concerns in the future. Formally diagnosing the problem could also help parents understand what their child is experiencing, and accurately labeling a psychiatric disorder facilitates help-seeking (Yap et al., 2014). Participants also talked about the ways in which different diagnoses require different 71 interventions or treatments. For example, encouraging a child to become more physically active might be helpful for an adolescent with depression who does not want to leave the house, but could be detrimental for an adolescent with an eating disorder who needs to gain weight to be physically healthy. The role of the school. Participants viewed SBMH providers as helpful for supporting adolescents with mental illnesses. Nearly three-fourths of the parents indicated that a school psychologist (87.50%, 92.86%), a school counselor (81.25%), and a teacher (71.43%) would be helpful for an eating disorder or depression respectively. Additionally, within each of the five main themes that emerged, parents mentioned how the school played a role in supporting student mental health. Participants felt that schools offered a variety of providers and resources that could be helpful for youth and families. For example, schools can help increase MHL by teaching students and parents about mental illness and healthy versus unhealthy behaviors. The parents felt that it would be helpful for schools to build this information into the curriculum and to spend more time talking about mental health in general. They also thought that schools could provide workshops to teach families more about mental health. Additionally, participants indicated that school staff such as counselors and teachers were in a good position to identify the cause of students’ mental health concerns and to provide interventions. Parents suggested that school counselors and school psychologists could address youth mental health concerns by recognizing the problem, identifying the cause of the problem, increasing social support for the child at school, providing counseling, and ensuring that the child is not being bullied. These strategies are consistent with SBMH services, which focus on identifying behavioral and mental health problems and providing interventions, including counseling and social-emotional learning (Dowdy et al., 2015). Strategies suggested by parents 72 for teachers included giving the child accommodations, communicating with parents, and pairing the student with positive peers to increase social skills. These suggestions are similar to the results from other qualitative studies, such as Li and Li’s (2017) finding that Chinese immigrant parents wanted teachers and schools to teach students social skills, strengthen communication with parents, and provide a good classroom learning environment. They are also consistent with the SBMH literature, which suggests that indigenous persons within the school, including teachers and peers, can act as agents of change by altering the classroom environment to be more positive and supportive (Atkins, Hoagwood, Kutash, & Seidman, 2010). While the majority of participants felt that school staff are helpful for addressing mental health concerns in students, parents also had concerns about U.S. schools, and felt that they could contribute to mental health concerns. For example, participants shared that secondary schools in U.S. lack homeroom teachers, which can make it hard for teachers to know their students well and notice changes in mood or behavior that could be caused by factors or events at school. Some parents also shared that they did not believe it was school staff’s job to notice mental health concerns in students, and that this was a parent’s responsibility. Thus, they may not seek out SBMH services for their children because they do not think it is the school’s responsibility to address mental health concerns. Additionally, parents mentioned a variety of structural, attitudinal, and knowledge barriers which inhibit help-seeking at school (Wang et al., in press). SBMH providers can take many steps to address these barriers while increasing Asian- American immigrant parents’ knowledge about and trust in SBMH services. For example, school-based providers can implement school-wide interventions to promote mental health knowledge and can offer parent workshops about prevention and intervention. Doing this would foster relationships between parents and school staff, and would give parents an opportunity to 73 better understand the role of SBMH providers. While existing literature suggests that parent- school communication is often limited in Asian-American immigrant communities (Dyson, 2001), SBMH providers could seek to increase this communication by offering resources and events based on parents’ interests and needs. For example, parenting workshops could increase parent-school collaboration and parent knowledge about mental health disorders while giving parents an opportunity to voice their concerns about U.S. schools. These concerns could be addressed by school personnel in order to dispel myths or misinformation (e.g., that SBMH services will be shared with colleges) and would allow school staff to better understand the experiences and beliefs of CLD parents. Although parent engagement is a significant barrier for implementing mental health services at school (Langley, Nadeem, Kataoka, Stein, & Jaycox, 2010), creating culturally-responsive programs and workshops for parents based on their needs could help address these challenges. The role of culture. Throughout the interviews, participants talked about ways in which culture influence mental health and the help-seeking process. Parents specifically talked about cultural values among Asian-Americans, including high expectations for academic success and a strong emphasis on attending prestigious colleges and universities. The participants acknowledged how these values, as well as immigration experiences and varying levels of acculturation, can cause stress in youth which may contribute to mental health concerns such as depression and anxiety. On one hand, parents recognized that they were a source of stress for their children due to factors such as high expectations and acculturative stress. On the other hand, parents saw themselves as a primary source of support for their children, and felt it was their responsibility to notice mental health concerns and intervene. This notion was also found in 74 a qualitative study by Li and Li (2015), who found that Chinese immigrant parents were identified by their children as the primary source of both support and stress. During the interviews, some parents discussed the importance of leaning on one’s cultural group for social support. Particularly, many of the parents emphasized establishing social networks that include other immigrant parents, as they share similar experiences. Because it can be challenging to find social support in a new country, parents felt that meeting other immigrant families and using technology to communicate with friends and family in their country of origin would help improve youth mental health. Participants mentioned that youth should participate in “Asian community activities” to increase positive feelings while making friends and building a network of social support. Several parents mentioned attending parenting workshops and classes designed for Asian-American parents, and shared how these classes taught them about both parenting and the effects of culture on their children and the family unit. While many participants talked about culture, neither the survey nor the interview questions specifically asked about the influence of one’s culture on the help-seeking process, including from where a parent would seek help for youth mental health concerns. Future research should specifically ask CLD participants how they believe their culture influences their beliefs about mental illness, help-seeking and preventative strategies, and the role of the school in addressing youth mental health concerns. It is also important to remember that culture impacts individuals’ beliefs and values, even when they do not explicitly discuss the influences of culture. Thus, culture affects the themes which emerged in this study in numerous ways, but only the explicit roles of culture could be analyzed. Mental Health Literacy. The majority of the literature utilizes a Western framework of MHL, rather than a culturally responsive framework (Na et al., 2016). These prior studies yield 75 results which suggest that CLD individuals have low MHL, particularly compared to White/Western individuals (e.g., Mendenhall & Frauenholtz, 2013). This finding was not supported by the present study. Both the survey results and themes indicate that parents have knowledge about the symptoms and development of mental illnesses, are aware of treatment options and have generally positive perceptions of these options, can identify strategies for preventing the development of mental illnesses, and possess knowledge and skills regarding self- help strategies and strategies for helping others experiencing mental health concerns. In both the surveys and the interviews, participants demonstrated knowledge and appreciation for formal treatment options (i.e., therapy, support groups, seeing a nutritionist) and informal strategies (i.e., exercising, talking to friends and family). Parents also talked about a progression of help-seeking options, including trying to handle the mental health concern within the family and then seeking professional help if the problem worsened or did not improve. In particular, the interviews provided participants with an opportunity to elaborate on their survey responses, such as explaining why a provider might not be helpful in their opinion. This qualitative methodology illuminated that many parents believe professionals are helpful, but face many barriers to actually seeking and receiving help from these providers (Wang et al., in press). Additionally, the interviews allowed participants to share treatment options, service providers, and self-help strategies that are valued in their culture and were not listed in the survey. For example, one parent talked about taking their child to a traditional Chinese medical doctor for help, while others talked about seeking support from Asian-American parenting groups. Thus, utilizing both qualitative and quantitative methodologies to examine and explore MHL allows for a more culturally responsive framework of MHL which gives participants an opportunity to explain their beliefs. Importantly, the purpose of this study was not to highlight 76 low MHL in this population nor to call attention to deficits in Western knowledge and beliefs. Rather, the purpose was to gain a better understanding of Asian-American immigrant parents’ knowledge and beliefs about mental disorders, and the strategies that they value for addressing youth mental illness. Help-seeking framework. Cauce et al’s (2002) help-seeking model suggests that there are three interconnected steps of the help-seeking process: recognizing a problem, deciding to seek help, and selecting appropriate services, and each of these steps is influenced by culture. The themes that emerged from the interviews reflect these steps. For example, many parents talked about how both family members and school staff must first recognize that there is a mental health concern before it can be addressed. The participants suggested many strategies for recognizing a problem, including paying close attention to one’s children and learning more about mental health symptoms. They also shared experiences about deciding to seek help for their own children, and discussed some of the barriers to seeking help. Many parents saw the decision to seek help as a process, in which they first would need to identify the cause of the problem or diagnose the problem in order to determine if seeking help was necessary. Finally, parents discussed selecting appropriate services for youth mental illness. For example, participants felt that in some cases, informal help from family and friends would be sufficient, and encouraging children to engage in activities such as attending religious services or getting out in the sunlight would be helpful. In more severe cases, parents talked about selecting formal services from experienced providers. Many participants talked about taking their children for counseling, encouraging them to join support groups or call mental health hotlines, and asking doctors for medications such as antidepressants. 77 Cauce’s help-seeking model emphasizes the role of culture on each of the three steps, and the interviews illuminated this influence. Parents discussed how culture impacts help-seeking, including that their communities do not always support seeking help from professionals and that mental illness is not frequently discussed. Many parents talked about the influence of their social networks on the help-seeking process, and social networks can facilitate or inhibit help-seeking and service selection (Cauce et al., 2002). Parents who are part of tightly meshed networks where norms are not congruent with those of formal help-seeking may be discouraged from seeking formal help; and in communities where strong community and familial networks are common, families may not seek formal mental health services because their needs are met within the community (Cauce et al., 2002). Many parents discussed how social networks, such as Asian- American church communities, provide support and help, yet also acknowledged that these communities may be the source of stress or pressure for its adolescents. Parents also shared that their communities often have stigmatizing beliefs about mental illness and seeking formal help. CLD parents may struggle with the help-seeking process if they believe they or their children will be rejected if the community finds out about a mental health concern. Understanding parents’ culture-specific struggles and barriers to help-seeking can help providers better understand the experiences of the families with which they work while seeking to increase accessibility of services. Limitations and Future Directions While the present study adds much to the existing MHL literature, there are also several limitations. First, it should be noted that the primary author is a White American who is thus an outsider to the unique experiences and beliefs of Asian-American immigrant parents. Although the use of qualitative data and the inclusion of several Asian-Americans on the research team 78 allowed for a greater understanding of the participants’ experiences, the study is nonetheless affected by the author’s own cultural lens. Second, the study utilized a convenience sample of Asian-American immigrant parents, and this sampling procedure resulted in a rather homogeneous participant group which is not representative of the larger Asian-American immigrant population. For example, most of the participants were mothers from China with advanced degrees. Although Chinese Americans represent the largest Asian group in the United States (Pew Research Center, 2017), Asian-American immigrant parents represent a variety of ethnicities and have differing levels of education. Additionally, the sample did not adequately capture the voices of fathers, who may have different beliefs and experiences than do mothers. Thus, the experiences and opinions of the participants in this study do not represent those of all Asian-American immigrant parents and the results should not be over-generalized. An important limitation of this study is the use of a multiple-choice format for symptom recognition. When asked to identify the vignette characters’ main problem, participants were able to select more than one option from a list of mental illnesses. This may have led to an overestimate of parents’ symptom recognition, as almost all participants selected more than one problem from the list. Additionally, despite concerns that CLD parents are unaware of SBMH providers or are unsure what their role is (Li & Li, 2017), the present study did not ask parents to describe the role of the providers listed in the survey. Thus, it is possible that parents said that providers such as school psychologists would be helpful without fully knowing the difference between school psychologists and community-based psychologists. Future research should continue to modify the survey questions to include more SBMH services and activities (e.g., receiving a 504 plan, participating in a school-based mental health intervention). Future research should also continue to explore MHL among CLD parents and should utilize culturally 79 responsive frameworks that include sources of support that are valued among the participants’ communities. For example, spiritual leaders and community elders could be included on the list of providers on the survey. Conclusions The present study explored Asian-American immigrant parents’ beliefs about helpful strategies for addressing youth mental illness, with a focus on the role of schools and SBMH providers. The majority of prior research that has been done on MHL has been conducted on White, Western participants who are not identified as parents; The current work extends the literature to CLD parents. Asian-American youth are often at-risk for unmet mental health needs (Garland et al., 2005) and help-seeking has been found to be low in Asian-American immigrant communities (Abe-Kim et al., 2007). Because parents often serve at gatekeepers to mental health services (Gulliver et al., 2010), it is important to explore their ability to identify mental illnesses in youth and their beliefs about help-seeking and preventative strategies. Several main themes emerged from the interviews regarding helpful strategies for addressing youth mental health concerns. These strategies include providing social support; providing strategies to improve mental health; teaching adolescents about mental health; seeking help from professionals; and identifying the cause or diagnosing the problem. Parents discussed the many ways in which they could implement these strategies, as well as the ways in which school staff, including teachers, counselors, and psychologists, could be helpful for youth with mental health concerns. Thus, despite previous research findings that suggest that CLD adults have low MHL and do not view formal help-seeking methods as helpful compared with White parents, the current study found that Asian-American immigrant parents value both formal and informal sources of support for youth with mental illness. 80 Asian-American immigrant parents felt that the school plays an important role in identifying, intervening, and preventing mental health concerns in students, although a prior study showed that this sample of Asian-American parents also identified many barriers for their children to seek SBMH services (Wang et al., in press). Schools should thus work to understand and reduce these barriers, while continuing to develop a better understanding of the specific needs of the CLD students and families with whom they work. SBMH providers must recognize the impact of culture on the help-seeking process for both students and parents, and work to increase service utilization among Asian-American students by taking culture into account. For example, Asian-American parents valued professional help but also wanted to play an active role in helping their children overcome mental health concerns. They also felt that their communities could be helpful sources of support. Thus, schools should make parenting workshops and classes about mental health more readily available to members of the Asian-American community, and should involve cultural brokers to help increase rapport and trust between the schools and the communities. Asian-American immigrant parents want to be actively involved in identifying and treating mental health concerns that arise in their adolescents. They view themselves as responsible for ensuring the healthiness and happiness of their children, and utilize a variety of formal and informal strategies to prevent the development of mental illnesses and promote mental health. However, parents recognize that both they and their children often lack knowledge about mental illnesses and treatment options, particularly SBMH services, and desire more education on these topics. Learning more about CLD parents’ beliefs and experiences is an important first step in understanding their values regarding youth mental illness and the help- seeking process. By exploring the influence of culture on parents’ beliefs, SBMH providers can 81 begin to better understand the needs of the families they serve, and begin working toward creating more culturally responsive SBMH services. As the United States continues to become more diverse, with growing immigrant communities, it will become even more imperative that schools understand the experiences of CLD families and work to increase SBMH service utilization. 82 Tables Table 1 Themes and sub-themes of strategies or actions parents believe are helpful for addressing adolescent mental illness Theme % Participants Providing social support 94.7 Communicating about problem 73.7 Paying attention to adolescent’s mood/behavior 36.8 Providing a sense of belonging/security 31.6 Spending time together 26.1 Sharing experiences 21.1 Reducing stigma 5.3 Providing strategies for improving mental health/alleviating concerns 89.5 Providing/teaching youth strategies to reduce symptoms 78.9 Parents change expectations/environment for child 57.9 Referring for help/Encouraging help-seeking 47.2 Parents learn strategies for helping child 15.8 Teaching adolescents about mental health 63.2 Teaching adolescents healthy habits 57.9 Teaching adolescents about signs and symptoms of mental illness 21.1 Recognizing the benefits of seeking help from professionals 63.2 Professionals have training/expertise in mental health 52.6 Professional will keep confidentiality/doesn’t know child 21.1 Teen will listen to professional 15.8 Identifying cause/diagnosing problem 57.9 83 Appendices Appendix A Survey Questions. 1. Parent Name (open-ended) 2. Child’s Name (open-ended) 3. Relationship to Child (open-ended) 4. Age (open-ended) 5. Gender (open-ended) 6. Grade Level/Highest Level of Education (open-ended) 7. Race/Ethnicity (open-ended) 8. Country of Origin (open-ended) 9. Years Living in the United States (open-ended) Please read the following story and answer the questions based on what you read. Linlin is a 12 year old girl. Linlin’s current weight is below average for her age and height. However, she thinks she is overweight. Upon starting sixth grade, Linlin started running regularly every day after school. Through this effort she gradually began to lose weight. Linlin then start to “diet,” avoiding all fatty foods, not eating between meals, and trying to eat set portions of “healthy foods,” mainly fruit and vegetables and bread or rice, each day. Linlin also continued running, losing several more pounds. However, she has found it difficult to maintain the weight loss and for the past 18 months her weight has been continually fluctuating, sometimes by as much as 5 pounds within a few weeks. Linlin has also found it difficult to control her eating. While able to restrict her dietary intake during the day, at night she is often unable to stop eating, bingeing on, for example, a loaf of bread or several pieces of fruit. To counteract the effects of this bingeing, Linlin takes laxative tablets. On other occasions, she vomits after overeating. Because of her strict routines of eating and over exercising, Linlin stopped hanging out with her friends on the weekend, like she used to. 10. What would you say is Linlin’s main problem? (choose all that apply) a. Mental illness b. An exercise disorder or problem c. Anorexia nervosa d. A nutritional deficiency e. No real problem, just stress f. Low self-esteem or lack of self-confidence g. A hormone problem h. Loneliness i. Yo-yo eating j. An anxiety disorder or problem k. Diabetes l. A binge eating disorder or problem m. Depression n. Bulimia nervosa 11. Which of the following people do you think would be helpful, harmful, or neither helpful nor harmful to Linlin’s problem? 84 a. General doctor b. Pharmacist c. School counselor d. School psychologist e. Psychiatrist f. School social worker g. Alternative therapist h. Dietician or nutritionist i. Personal trainer j. Commercial weight loss program k. Community mental health worker (not school-based) l. Self-help support group m. Minister n. Family member o. Close friend 12. Which of the following activities do you think would be helpful, harmful, or neither helpful nor harmful for Linlin’s problem? a. Cutting back on exercise a bit b. Alternative therapy c. Assertiveness/social skills training d. Using a self-help treatment manual e. Admission to the psychiatric ward of a public hospital f. Getting advice about diet or nutrition g. Getting out and about more/finding new hobbies h. Counseling i. Just talking about the problem j. Psychotherapy k. Hypnosis l. Relaxation therapy, meditation, etc. m. Cognitive behavior therapy n. Trying to deal with the problem on her own o. Getting information about problem eating and available services Please read the following story and answer the questions based on what you read. Wenwen is a 13 year old girl who is feeling unusually sad for the last few weeks. She feels tired all the time and she has problems falling asleep. When she is able to fall asleep, she wakes up many times. She has lost her appetite and lately has lost some weight. It is difficult for her to concentrate and her grades have dropped. Her daily activities are a lot for her to handle, which led to her decision to stop attending piano lessons. She also stopped hanging out with her friends, who she used to spend time with every Friday afternoon. Her parents and friends are very worried about her. 13. In your opinion, what is going on with Wenwen? (choose all that apply) a. I do not know b. There is nothing wrong with her c. She has depression d. She is schizophrenic 85 e. She has a mental illness f. She has bulimia g. She is having a nervous breakdown h. She has cancer i. Other (please specify) 14. There are different types of people who can help Wenwen. Please indicate if you think getting help from these people would be helpful, harmful, or neither for Wenwen. If you are unsure, check the “I don’t know” box. a. General doctor b. School nurse c. Teacher d. School psychologist e. School social Worker f. Psychiatrist g. Close friend h. Telephone hotline 15. There are some types of products that might help Wenwen. Please indicate what you think will be helpful, harmful, or neither for Wenwen. If you are unsure, check the “I don’t know” box. a. Vitamins b. Tea c. Antidepressants d. Antipsychotics e. Sleeping pills f. Alcohol 16. There are different activities that could help Wenwen. Please indicate which activities you think will be helpful, harmful, or neither for Wenwen. If you are unsure, check the “I don’t know” box. a. Becoming more physically active b. Getting relaxation training c. Practicing meditation d. Getting acupuncture e. Getting up early each morning and getting out into the sunlight f. Receiving therapy with a specialized professional g. Looking up information on a website about her problem h. Joining a support group of people with similar problems i. Going to a specialized mental health service j. Using alcohol to relax k. Using cigarettes to relax 17. If Wenwen was your child, which of the following actions do you think would be helpful, harmful, or neither to Wenwen? If you are unsure, check the “I don’t know” box. a. Talk to her firmly about getting her act together b. Suggest she get professional help c. Make an appointment for her to see a general doctor with her knowledge d. Ask her whether she is feeling suicidal e. Suggest she have a few drinks to forget her troubles 86 f. Rally friends to cheer her up g. Ignore her until she gets over her problem h. Keep her busy to get her mind off her problems i. Encourage her to become more physically active 18. Of the following options, which do you think are ways to prevent mental illness? (Options: Yes, this item prevents mental illnesses; No, this item does not prevent mental illnesses; I don’t know whether or not this item prevents mental illnesses) a. Keeping physically active b. Avoiding situations that might be stressful c. Keeping regular contact with friends d. Keeping regular contact with family e. Not using drugs f. Never drinking alcohol g. Making regular time for relaxing activities h. Having a religious or spiritual belief 87 Appendix B Interview Protocol. Please read the following story: Linlin is a 12 year old girl. Linlin’s current weight is below average for her age and height. However, she thinks she is overweight. Upon starting sixth grade, Linlin started running regularly every day after school. Through this effort she gradually began to lose weight. Linlin then started to ‘‘diet’’, avoiding all fatty foods, not eating between meals, and trying to eat set portions of ‘‘healthy foods’’, mainly fruit and vegetables and bread or rice, each day. Linlin also continued running, losing several more pounds. However, she has found it difficult to maintain the weight loss and for the past 18 months her weight has been continually fluctuating, sometimes by as much as 5 pounds within a few weeks. Linlin has also found it difficult to control her eating. While able to restrict her dietary intake during the day, at night she is often unable to stop eating, bingeing on, for example, a loaf of bread and several pieces of fruit. To counteract the effects of this bingeing, Linlin takes laxative tablets. On other occasions, she vomits after overeating. Because of her strict routines of eating and exercising, Linlin stopped hanging out with her friends on the weekends, like she used to. 1. This question is related to the story you just read about Linlin. In your opinion, what is going on with Linlin? How often do you see what happened to Linlin happening among female Asian teens? If what happened to Linlin happened to your daughter (or son), what would you do? 2. Have you ever personally known a friend or teenager who you think might have an eating disorder? Tell me what you see or saw in that person that makes you think he/she might have an eating disorder. 3. If someone is struggling with an eating disorder, what do you think are some appropriate forms of support or services for them? 4. How to prevent eating disorder? What can teachers or school do to prevent eating disorder? Wenwen is a 13 year old girl who is feeling unusually sad for the last few weeks. She feels tired all the time and she has problems falling asleep. When she is able to fall asleep, she wakes up many times. She has lost her appetite and lately has lost some weight. It is difficult for her to concentrate and her grades have dropped. Her daily activities are a lot for her to handle, which led to her decision to stop attending piano lessons. She also stopped hanging out with her friends, who she used to spend time with every Friday afternoon. Her parents and friends are very worried about her. 5. This question is related to the story you just read about Wenwen. In your opinion, what is going on with Wenwen? What do you think can be done to help Wenwen? If Wenwen is your daughter (or son), what would you do? 6. Have you ever personally known a friend or teenager (or maybe even you) who you think might be depressed? Tell me what you see or saw in that person that makes you think he/she might be (or was) depressed. 7. Have you ever personally known a friend (or maybe even you) who you think might be anxious? Tell me what you see or saw in that person that makes you think he/she might be (or was) anxious. 88 8. If someone is struggling with depression or anxiety, what do you think are some ways to help them? 9. Do you know any teens who have sought help from a counselor or psychologist for anxiety or depression [at school or outside of school]? a. Did you talk about their experiences with them? b. What did they tell you? What did you think about what they told you? 10. What do you think are the barriers for teenagers to seek help from counselors or psychologist for eating disorder, depression or anxiety at school? How are those barriers different from seeking help from counselors or psychologists outside of school? 89 Appendix C Helpful Counts from Surveys. Eating Disorders Sources of Support (Providers) % of Participants Close friend 93.75 School psychologist 87.50 Family member 87.50 School counselor 81.25 Community mental health worker 81.25 Self-help support group 81.25 Psychiatrist 68.75 Dietician or nutritionist 68.75 General doctor 56.25 School social worker 43.75 Minister 43.75 Alternative therapist 37.50 Personal trainer 31.25 Pharmacist 12.50 Commercial weight loss program 6.25 Which providers parents think are helpful for the adolescent in the bulimia vignette. Sources of Support (Activities) % of Participants Getting advice about diet or nutrition 93.75 Getting information about problem eating and 93.75 available services Counseling 87.50 Getting out more/finding new hobbies 81.25 Psychotherapy 75.00 Relaxation therapy/meditation 68.75 Cutting back on exercise 62.50 Self-help treatment manual 62.50 Just talking about the problem 62.50 Cognitive behavior therapy 62.50 Alternative therapy 56.25 Admission to the psychiatric ward 50.00 Social skills training 43.75 Hypnosis 31.25 Trying to deal with the problem on her own 12.50 Which activities parents think are helpful for the adolescent in the bulimia vignette. 90 Depression Sources of Support (Providers) % of Participants Close friend 100.00 School psychologist 92.86 Teacher 71.43 Psychiatrist 64.29 General doctor 57.14 School social worker 50.00 Telephone hotline 50.00 School nurse 21.43 Which providers parents think are helpful for the adolescent in the depression vignette. Sources of Support (Products) % of Participants Vitamins 57.14 Antidepressants 50.00 Tea 35.71 Sleeping pills 35.71 Antipsychotics 7.14 Alcohol 0.00 Which products parents think are helpful for the adolescent in the depression vignette. Sources of Support (Activities) % of Participants Getting relaxation training 100.00 Reading a self-help book on her problem 92.86 Receiving therapy with a specialized 85.71 professional Joining a support group of people with similar 85.71 problems Going to a specialized mental health service 78.57 Becoming more physically active 71.43 Practicing meditation 71.43 Getting up early and getting into the sunlight 71.43 Looking up information on a website about 71.43 her problem Getting acupuncture 21.43 Using alcohol to relax 0.00 Using cigarettes to relax 0.00 Which activities parents think are helpful for the adolescent in the depression vignette. Sources of Support (Parent Action) % of Participants Encourage her to become more physically 92.86 active Suggest she get professional help 85.71 91 Make an appointment for her to see a general 71.43 doctor Talk to her about getting her act together 64.29 Rally friends to cheer her up 57.14 Keep her busy to get her mind off her 42.86 problems Ask her whether she is feeling suicidal 28.57 Suggest she have a few drinks to forget her 0.00 troubles Ignore her until she gets over her problem 0.00 Which parents would do if their child exhibited the symptoms from the depression vignettes. 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