pdf[1]

PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ May 2007 Vol. 58 No. 5 661199

Recent events involving vio-lence initiated by school-agechildren have raised concerns

about how mental health problemsmay be implicated (1,2). For example,the National Research Council’sanalysis of eight cases of lethal school

violence noted that “Serious mentalhealth problems, including schizo-phrenia, clinical depression, and per-sonality disorders, surfaced after theshootings for six of the eight boys” (3).Researchers also have maintained thatan important risk factor for violence is

untreated conduct disorder (4,5), asreflected in the high levels of untreat-ed mental health problems among ju-venile detainees (6–8). Finally, data onthe decision to hospitalize childrenshow a clear association with percep-tions of dangerousness (9).

By law and custom, parents serve asprimary gatekeepers or “key recog-nizers” (10) of children’s mentalhealth, at least until that point in ado-lescence when responsibility mightbe shared with the child. However,mental health problems often cometo light only through the child’s schoolor through social welfare or criminaljustice systems. Parents may respondrather than initiate action when prob-lems arise. Unfortunately, researchalso suggests that experts in these sys-tems, as well as those in the primarycare system, are not well equipped todiagnose mental health problems(11). Furthermore, a dilemma uniqueto mental health is faced by parentswho may be required to give upparental rights in order to providechildren with needed services (11).This unique constellation of problemsfaced by children, their parents, andothers suggests that cultural climatemay shape children’s pathways to careand the understanding of the socio-cultural context, and it may offer im-portant information for clinical en-counters and policy.

Arguments such as these often leadto greater societal anxiety and stigmaregarding the presumed dangerous-ness of children with mental healthproblems. Although incidents of ex-

Perceived Dangerousness of Children With Mental Health Problems and Support for Coerced TreatmentBBeerrnniiccee AA.. PPeessccoossoolliiddoo,, PPhh..DD..DDaanniieellllee LL.. FFeetttteess,, MM..AA..JJaacckk KK.. MMaarrttiinn,, PPhh..DD..JJoohhnn MMoonnaahhaann,, PPhh..DD..JJaannee DD.. MMccLLeeoodd,, PPhh..DD..,, MM..PP..HH..

Dr. Pescosolido, Ms. Fettes, Dr. Martin, and Dr. McLeod are affiliated with the Depart-ment of Sociology, Indiana University, 1020 E. Kirkwood Ave., Ballantine Hall 744,Bloomington, IN 47405 (e-mail: [email protected]). Dr. Monahan is with the Schoolof Law, University of Virginia, Charlottesville. This article is part of a special section ofreports based on the 2002 National Stigma Study–Children, for which Dr. Pescosolidoserved as guest editor.

Objective: This study examined the public’s beliefs regarding the poten-tial for harm to self and others and the public’s willingness to invoke co-ercive or legal means to ensure treatment of children. Methods: Usingdata from the National Stigma Study–Children (NSS-C), which present-ed vignettes to 1,152 individuals, the investigators compared public per-ceptions of the dangerousness of children with attention-deficit hyper-activity disorder (ADHD), major depression, asthma, and “daily trou-bles.” Multivariate analyses were used to examine the predictors of per-ceptions of dangerousness and the willingness to support legally en-forced treatment of these conditions. Results: Children with ADHD andchildren with major depression were perceived (by 33% and 81% of thesample, respectively) as somewhat likely or very likely to be dangerousto themselves or others, compared with children with asthma (15%) orthose with “daily troubles” (13%). Over one-third of the sample (35%)were willing to use legal means to force children with depression to seea clinician. However, even more (42%) endorsed forced treatment for achild with asthma. Furthermore, individuals who labeled the child as“mentally ill” were approximately twice as likely to report a potential forviolence and five times as likely to support forced treatment. Conclu-sions: Large numbers of people in the United States link children’s men-tal health problems, particularly depression, to a potential for violenceand support legally mandated treatment. These evaluations appear toreflect the stigma associated with mental illness and the public’s concernfor parental responsibility. (Psychiatric Services 58:619–625, 2007)

SSppeecciiaall SSeeccttiioonn oonn tthhee NNaattiioonnaall SSttiiggmmaa SSttuuddyy––CChhiillddrreenn

pesper.qxd 4/17/2007 11:02 AM Page 619

treme school violence (such as the1999 shootings at Columbine HighSchool) are rare, and extant researchindicates that mental illness is not aprimary cause of violence amongyouths in the United States (12),statements by some child develop-ment experts continue to raise thisspecter. According to Garbarino, asquoted in McFarling (13), “Virtuallyevery school in America contains boyswho are troubled enough, violentenough, and righteous enough thatthese shootings are destined to be-come part of the fabric of Americanadolescence.”

These societywide concerns raise atleast four questions. First, how dan-gerous does the public perceive chil-dren and adolescents with mentalhealth problems to be? Although vio-lence is tied to criteria for some child-hood mental health disorders—suchas conduct disorder and oppositionaldefiant disorder (14)—a link betweenviolence and mental health problemshas been difficult to ascertain evenamong adults. Evidence suggests onlya modest relationship between men-tal disorder and violence, a relation-ship that is largely attributable to co-occurring substance abuse (15). Un-fortunately, public perceptions thatmental illness and violence go hand inhand may be more important than theevidence (16–18). Puzzling over find-ings that stigma associated with men-tal illness has increased, the SurgeonGeneral asked why stigma is so perva-sive, despite a more informed publicunderstanding of mental illness. Theanswer, he concluded, appears to berooted in a fear of violence (19). Weask, How does the general publicview the potential of harm to self andothers among children and adoles-cents with mental health problems?

A second question targets the ex-tent to which legal measures and so-cial pressures endorse treatment forchildren and adolescents with mentalhealth problems. Again, research onchildren is virtually absent. A recentstudy found that 51% of adults receiv-ing treatment for serious mental dis-orders experienced some form of“leverage” into care (20). Not surpris-ingly, then, coercion remains a “flash-point” in mental health law (20). Yet,what we know about the topic is limit-

ed. Discussions of the legality andethics of coercion are contentious(21,22) and represent one of thelongest-running controversies amongmental health professionals and civilliberties groups (23–26). Justificationsfor coercion include ensuring publicsafety and delivery of mental healthservices to reluctant or noncompliantindividuals believed to need treat-ment. Although most existing publichealth laws affirm the right of peoplewith mental disorders to withholdconsent for treatment, all Westerncountries, motivated by concerns forboth society (potential harm to others)and for the individual (potential harmto self), have legislation that allows in-voluntary treatment (27,28).

The situation for children and ado-lescents is more complicated and lessdiscussed. A clash of rights exists, pit-ting the rights of parents to rear chil-dren as they see fit against the rightsof children to receive treatment andagainst the rights of the community tobe protected. Forcing a child intotreatment is seen by some as “a legit-imate role for parents or guardians . . .especially in the case of school-agechildren, who only rarely initiate re-quests for help” (29). Children andadolescents infrequently initiatetreatment; they tend to enter servicesthrough the efforts of “gatewayproviders” (10), including parents,teachers, and juvenile justice authori-ties (30,31). Regardless, Costello andcolleagues’ (10) question remains;that is, “Under what conditions is itthe mark of good parenting to consulta professional, and a cause for con-cern if the family cannot or will not doso?” The answer is not simple andcenters on the cultural norms in bothlay and professional communities.Simply stated, what does the publicexpect when mental health problemsarise?

Third, to what extent do differentsubgroups in the community stigma-tize persons with mental health prob-lems? For example, it is well docu-mented that tolerance of individualsconsidered to be “different” varies bythe characteristics of the evaluator—for example, better educated evalua-tors tend to exhibit more toleranceacross a range of issues, by region ofresidence (that is, residents of south-

ern states are generally less tolerantthan residents elsewhere), and size ofplace of residence (that is, urbandwellers are generally more tolerantthan nonurban dwellers) (32).

Fourth and finally, does the label of“mental illness” per se contribute toperceptions of dangerousness or awillingness to invoke coercive means?We hypothesized that children de-scribed as having a mental healthproblem (specifically, attention-def-icit hyperactivity disorder [ADHD]or major depression) and those whomrespondents see as having a mentalillness will be more likely to be per-ceived as dangerous to self or othersand more likely to be seen as candi-dates for legally coerced treatmentwhen compared with children de-scribed as having asthma or routineproblems.

Using data from the National Stig-ma Study–Children (NSS-C), we ex-amined these competing questionsby evaluating responses to two vi-gnettes describing children who metDSM-IV diagnostic criteria forADHD and those who met criteriafor major depression. As a control,two additional vignettes describedchildren who had “daily troubles”and those who had asthma. [Vi-gnettes are included as an online sup-plement to this article at ps.psychiatryonline.org.] We examined com-munity-based beliefs on dangerous-ness, community norms surroundingwillingness to coerce treatment, thelink between the two, and the links tocultural subgroups. This research de-sign allowed for a test of Costello andcolleagues’ (10) claim that thethreshold for initiating treatment formental health is set higher than thatfor physical health problems.

MethodsSampleData came from the 1,152 respondentsto the 2002 General Social Survey withcomplete data on the coercion anddangerousness items in the NSS-Cmodule (33). Of this subsample, 899(78%) were white, 172 (15%) wereAfrican American, and 81 (7%) were ofanother race (such as Asian American).Respondents had a mean±SD age of44±16.4 years. They also had 12.0±2.8years of education and a family (house-

PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ May 2007 Vol. 58 No. 5662200


hold) income of $50,000±$39,490. Inthe analyses reported here, we useddata from responses about two vi-gnettes that described youths who metcriteria for ADHD and depression orwho had asthma and “daily troubles.”The sample used in this analysis wasself-weighting. Institutional reviewboard approval for the General SocialSurvey was provided by the Universi-ty of Chicago, and approval for sec-ondary data analysis was given by In-diana University. Per standard proto-col for in-person surveys, oral in-formed consent was secured at thetime of the interviews.

Dependent variablesRespondents were asked how likelythe vignette child was to be danger-ous to self or others. Specifically,“How likely in your opinion is it[Name] would do something violenttoward other people—is it very likely,somewhat likely, not very likely, or notat all likely?” and “How likely in youropinion is it [Name] would do some-thing violent to [him/her]self?” Re-sponse categories were coded from 4to 1, respectively. In all multivariateanalyses (Tables 1 and 2), the “verylikely” and “somewhat likely” re-sponses were combined and coded 1.The “not very likely” and “not at alllikely” responses were also combinedand were coded 0.

Respondents were also asked, “Doyou think that parents of children like[Name] should be forced by law tohave [Name] treated at a clinic or bya doctor?”, “. . . to take a prescriptionmedication to control [Name’s] be-havior?”, and “. . . to admit [Name] toa hospital for treatment?” Responsecategories were yes (coded 1) and no(coded 0).

Independent variablesVignette types were coded into a setof binary dummy variables (ADHD,depression, and asthma), with the“daily troubles” condition serving as areference category. Three character-istics of the child described in the vi-gnette were coded: gender (female, 1;male, 0), race (African American, 1;white, 0), and age (14 years old, 1;eight years old, 0). Respondents werealso asked whether the vignettechild’s problem represented a mental

illness, a physical illness, or both (ill-ness labels were coded 1 for yes and 0for no).

Five sociodemographic variablesdetermined relevant for assessmentsof dangerousness or coercion by pre-vious research (28,32,35) were in-cluded to describe respondents: age(in years), gender (men, 1; women,0), race (African Americans, whereAfrican Americans and respondentsof other races were coded 1 andwhites were coded 0), family income(annual total family or household in-come in tens of thousands of dollars),and education (in years).

AnalysesBivariate and multivariate analysesassessed responses on perceived dan-gerousness and willingness to use co-ercion. Bivariate techniques (chisquare analyses) were used to deter-mine whether dangerousness and co-ercion varied according to the vi-gnette child’s type of problem. Esti-mates from ordered logistic regres-sion models were used to examinewhether children’s or respondent’scharacteristics shaped perceptions of

potential for violence. Bivariate logitregression estimated these predic-tors’ effects on coercion. Additionalanalyses (not shown) were conductedwith multinomial logistic models, andresults were consistent. Odds ratiosand 95% confidence intervals are re-ported, and all significance tests weretwo-tailed.

ResultsExamination of the bivariate data in-dicates that public perceptions ofdangerousness and willingness to usecoercion differed significantly by vi-gnette type (Table 3). For perceiveddangerousness, significantly more re-spondents saw the child with ADHDor depression (versus the other chil-dren) as likely to be violent towardothers (χ2=231.50, df=9, p<.001). Aneven stronger pattern emerged re-garding violence toward self, where33% perceived the child with ADHD,and an overwhelming 81% viewed thechild with depression, as at leastsomewhat likely to be at risk of harm-ing him- or herself (χ2=481.14, df=9,p<.001).

A somewhat different pattern


TTaabbllee 11

Predictors of the public’s perceptions of the dangerousness of children, from the2002 National Stigma Study–Children (N=1,152)a

Violent toward othersb Violent toward selfc

Item (reference group) OR 95% CI OR 95% CI

Vignette characteristicADHD (daily troubles)d 2.04∗∗∗ 1.45–2.88 1.90∗∗∗ 1.36–2.66Depression (daily troubles) 2.15∗∗∗ 1.50–3.10 10.43∗∗∗ 7.13–15.26Asthma (daily troubles) .41∗∗∗ .28–.62 .56∗∗ .38–.82Female (male) .60∗∗∗ .48–.75 .78∗ .63–.98African American (white) .87 .70–1.09 .99 .79–1.2414 years old (8 years old) .73∗∗ .58–.91 1.00 .80–1.24

Illness labelMental illness (not) 5.08∗∗∗ 3.78–6.84 5.72∗∗∗ 4.26–7.69Physical illness (not) 1.19 .90–1.56 1.53∗∗ 1.16–2.02

Respondent characteristicFemale (male) 1.01 .80–1.27 1.12 .89–1.40African American (white) .77 .55–1.08 .81 .58–1.12Other race (white) 1.32 .83–2.08 1.52 .96–2.41Age 1.01 1.00–1.01 1.00 .99–1.01Education .96 .92–1.00 1.01 .96–1.05Income 1.00∗∗ 1.00–1.00 1.00∗ 1.00–1.00

a Significance levels were based on regression coefficients. All tests were two-tailed.b Model χ2=429.7, df=14, p<.05c Model χ2=692.5, df=14, p<.05d Attention-deficit hyperactivity disorder

∗p<.05∗∗p<.01

∗∗∗p<.001


emerged across coercion types. Sim-ply stated, regardless of treatmenttype (visits with a clinician, medica-tion, or hospitalization), respondentswere significantly more likely to en-dorse forced treatment for childrenmeeting criteria for depression orasthma. This pattern was particularlyclear for forced clinical visits, wheremore than one-third of respondentswould force a clinical visit for a de-pressed child, and more than 40%would force a visit for an asthmaticchild (χ2=114.22, df=3, p<.001). Asimilar pattern was shown for thewillingness to force medication (χ2=39.92, df=3, p<.001) and hospitaliza-tion (χ2=72.40, df=3, p<.001), whererespondents were also significantlymore likely to invoke coercive meansfor the child with asthma and thechild with depression.

Predictors of dangerousnessThe ordered logistic regression ofperceived dangerousness toward oth-

ers (model 1) and toward self (model2) indicated that the behaviors de-scribed in the vignettes were signifi-cant correlates of public responses(Table 1). Respondents were mostconcerned with likelihood of violenceamong children with depression. In-deed, compared with the child with“daily troubles,” the vignette childwith depression was more than twiceas likely to be assessed as dangeroustoward others and ten times as likelyto be assessed as dangerous towardhimself or herself.

A similar pattern emerged in re-gard to children with ADHD. Com-pared with the child with “daily trou-bles,” the child with ADHD was per-ceived as roughly twice as likely to bedangerous to others and to self.However, respondents saw childrenwith asthma as only half as likely tobe violent. Equally notable, regard-less of the referent (dangerousnessto self or others or both), individualswho labeled the child as having a

mental illness were more than fivetimes as likely to perceive a potentialfor violence.

Only a few other factors mattered,although the effects tended to be in-consistent. Respondents evaluatedgirls as less dangerous to self or toothers. The 14-year-old was also per-ceived as significantly less likely thanthe eight-year-old to be dangerous toothers. Finally, respondents withhigher incomes were nominally morelikely to see potential for both typesof violence.

Predictors of coercionRelative to disorder types, respon-dents also varied in willingness to usecoercive means to ensure treatment(Table 2). The largest effects were ob-served for the child with asthma,where, compared with the child with“daily troubles,” respondents wereeight to ten times as likely to supportcoercion. Respondents were alsomore likely to support coercion for


TTaabbllee 22

Predictors of the public’s willingness to coerce treatment of children, from the 2002 National Stigma Study–Children(N=1,152)a

Force outpatient visitb Force medicationc Force hospitalizationd

Item (reference group) OR 95% CI OR 95% CI OR 95% CI

Vignette characteristicADHD (daily troubles)e 1.90∗ 1.05–3.41 1.15 .61–2.18 1.68 .84–3.35Depression (daily troubles) 3.88∗∗∗ 2.16–6.98 2.17∗ 1.15–4.09 3.39∗∗∗ 1.72–6.70Asthma (daily troubles) 10.10∗∗∗ 5.58–18.29 2.57∗∗ 1.35–4.90 7.93∗∗∗ 4.02–15.66Female (male) 1.52∗∗ 1.12–2.05 1.33 .93–1.90 1.32 .94–1.85African American (white) 1.29 .96–1.72 1.18 .83–1.68 .99 .70–1.3814 years old (8 years old) .68∗∗ .50–.92 .72 .50–1.02 .60∗∗ .43–.84

Illness labelMental illness (not) 1.80∗∗ 1.22–2.65 1.61∗ 1.02–2.56 1.90∗∗ 1.22–2.97Physical illness (not) 1.17 .81–1.68 1.76∗∗ 1.14–2.71 1.32 .87–2.00

Respondent characteristicFemale (male) 1.09 .80–1.47 .79 .55–1.12 .99 .70–1.39African American (white) 1.72∗ 1.14–2.61 1.50 .92–2.43 1.45 .90–2.33Other race (white) 1.78∗ 1.02–3.11 2.22∗∗ 1.19–4.12 2.24∗∗ 1.24–4.06Age 1.01∗∗ 1.00–1.02 1.02∗∗∗ 1.01–1.03 1.02∗∗∗ 1.01–1.03Education .96 .91–1.02 .95 .88–1.02 1.00 .93–1.06Income 1.00 1.00–1.00 1.00 1.00–1.00 1.00 1.00–1.00

Perceived dangerViolence to others 1.95∗∗∗ 1.31–2.91 2.78∗∗∗ 1.74–4.45 2.55∗∗∗ 1.62–4.02Violence to self 1.24 .80–1.92 .89 .53–1.50 .94 .57–1.55

a Significance levels are based on regression coefficients and are associated with the confidence that the odds ratios are within a 95% interval.b Model χ2=210.3, df=16, p<.001c Model χ2=138.3, df=16, p<.001d Model χ2=163.3, df=16, p<.001e Attention-deficit hyperactivity disorder

∗p<.05∗∗p<.01

∗∗∗p<.001


medication of the asthmatic child.Respondents were also more likely

to support coercion for the child withdepression than for the child with“daily troubles.” A somewhat differ-ent pattern emerged for the childwith ADHD. Here, with the excep-tion of a forced clinical visit, respon-dents were not willing to use legalmeans to force the child with ADHDto take medication or be admitted toa hospital.

In the case of clinical visits, re-spondents were more willing to usecoercion for girls or for those labeledas having a mental illness. Indeedthe label of mental illness signifi-cantly increased the likelihood thatrespondents would support coercionfor clinical visits, medication, andhospitalization.

Finally, respondents were less sup-portive of clinical or hospital-basedtreatment options for the 14-year-oldthan for the eight-year-old. African

Americans and individuals of otherraces were more supportive of co-erced clinical visits, with the lattergroup more supportive of medicationand hospitalization. Older respon-dents also were more likely to sup-port forced treatment by clinicians,prescription medications, and hospi-talization. Finally, respondents evalu-ating the child as more likely to bedangerous to others were roughlytwice as likely to support coercivetreatment.

DiscussionInformed by the contemporary cli-mate of concern about violence inschools and a hypothesized link tomental health problems among chil-dren and adolescents, we targetedpublic views of the dangerousness ofchildren and the concomitant willing-ness to use legal means to force chil-dren into treatment. Our results indi-cate that the public perceives boys

and children with depression orADHD as the groups most likely tobe dangerous to self or others.

Although the findings relative todangerousness are clear and consis-tent, the findings on coercion re-vealed some surprises in how theAmerican public thinks about med-ical care for children with physicaland mental disorders. Over one-thirdof respondents were willing to use le-gal means to force children with de-pression to visit a clinician, and evenmore were willing to do so for theasthmatic child. This finding suggeststhat more than social control and fearunderlie attitudes about involuntarytreatment in this country. Indeed, inthe case of a physical illness such asasthma, where standard treatmentsare readily available, our respondentswere most willing to support legalmeans to ensure that these childrenreceived medical care, apparently ig-noring the realization that similarly


TTaabbllee 33

Public views of dangerousness and the need for coercion, by child’s type of problem from the 2002 National StigmaStudy–Children (N=1,152)

Child’s problem

Attention-deficithyperactivity disorder Depression Asthma “Daily troubles”(N=289) (N=314) (N=256) (N=293)

Item and response N % N % N % N %

DangerousnessViolent toward othersa

Not at all likely 43 15 30 10 142 56 118 40Not very likely 156 54 152 48 91 36 136 46Somewhat likely 73 25 105 33 17 7 34 12Very likely 17 6 27 9 6 2 5 2

Violent toward selfb

Not at all likely 38 13 6 2 118 46 115 39Not very likely 149 52 55 18 99 39 139 47Somewhat likely 80 28 144 46 31 12 34 12Very likely 22 8 109 35 8 3 5 2

CoercionForce visit to a clinicianc

No 239 83 203 65 151 59 273 93Yes 50 17 111 35 105 41 20 7

Force medicationd

No 255 88 242 77 209 82 274 95Yes 34 12 72 23 47 18 19 7

Force hospitalizatione

No 256 89 237 76 184 72 279 95Yes 33 11 77 25 72 28 14 5

a Model χ2=231.50, df=9, p<.001b Model χ2=481.14, df=9, p<.001c Model χ2=114.22, df=3, p<.001d Model χ2=39.92, df=3, p<.001e Model χ2=72.40, df=3, p<.001


well-documented standardized regi-mens are available for treating de-pression and ADHD. This findingsupports Costello and colleagues’ (10)contention that the threshold formental health problems may well beset higher than for physical problems.

Our findings also clearly illustratethat the stigma attached to child andadolescent mental health problems isassociated with the label of mental ill-ness. It is this condition that may bethe most potent trigger for initiatingtreatment. Individuals labeling “thesituation” as mental illness, after theanalysis controlled for the behaviorsdescribed, were five times as likely toreport likelihood of violence. This la-bel, along with evaluating the vignettechild as dangerous to others (but notto self), doubled the likelihood thatthe public would support use of coer-cion. Consistent with data collectedfrom adults with mental health prob-lems, these results continue to reflectunderlying negative attitudes towardpersons presumed to have mentalhealth problems (34). What alsoclearly emerged from these analyseswas that sociodemographic character-istics did not offer powerful proxies ofthe cultural beliefs, values, and normsof the public.

Regarding limitations, this studyasked only about legal coercion anddid not explore what has been called“informal,” “extra-legal,” or “covert”coercion (35,36). Also it did not ad-dress reactions to possible agents ofcoercion (such as family, teachers orother educators, and police).

ConclusionsAnalyses from the NSS-C suggestthat the U.S. public stigmatizes chil-dren with mental health problems.Particularly in regard to depression,the public is likely to attribute dan-gerousness to youths and endorsethe use of coercion into treatment.However, more than stigma is evi-dent. More of the public supportsthe use of physicians, even throughlegal means, to ensure that childrenwith asthma receive care. Thesefindings highlight concern amongthe public regarding parents andtheir responsibilities.

Hannigan and Cutcliffe (37) main-tained that policy and legal frame-

works surrounding the provision ofmental health care are becomingmore coercive globally. Furthermore,Anthony (38) agreed that the mentalhealth system cannot move to a re-covery model under a climate of coer-cion. If this is the case, the need tounderstand public, provider, andclient views of coercion and their linkto perceptions of dangerousness ispressing. As Solomon (39) noted, “theconsequences of the competing val-ues between preserving individualautonomy and protecting vulnerableindividuals” are becoming “increas-ingly visible.” Nowhere may this bemore important than in the case ofchildren and adolescents with mentalhealth problems.

Acknowledgments and disclosures

The authors acknowledge project support bythe National Science Foundation to the Na-tional Opinion Research Center; Eli Lilly andCompany; the Office of the Vice President forResearch, Indiana University; and grant K02-MH-012989 from the National Institutes ofHealth and National Institute of Mental Healthto Dr. Pescosolido, principal investigator. Theauthors thank Tom Smith and staff members ofthe Indiana Consortium for Mental HealthServices Research, Schuessler Institute for So-cial Research, Indiana University.

The authors report no competing interests.

References

1. Chunn S: Teen-ager enters guilty pleas inGA school shooting. Conyers, Ga, Associat-ed Press, Oct 2, 2000

2. Goodstein L, Glaberson W: The well-marked roads to homicidal rage. New YorkTimes, Apr 10, 2003, Health section. Avail-able at query.nytimes.com/gst/fullpage.html?sec=health&res=9800EEDC1231F933A25757C0A9669C8B63

3. Moore M, Petrie C, Braga A, et al: DeadlyLessons: Understanding Lethal School Vio-lence. Washington, DC, National Acade-mies Press, 2003

4. Rivara FP, Farrington DP: Prevention of vi-olence: role of the pediatrician. Archives ofPediatrics and Adolescent Medicine 149:421–429, 1995

5. Lewis DA, Goetz E, Schenfield M, et al:The negotiation of involuntary civil com-mitment. Law and Society Review 18:630–649, 1984

6. Thomas CR, Penn JV: Juvenile justice men-tal health services. Child and AdolescentPsychiatric Clinics of North America 11:731–748, 2002

7. McCabe K, Yeh M, Hough RL, et al:Racial/Ethnic Representation Across FivePublic Sectors of Care for Youth. SanDiego, Center for Research on Child and

Adolescent Mental Health Services, 1998

8. Teplin LA, Abram KM, McClelland GM, etal: Psychiatric disorders in youth in juveniledetention. Archives of General Psychiatry59:1133–1143, 2002

9. Leon SC, Uziel-Miller ND, Lyons JS, et al:Psychiatric hospital service utilization ofchildren and adolescents in state custody.Journal of the American Academy of Childand Adolescent Psychiatry 38:305–310,1999

10. Costello EJ, Pescosolido BA, Angold A, etal: A family network–based model of accessto child mental health services, in SocialNetworks and Mental Illness. Edited byMorrissey JP. Stamford, Conn, JAI Press,1998

11. Report of the Surgeon General’s Confer-ence on Children’s Mental Health: A Na-tional Action Agenda. Washington, DC, USDepartment of Health and Human Ser-vices, Public Health Service, 1999

12. Dukarm CP, Holl JL, McAnarney ER: Vio-lence among children and adolescents andthe role of the pediatrician. Bulletin of theNew York Academy of Medicine 72:5–15,1995

13. McFarling UL: APA puzzled by precisecauses of teen violence. Washington, DC,Knight Ridder/Tribune News Service, May17, 1999

14. Diagnostic and Statistical Manual of Men-tal Disorders, 4th ed. Washington DC,American Psychiatric Association, 1994

15. Steadman HJ, Mulvey E, Monahan J, et al:Violence by people discharged from acutepsychiatric inpatient facilities and by othersin the same neighborhoods. Archives ofGeneral Psychiatry 55:393–401, 1998

16. Phelan JC, Bromet EJ, Link BG: Psychi-atric illness and family stigma. Schizophre-nia Bulletin 24:115–126, 1998

17. Pescosolido BA, Martin JK, Link BG, et al:Americans’ Views of Mental Illness andHealth at Century’s End: Continuity andChange. Public Report on the MacArthurMental Health Module, 1996 General So-cial Survey. Bloomington, Indiana Consor-tium for Mental Health Services Research,2000

18. Martin JK, Pescosolido BA, Olafsdottir S,et al: The construction of fear: modelingAmericans’ preferences for social distancefrom children and adolescents with mentalhealth problems. Journal of Health and So-cial Behavior 48:50–67, 2007

19. Mental Health: A Report of the SurgeonGeneral. Washington, DC, Department ofHealth and Human Services, US PublicHealth Service, 1999

20. Monahan J, Redlich A, Swanson JW, et al:Use of leverage to improve adherence topsychiatric treatment in the community.Psychiatric Services 56:37–44, 2005

21. Monahan J, Swartz M, Bonnie RJ: Mandat-ed treatment in the community for peoplewith mental disorders. Health Affairs22(5):28–38, 2003

22. O’Leary JC: An analysis of the legal issue


pesper.qxd 4/17/2007 11:02 AM 24

surrounding the forced use of Ritalin: pro-tecting a child’s right to “just say no.” NewEngland Law Review 27:1173–1209, 1993

23. Panneton JP: Children, commitment andconsent: a constitutional crisis. Family LawQuarterly 10:295–334, 1977

24. Allen M, Smith VF: Opening Pandora’sbox: the practical and legal dangers of in-voluntary outpatient commitment. Psychi-atric Services 52:342–346, 2001

25. Appelbaum PS: Thinking carefully aboutoutpatient commitment. Psychiatric Ser-vices 52:347–350, 2001

26. Lidz C: Coercion in psychiatric care: whathave we learned from research? Journal ofthe American Academy of Psychiatry andthe Law 26:631–637, 1998

27. Miller RD: Coerced treatment in the com-munity. Psychiatric Clinics of North Amer-ica 22:183–196, 1999

28. Pescosolido BA, Monahan J, Link BG, et al:The public’s view of the competence, dan-gerousness, and need for legal coercion ofpersons with mental health problems.American Journal of Public Health 89:1339–1345, 1999

29. Group for the Advancement of Psychiatry:Forced Into Treatment: The Role of Coer-cion in Clinical Practice. Washington, DC,American Psychiatric Press, 1994

30. Stiffman AR, Pescosolido BA, Cabassa LJ:Building a model to understand youth serv-ice access: the gateway provider model.Mental Health Services Research 6:189–198, 2004

31. Burns BJ, Friedman RM: Examining theresearch base for child mental health serv-ices and policy. Journal of Mental HealthAdministration 17:87–98, 1990

32. Ishizuka C, Nakatani Y, Morita N, et al: So-ciodemographic and clinical characteristicsof psychiatric patients coercively brought tohospitals. Psychiatry and Clinical Neuro-sciences 55:147–156, 2001

33. Pescosolido BA: Culture, children, andmental health treatment: special section onthe National Stigma Study–Children. Psy-chiatric Services 58:611–612, 2007

34. Martin JK, Pescosolido BA, Tuch SA: Offear and loathing: the role of disturbing be-havior, labels and causal attributions inshaping public attitudes toward persons

with mental illness. Journal of Health andSocial Behavior 41:208–233, 2000

35. Pescosolido BA, Brooks-Gardner CB,Lubell KM: How people get into mentalhealth services: stories of choice, coercionand “muddling through” from “first-timers.” Social Science and Medicine 46:275–286, 1998

36. Everett B: Community treatment orders:ethical practice in an era of magical think-ing. Canadian Journal of Community Men-tal Health 20:5–20, 2001

37. Hannigan B, Cutcliffe J: Challenging con-temporary mental health policy: time to as-suage the coercion? Journal of AdvancedNursing 37:477–484, 2002

38. Anthony EJ: The impact of mental andphysical illness on family life. AmericanJournal of Psychiatry 127:56–64, 1970

39. Solomon P: Research on the coercion ofpersons with severe mental illness, in Coer-cion and Aggressive Community Treat-ment: A New Frontier in Mental HealthLaw. Edited by Dennis DL, Monahan J.New York, Plenum, 1996


SSuubbmmiissssiioonnss ffoorr DDaattaappooiinnttss IInnvviitteedd

Submissions to the journal’s Datapoints column are invited. The column pub-lishes analyses of data on mental health services of relevance to psychiatric clin-ical or policy issues. National data are preferred. Areas of interest include diag-nosis and practice patterns, treatment modalities, treatment sites, patient char-acteristics, and payment sources. The analyses should be straightforward, so thatthe figure or figures tell the story. The text should follow the standard researchformat to include a brief introduction, description of the methods and data set,description of the results, and comments on the implications or meanings of thefindings.

Datapoints columns are typically 350 to 400 words of text with one or two fig-ures. Maximum text length is 500 words, including title, author names, affilia-tions, references, and acknowledgments. Submissions over the word limit willbe returned. Submissions will be reviewed promptly; additional peer review maybe warranted.

Inquiries or submissions should be directed to Harold Alan Pincus, M.D., TerriL. Tanielian, M.S., or Amy M. Kilbourne, Ph.D., M.P.H., who are editors of thecolumn. Contact Ms. Tanielian at RAND, 1200 South Hayes St., Arlington, VA22202 (e-mail: [email protected]).


Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

pdf[1]

Documents