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Qualitative interviews were conducted with 18 urban, African American boys, ages 14 to 18, who were ..... you say you don't have the courage or you say.
Help-Seeking Behaviors and Depression among African American Adolescent Boys Michael A. Lindsey, Wynne S. Korr, Marina Broitman, Lee Bone, Alan Green, and Philip J. Leaf

This study examined the help-seeking behaviors of depressed, African American adolescents. Qualitative interviews were conducted with 18 urban, African American boys, ages 14 to 18, who were recruited from community-based mental health centers and after-school programs for youths. Interviews covered sociodemographic information, questions regarding depressive symptomotology, and open-ended questions derived from the Network-Episode Model— including knowledge, attitudes and behaviors related to problem recognition, help seeking, and perceptions of mental health services. Most often adolescents discussed their problems with their family and often received divergent messages about problem resolution; absent informal network resolution of their problems, professional help would be sought, and those receiving treatment were more likely to get support from friends but were less likely to tell friends that they were actually receiving care. Implications for social work research and practice are discussed. KEYWORDS: adolescents; African Americans; depression; service use; social networks

hildhood depression is a serious public health concern for families, schools, social workers, and other mental health practitioners. Annual estimates in the general population indicate that 8.3 percent of adolescents suffer from depression (Birmaher et al., 1996). Although research indicates that depression is highly amenable to treatment (Petersen et al., 1993), the Surgeon

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General's Report on Mental Health (U.S. Department

of Health and Human Services [HHS], 2001) indicated that few children and adolescents with a depressive disorder receive care. African American adolescents who reside in urhan, high-risk communities may be among the most underserved populations. African American adolescents experience depression more than adolescents from other racial and ethnic groups (Garrison,Jackson,Marsteller, McKeown,&Addy, 1990; Roberts, Roberts, & Chen, 1997;Wu et al., 1999). Because African American adolescents are more likely than other groups to live in low-income households, they may be at particularly high risk of depression. Depression among African American adolescent boys, in particular, has been linked

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to having fewer perceived future opportunities (Hawkins, Hawkins, Sabatino, & Ley, 1998); low neighborhood social capital and kinship social support (Stevenson, 1998); and violent behavior in African American adolescent boys living in an urban, high-risk setting (DuRant, Getts, Cadenhead, Emans, & Woods, 1995). Furthermore, African American adolescents may experience barriers to identifying and using effective treatments. Although African American adolescent boys have been recognized as a group having multiple needs, few of these discussions address their mental health needs. High rates of substance abuse, academic failure (that is, dropout rates), and high arrest and incarceration rates are problems disproportionately experienced by urhan African American adolescent boys (Gibbs, 1990; Hutchinson, 1996; Majors & Billson, 1992). Unrecognized and untreated mental illness may underlie these prohlems. Although researchers have recognized that few African American children and adolescents in need of mental health services receive them (Angold et al., 2002; HHS, 2001), there has been litde discussion of the attitudes and beliefs of the youths, their families,

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and their peers that might contribute to their underutilization of mental health services. It is unlikely that access to services will increase unless we achieve a better understanding of how these youths view their symptoms and service options and how their networks influence these views. For example, studies indicate African American adolescents and adults are less likely than white adolescents and adults to acknowledge the need for mental health services and to be skeptical of using mental health services, especially when they believe they may be stigmatized by their social networks because of their service use (McKay, Nudelman, McCadam, & Gonzales, 1996; Richardson, 2001). African American adolescents and their families are therefore likely to have many negative perceptions (and experiences) of mental health care that reduce the likelihood of their seeking care even when it is available. Social networks (peers and families) play an important role regarding help-seeking behaviors and responses to ill health (Pescosolido & Boyer, 1999; Pescosolido, Wright, Alegria, & Vera, 1998; Rogler & Cortes, 1993). Studies regarding access to care indicate that pathways to care are shaped by the type of problem experienced, as weU as the social support provided by network members (Bussing et al., 2003; Pescosolido, Gardner, & LubeU, 1998). Social networks may attempt to provide care or are used as a resource for identifying pathways to formal help, sometimes coercing the affected individual into care (Pescosolido, Gardner, & LubeU; Pescosolido & Boyer). Social networks also monitor the care received and provide assistance with maintenance of care (that is, offer transportation to care, give appointment reminders), or network members may perpetuate stigma regarding formal service use. Earlier studies examining the use of mental health services have tended to ignore the social processes related to seeking care and advice (Pescosolido, 1991), but these processes may be particularly cogent in considering service seeking among African American adolescent boys. A majority of African American adults use informal help sources exclusively or in combination with professional help in response to psychological distress (Chatters,Taylor, & Neighbors, 1989), These processes are particularly important to consider when discussing adolescents, because adolescents turn first to family members and friends when experiencing a mental

health problem (Boldero & Fallon, 1995; Offer, Howard, Schonert, & Ostrov, 1991; Saunders, Resnick, Hobermann, & Blum, 1994). It is important to improve access to care for African American adolescent boys in mental health treatment.Therefore, the purpose of this study was to explore the help-seeking behaviors and mental health attitudes of depressedAfrican American adolescent boys.To better control for variability in disorder type, the study focused on depression in youths,To better understand the factors that facilitate or hinder entree into treatment, participants included both youths receiving mental health services and youths not in treatment. Findings from this study can inform social work practitioners and other mental health providers in their efforts to facilitate this group's use of services through better understanding of the role that network members play in facilitating or inhibiting service use; and increase the number of services perceived as acceptable and effective to this underserved group through the design of more culturally appropriate interventions and engagement strategies, METHOD Participants and Data Collection Eighteen respondents ages 14 to 18 who were already participating in a broader study titled "Social Network Influences on African-American Adolescents' Mental Health Service Use" (Lindsey, 2002) were recruited for this study. Participants (n = 10) were recruited from community-based mental health treatment centers and a mental health practitioner in private practice and from communitybased, nonclinical programs for high-risk youths (that is, a violence prevention program, truancy abatement center, and homeless shelter) (n = 8). In each setting, all potential participants were individually approached by a therapist or program staff member who explained the study and assessed their participation interest. Flyers were posted in each recruitment site describing the study. Informed consent for participation was obtained from parents or guardians, and informed assent was obtained from participants. Participants in this study were selected on the basis of elevated depressive symptoms as assessed by the Center for Epidemiologic Studies Depression Scale (CES-D) (Radloff, 1977). Of the 69 who participated in the original study, 18 met this criterion and agreed to participate. This study

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received Institutional Revie'w Board (IRB) approval at the University of Pittsburgh (IRB Approval: #001132). Data were collected through a semi-structured interview schedule. Questions were derived from the Network-Episode Model (NEM) (Pescosolido, 1991), in particular the NEM concept network content (that is, degree of support, attitudes, and beliefs toward mental illness and mental health care). In addition to network content, questions were derived from the literature on help-seeking behaviors among adolescents (that is, help-seeking pathways engaged in by youths), as well as the literature on mental health service utilization among African Americans. (See Table 1 for examples of the questions and follow-up probes used in the protocol.) Most of the interviews were conducted in the respondents' homes and a few in community sites: mental health centers or community-based organizations. All interviews were conducted in private areas and lasted between 45 minutes and one hour and 45 minutes. The interview covered processes and help-seeking patterns, network influences, and attitudes toward mental health care and race or ethnicity of the provider.The first author and a trained research assistant conducted the interviews. Participants were encouraged to talk at length about their help-seeking behaviors in relation to their depressive symptoms, with detailed accounts regarding the ways their network influenced their behaviors.They were also asked how they conceptualized and defined mental health and associated emotional and psychological struggles (described in the protocol as "feeling sad or hurt inside").

Interviews were tape recorded, transcribed, and analyzed using inductive coding techniques (Miles & Huberman, 1994).Three readers, including the first author and two research assistants, independently reviewed and coded transcripts to identify patterns and themes emerging from the data. After the review and designation of codes, the readers convened consensus sessions to determine the categories and subcategories of themes. Afinalcoding matrix was developed by the first author to indicate the category and subcategory of themes, a definition clarifying the meaning for each category and subcategory, and corresponding sample quotes that best captured the theme. FINDINGS Themes emerged in the following areas: type of problems experienced, descriptions of help-seeking behaviors, dealing with emotional pain, influence of the social network on help seeking, and perceptions of mental illness and mental health care. Within these themes, differences emerged between respondents in treatment for their depressive symptoms and those not in treatment (Table 2). Influences of Social Network on Experiences of Depression Family members played an important role as sources for help and support as the respondents discussed how they actively sought out family members for help when dealing with depressive symptoms—that is, feeling sad or hurt inside. In many cases, respondents from both groups reported that their mother was the family member they talked to most frequently:

Table 1: Sample Interview Questions and Follow-Up Probes Regarding the Help-Seeking Behaviors among African American Adolescent Boys Question When you start feeling like something makes you feel sad or hurt inside what do you do?

Probes •

How did you know that you needed to talk with somebody?

•

Was there anyone who helped you to recognize or identify the feelings that you were having? Whom did you turn to first for help?

•

If you felt you just couldn't handle things going on in yout life, where would you prefer to go for help? Why?

•

Are there other things you tried to do to help you feel better beyond talking with other people?

• •

How did these other things work? (If therapist/counselor not mentioned) Why wouldn't you go to a therapist/ counselor?

•

What would your friends think if you went to a therapist/counselor?

•

What about your family?

LiNDSEY ET AL. / Help-Seeking Behaviors and Depression among African American Adolescent Boys

Table 2: Emerging Themes Regarding Hetp Seeking and Depression among African American Adolescent Boys, by Treatment Status (n = 8) ^in treatment (n a ,10) Problems experienced

Interpersonal conflict among peers

Family strain

Problems at school (behavioral or academic) Behaviors when dealing with a problem

Talks to family and friends Isolation

Talks to fomily only

People helping to identify the problem (other than family)

Self

No one

Preference for help

Family first, then professionals

Teacher or other school personnel

When problems are too bad where I just can't, I can't hke stop them, I can't do nothing, can't control it or nothing. I try to go out and play, but for some reason it pops back up in my head, and I can't get it out so I go to her [referring to his mother], (participant not in treatment) * * * (Referring to what prompts him to talk to his mother)

Like I mean if something happened like with me or my friends that we couldn't handle as friends, we couldn't handle as minors, but something that my mother should know... I mean I'm thankful that I have an understanding mom and all that, (participant in treatment) Family members were equally important for both groups regarding advice or counsel received when feeling sad or hurt inside. However, those in treatment typically received advice and counsel from friends as well, whereas those not in treatment typically sought the advice and counsel of only their family members. As a way to deal with feeling sad or hurt inside, some respondents talked about how they would spend time alone or isolate themselves before or in place of talking with someone in their network: Just deal with it. There's nothing—I mean it's just life. I go through. I mean I don't know. I don't seek no help. I don't talk to nobody or nothing. I just go on with whatever I'm doing, (participant in treatment) * * * I try to go within myself so I pretty much get the answers. It's like a self-conscious, (participant in treatment)

Family only

Adolescent boys in treatment typically identified their emotional and psychological struggles on their own,first,with eventual assistance from family members: I just feel it It's a certain, it's a certain rush that you get sometimes. Nothing like on a football field or anything, but just your heart's racing, and I think that's the best sign of you knowing when to talk to someone. Even if you say you don't have the courage or you say you don't want to, but deep down you really do because the only way to really solve anything is to talk to someone, (participant in treatment) Engagement in religious or spiritual activities was not a common response to feeling sad or hurt inside among this sample. This finding was striking given the historical role of spirituality and religion as a source for coping, support, and healing among African Americans. Only two of the 18 respondents, one from each group, reported that they currently engaged in activities such as praying or going to church. Influences of Social Network on Help Seeking and Service Use Network's Influence on Receipt of Formal Services. The respondents who were in treatment (n = 10) were asked to address questions regarding the process by which they were initially referred to formal mental health treatment. Five of the 10 respondents reported that they were referred to treatment by their school when teachers noted a decrease in functioning (academically and behaviorally) and parents

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or guardians agreed that professional help should be sought for these problems: They |teachers and school officials] were like, maybe what you should do is and they were feeding her [mother] — and it's like more than one teacher saying it... And they're like maybe you should do this. And then she put me in the program up at [outpatient treatment facility]. It was a recommendation... It was a recommendation, yeah, from a lady at school... to niy mother. And they had said, you know, try this out. They thought I had ADHD, they thought I was bipolar and all this stuff, but they couldn't put their finger on it. There was nothing that they could do to figure out exactly what was wrong with me. Four ofthe 10 reported that a parent suggested or referred them for treatment: My mom,yeah.Because she thought I had,you know, problems, issues or whatever. She just got me a counselor. A parent's suggestion, however, should be distinguished here from a parental mandate. Several respondents (three of 10) reported that a parent mandated formal mental health treatment, and they disagreed with this mandate:

stead of just being alone and coming here... That [if family was not supportive] would definitely affect my mood at least. Maybe not necessarily coming here, but confidence-wise, it would definitely be a lot lower than what it is right now. (participant in treatment) In contrast to those respondents not in treatment who reported that their family \vould support their use of mental health services, some from this group said that their family would not support their use of formal services. This finding should be further viewed in light ofthe problem the not-intreatment group typically reported experiencing: family strain (problems related to family relations). Two respondents not in treatment reported that their family would want to handle problems regarding family relations among themselves without seeking professional help: Because they feel as though why go to a counselor when I could come to them. iff

H;

:/p

I think my mom would probably ask me why I didn't come to herfirstor something like that. "What's wrong with you?" She'd probably get mad. I don't know. But it's like why didn't I come to her first and talk to her about it instead of me going to a therapist.

Respondents not in treatment also said that they would not talk to friends about their problems, typically because their friends would not be supShe's making me [go to a MH professional]. If portive of their receipt of formal mental health serI had a choice or my say so, all this wouldn't be vices. In contrast, many respondents in treatment going on because I'm cool. I don't feel there's would talk to their friends when dealing with denothing wrong. I don't need no help. She asked pressive symptoms. However, they would not tell me ifl did. I laughed at her like,'What? Yeah, their friends they were receiving mental health right.' treatment—fearing that friends would laugh, joke, Network Members' Thoughts about Respondent's or tease them: Use of Formal Services, When asked whether family or friends would be supportive of their use of They'd probably think—they might joke mental health services, respondents from both around and say like, it's bad for me, you know, groups said that their family would support their like I'm crazy or something so I would like use of formal mental health treatment: keep it to niy family and myself, (respondent in treatment) They've [family] always been very supportive... Even though a lot of them aren't really around Attitudes toward Mental Health Care me, aren't really that close to me. There's still and Professionals enough love to go around. And with that, it Respondents from both groups w^ere asked to share makes it easier to come here [to treatment] intheir thoughts and perceptions regarding why it is

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difficult for mental health treatment providers to engage African American adolescent boys in mental health services. The respondents talked about the issue of stigma as a barrier associated with mental health service use. In particular, shame, embarrassment, and exclusion emerged from the interviews as themes regarding the influences of the network on mental health service use: Because their friends might sometimes think like they're crazy and stuff like that. Wouldn't want to hang around them. And they'll just sit there and make up more excuses to stay away from them. It [mental health treatment] would draw all that person's friends away from him too.Then that person would just be, like, down in the dumps, (respondent in treatment) Respondents from both groups said that many African American adolescent boys sought to handle their problems on their own or had too much pride to go to formal mental health treatment: And I guess a lot of them would think, well, I don't need it. I'm this. I'm from here. I can do this. I can do that. So they would... they have a certain feeling where they think they could get through it alone when they really couldn't, (respondent in treatment) * * * (Referring to pride) Like I'm not, you know, I'm too good to go to a counselor. Like I don't think I'm very sick or I don't think nothing's wrong with me. I act normal. I'm normal.You know, difFerent things like that. False sense of themselves, (respondent not in treatment) Furthermore, respondents shared their perceptions that talking to a mental health professional, for some African American adolescent boys, meant that they would have to express their emotions associated with feeling sad or hurt inside, and that the expression of emotions was viewed as a sign of weakness among this population: Like they weren't manly enough. Like little girls, (respondent in treatment) * * * (Askingfor help) .. .means that you're gay.That's what it means.That's how they [African American adolescent boys] interpret it. It means—

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well, I mean you go down the line. If you ask for help, or if you cry, or if you look emotional, if you feel depressed, that means you're soft. If you're soft, then you're gay and you're not hard and not tough You can't let anybody know that you're soft. I swear it's like being in jail, (respondent in treatment) These comments reflect a certain machismo related to what may be defined among this population as a lack of strength when expressing emotions (that is, crying) or asking for help. Similarly, use of the vernacular "gay" among this group is part of a machismo culture that ascribed being weak or lacking strength to being feminine and further serves as an impediment to acknowledging the need for help and engaging in healthy forms of emotional expression. When asked whether race of the provider affected mental health service utilization among African American adolescent boys, respondents said: [Tjhey [African American adolescent boys] don't think that they [white professionals] can understand what they're coming from, (respondent in treatment) * * * And I mean it might be one of the . . . it might be a race issue because some—I think that there are some black people who close themselves off from white people. And, you know, in the mental health field, there is a majority of white people, I think, (respondent in treatment) Although the majority of the respondents said that race mattered, a few indicated that race of the provider was not as important; rather, what was important was how the provider treated them and how well the provider engaged them. One respondent said: I can't say it [race of the provider] would make a difference at all because it's about getting help. It's about having someone that's there for you to understand what you're going through and to give you advice, to give you encouragement, to help you sort out things that you're going through. So with me, white or black doesn't really make a difference. What matters is that we're trustworthy of each other, (respondent in treatment)

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DISCUSSION The adolescent boys in this study were generally similar to those in broader studies of nonclinical populations (see Boldero & Fallon, 1995; Snell, 2002) in terms of seeking help first from family and at other times from friends and peers. In particular, peers appear to have a powerful influence on this group regarding the admission of emotional or psychological problems, as well as the acknowledgment ofthe receipt of formal mental health services. Those who were in treatment said that they received emotional support from their friends, and that they were able to talk to friends about their problems. However, additional analyses of this group revealed that most were reluctant to tell their friends that they were going to formal mental health services, fearing that friends would poke fun at them. These contrasting findings reflect the importance of distinguishing between individually felt stigma (that is, negative beliefs or perceptions of service use emanating from within the individual) and network-induced stigma (that is, negative beliefs or perceptions articulated by friends regarding the affected individual's service use) when developing interventions and strategies to combat stigma related to service use for this group. Findings regarding the influence of peer networks also reflect the seemingly reasoned calculation about friends by respondents in this study, such as when to talk to them, what to share with them, and how supportive friends would be regarding the problem they are facing. This study gives a detailed description of the pathways to help seeking for African American adolescent boys with depressive symptoms, in particular, the roles of family, schools, and social agencies. For respondents receiving mental health care, identification of their mental health problems was more likely to come from family members and school personnel. Although respondents in mental health treatment reported that they initially tried to solve their problems on their own, family members and school personnel still played an active role in confirming their depressive symptoms and facilitating their access to mental health services. It is worth noting that the majority ofthe respondents who were receiving mental health services reported that the types of problems they experienced concerned issues associated with the school environment (that is, academic achievement or behavioral

problems). This finding highlights the important role teachers and other school personnel (such as school social workers) play in the assessment of mental health problems and making referrals to treatment. Challenges for Social Work Adolescent boys with high levels of depressive symptoms who are not in treatment, however, may pose a special challenge. Respondents who were not in treatment in this study reported that the problems they most often experienced concerned strained family relations. However, family members often counseled them against going to a professional for help regarding these emotional problems. The predicament ofthe subgroup of respondents in this study who were experiencing high levels of depressive symptoms but were not in mental health treatment raises concern. At the time of the interview, each respondent was involved in communitybased programs targeting high-risk youths, including a youth employment program, a violence prevention program, a truancy abatement program, and a homeless shelter. However, no one in these settings engaged them about their emotional and psychological struggles by attending to their needs or referring them to care. Although it is important that social work practitioners and other mental health professionals target the development of strategies to address the attitudes ofyouths toward mental illness and treatment, the situation for this subgroup of youths also reveals that those involved 'with serving them need to be more sensitive to their mental health needs.These professionals could provide assistance to youths by being referral agents and sources of personal support. For this high-risk group, religious congregations and affiliated organizations that address contemporary youth problems from a spiritual perspective may serve as an alternative to seeking formal professional help when dealing with mental health problems. However, unlike earlier literature (for example, Varon & Riley, 1999) that documented the importance of spirituality and the church in the lives of African Americans, problem solving through prayer or seeking support from the church did not play a significant role in the lives of respondents in this study.This finding could be misleading and illustrates the need for more empirical research to examine the extent to which the general population of African American adolescent boys seeks

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help from lay and ministry counselors and other adult spiritual figures. Functional impairment as a result of experiencing depressive symptoms may clarify the issue of why two subgroups of youths with similar depressive symptom scores have disparate treatment trajectories. Based on the self-report of problems experienced between the two subgroups, respondents in treatment said that their problems related to interpersonal conflict and problems at school—behavioral or academic, whereas respondents not in treatment said that their problems related to family strain. Depressive symptoms and associated problems seemed to be recognized or identified by network members when there was an accompanying issue related to functionahty. Thus, the perceptions of network members regarding what constitutes impairment needs to be understood as a potential facilitator or barrier to formal mental health treatment. Limitations of the Study Because this study focused on depressive symptoms as an indicator of mental health need, we cannot determine how other mental health problems, for example, behavioral disorders (such as conduct disorder and ADHD), in addition to depressive disorders might differentially or concomitantly affect service referral or service use. Confirmatory and comparative analyses from the perspective of actual network members would have been desirable, but limitations of time and funding dictated that this study be restricted to the adolescents' perceptions of their social network's influences on mental health services use or nonuse. Although the findings are based on the perspectives of a subgroup ofAfrican American adolescent boys, this study laid the groundwork for a more extensive investigation of these issues in follow-up studies and for the design of an outreach and an engagement strategy for depressed African American adolescents. IMPLICATIONS FOR PRACTICE

Findings from this study have important implications regarding the recognition and identification of depressive symptoms among African American adolescent boys. Strategies to improve the identification and recognition of depressive symptoms among members of this group are needed, especially in schools and other community-based or-

ganizations. Social workers and mental health services providers might be looking for depressive symptom expression that fits the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)

criteria (American Psychiatric Association, 2000) and may miss the more subtle forms of expression unique to this group. Social workers and mental health service providers need to work collaboratively with community-based organizations serving this group. For example, social workers may provide training and education to staff regarding the signs and symptoms of depression, target strategies that attempt to ameliorate the perceived stigma among this group and those in their network, and develop intervention models that better engage families by incorporating them into the treatment process throughout the course of care. Better identification of mental health problems (that is, depression) by social network members and those who provide treatment needs to become a targeted education strategy. Quite often professional help is a source of mental health care of last resort.There are multiple barriers regarding the help-seeking behaviors among adolescents enrolled in community-based programs, including stigma associated with mental illness, machismo and pride, and families and adolescents who believe that depression can be resolved without professional help. Therefore, it is necessary to reframe help seeking as a positive, proactive behavior among African American adolescent boys and their families. IMPLICATIONS FOR RESEARCH

Future research needs to address the role of family and peers in the help-seeking process. Interventions that are effective for African American youths are particularly needed because social and family networks are not likely to be active usen of mental health services, except when these are initiated through school. Survey research is needed to determine the extent to which the attitudes shown by youths in the single community studied are consistent across the country and the extent to which these attitudes are similar to or different from those of youths from other racial and ethnic groups. Particular attention should be given to determining the extent to which parents, especially mothers, and peers may inhibit help seeking among this group. Once a better understanding of the network members' role in inhibiting the help-seeking process is

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ascertained, strategies for removing these barriers can be developed. Studies examining the impact of referral type (mandated versus choice) on perceptions and use of mental health services have been done with adults (Pescosohdo, Gardner, & Lubell, 1998). However, future research needs to examine this issue among adolescents of color, as well as the extent to which parent and child disagreement regarding problem identification and definition negatively affect the engagement process and utilization of mental health services. Finally,findingsfrom this study indicate that race ofthe provider was seen as an important issue among some respondents, particularly the belief that providers who were not African American would be unable to effectively treat this population. Thus, future research regarding the mental health treatment experiences of this group is necessary to determine how provider characteristics (that is, race and gender) affect engagement and mental health treatment. REFERENCES American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders {text revision) (DSM-IV-TR). Washington, DC: American Psychiatric Press. Ango)d,A.,Erkanli,A., Farmer, E. M. Z., Fairban)c,J. A., Burns, B. J., Keeler, G , & Coste))o, E. J. (2002). Psychiatric disorder, impairment, and service use in rura) African American and white youth. Archives of General Psychiatry, 59, 893-901. Birmaher, B., Ryan, N. D.,Williamson, D. E., Brent, D. A., Kaufman,J., Dahl, R. E., Perel,J., & Nelson, B. (1996). Childhood and adolescent depression: A review ofthe past 10 years. Part \.Journal ofthe American Academy of Child & Adolescent Psychiatry, 35, 1427-1439. Boldero,J.; & Fallon, B. (1995).Adolescent help-seeking: What do they get help for and from vihorni journal ofAdolescence, t8, 193-209. Bussing, R., Zima, B.T., Gary, F. A., Mason, D. M., Leon, C. E., Sinha, K., & Garvan, C.W. (2003). Social networks, caregiver strain, and utilization of mental health services among elementary school students at high risk for ADHD. Jowrafl/ of the American Academy of Child & Adolescent Psychiatry, 42, 842— 850. Chatters, L.,Taylor, R., & Neighbors, H. (1989). Size of informal helper network mobilized during a serious personal problem among black Americans. Joiirna/ of Marriage and the Family, 51,667—676. DuRant, R. H., Getts, A., Cadenhead, C , Emans, S. J., & Woods, E. R. (1995). Exposure to violence and victimization and depression, hopelessness, and purpose in life among adolescents living in and around public housing. Developmental and Behavioral Pediatrics, 16,233-237. Garrison, C., Jackson, K., Marsteller, R, McKeown, R., & Addy, C. (1990). A longitudinal study of depressive symptomotology in young adolescents.JowrMa/ ofthe

American Academy of Child & Adolescent Psychiatry, 29, 581-585. Gibbs,J. (1990). Mental health issues of black adolescents: Implications for policy and practice. In A. Stiffman & L. Davis (Eds.), Ethnic issues in adolescent mental health (pp. 21-52). Newbury Park, CA: Sage Publications. Hawkins,W., Hawkins, M., Sabatino, C , & Ley, S. (1998). Relationship of perceived future opportunity to depressive symptomotology of inner-city AfricanAmerican adolescents. Children and Adolescent Services, 20, 757-764. Hutchinson, E. (1996). The assassination ofthe black male image. Los Angeles: Middle Passage Press. Lindsey, M. (2002). Social network influences on AfricanAmerican adolescents' mental health service use. Unpublished doctoral dissertation. University of Pittsburgh. Majors, R., & Billson,J. (1992). Cool pose—The dilemmas of black manhood in America. NewYork: Lexington Books. McKay, M., Nudelman, R., McCadam, K., & Gonzales, J. (1996). Involving inner-city families in mental health services: First interview engagement skills. Research on Social Work Practice, 6, 462-472. Miles, M., & Huberman,A. (1994). Qualitative data analysis: An expanded source book (2nd ed.).Thousand Oaks, CA: Sage Publications. Offer, D , Howard, K., Schonert, K., & Ostrov, E. (1991). To whom do adolescents turn for help? Differences between disturbed and nondisturbed adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 30, 623-630. Pescosolido, B. (1991). Illness careers and network ties: A conceptual model of utiUzation and compliance. Advances in Medical Sociology, 2, 161—184. Pescosolido, B., & Boyer, C. (1999). How do people come to use mental health services? Current knowledge and changing perspectives. In A. Horwitz &T. Scheid (Eds.), A handbook for the study of mental health: Social contexts, theories, and systems (pp. 392411). NewYork: Cambridge University Press. Pescosolido, B., Garner, C , & Lubell, K. (1998). How people get into mental health services: Stories of choice, coercion, and "muddling through" from "first timers." Social Science and Medicine, 46, 275—286. Pescosolido, B., Wright, E., Alegria, M., & Vera, M. (1998). Social networks and patterns of use among the poor with mental health problems in Puerto Rico. Medical Care, 36, 1057-1072. Petersen, A. C , Compas, B. E., Brooks-Gunn,J., Stemmler, M., Ey, S., & Grant, K. (1993). Depression in adolescence. ^mcricuM Psychologist, 48, 155-168. Radloff, L. S. (1977).The CES-D Scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385401. Richardson, L. (2001). Seeking and obtaining mental health services:What do parents expect? Archives of Psychiatric Nursing, 15, 223-231. Roberts, R., Roberts, C , & Chen, R. (1997). Ethnocultural differences in prevalence of adolescent depression. American Journal of Community Psychology, 25,95-110. Rogler, L., & Cortes, D. (1993). Help-seeking pathways: A unifying concept in mental health care. American Journal of Psychiatry, 150, 554-561. Saunders, S., Resnick, M., Hobermann, H., & Blum, R. (1994). Formal help-seeking behavior of adolescents identifying themselves as having mental health problems.JoHDifl/ of the American Academy of Child and Adolescent Psychiatry, 33, 718-728.

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Snell, C. (2002). Help-seeking and risk-taking behavior among black street youth: ImplicationsforHIV/ AIDS prevention and social policy. Jourwii/ of Health and Social Policy, 16, 21-32. Stevenson, H. (1998). Raising safe villages: Culturalecological factors that influence the emotional adjustment of adolescents. JoMrna/ of Black Psychology, 24, 44-59. U.S. Department of Health and Human Services. (2001). Mental health: Culture, race, and ethnicity—A supplement to mental health: A report of the surgeon general. Rockville, MD: Author. Varon, S., & Riley,A. (1999). Relationship between maternal church attendance and adolescent mental health and social functioning. Psychiatric Services, 50, 799-805. Wu, P., Hoven, C , Bird, H., Moore, R., Cohen, P., Alegria, M.,Dulcan, M., Goodman, S., Horwitz, S., Lichtman, J., Narrow,W., Rae, D , Regier, D., & Roper, M. (1999). Depressive and disruptive disorders and mental health service utilization in children and adolescents.Jowma/ of the American Academy of Child & Adolescent Psychiatry, 38, 10811090. Michael A. Lindsey, PhD, MSU^MPH, is assistant professor. School of SocialWork, University of Maryland, 525 West Redwood Street, Baltimore, MD 21201; e-mail: [email protected]. Wynne S. Korr, PhD, is dean and professor, School of Social Work, University of Illinois, Urbana-Champaign. Marina Broitman, PhD, is scientific review administrator. Division of Extramural Affairs, National Institute of Mental Health, Bethesda, MD. Lee Bone, MPH, RN, is associate public health professor, Bloomberg School of Public Health. Alan Green, PhD, is assistant professor. School of Counseling and Professional Services, and Philip J. Leaf, PhD, is professor, Bloomberg Schoot of Public Health, Johns Hopkins University, Baltimore. This study was funded by the National Institute of Mental Health through a dissertation grant (i RO3 MH63593-01) and theW.K. Kellogg Foundation (Community Health Scholars Program), Michael A. Lindsey, PhD, principal investigator, as well as the Grants for National Academic Centers of Excellence on Youth Violence Prevention (R49/CCR318627-01), Philip J. Leaf, PhD, principal investigator. An earlier version of this article was presented at the meeting of the Society for Social Work and Research, January 2004, New Orleans. Original manuscript received October 30, 2003 Finai revision received July 19, 2004 Accepted April 11,2005

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