Journal of Child Psychology and Psychiatry 46:7 (2005), pp 714734

doi: 10.1111/j.1469-7610.2005.01456.x

The stigmatization of mental illness in children and parents: developmental issues, family concerns, and research needs
Stephen P. Hinshaw
University of California, Berkeley, USA

The stigmatization that surrounds mental illness is increasingly recognized as a central issue, if not the central issue, for the entire mental health eld. In this article I dene the concept of stigma, discuss relevant theoretical perspectives, summarize evidence regarding the pervasiveness and impact of stigma regarding mental disorders, and focus on issues pertaining to (a) stigmatization of children and adolescents with mental illness and (b) stigmatization in the family context, when either a parent or a child has a mental disorder. Both empirical ndings and qualitative evidence provide documentation of the stigmatization that exists regarding mental illness in both parents and children. Stigmatization of child/adolescent conditions is related to the low status of children throughout history as well as the continuing devaluation of mental disorders. In terms of children as social perceivers of disordered behavior in peers, little is known about developmental factors related to childrens knowledge of mental illness, yet from early ages it is clear that children hold persistently negative attitudes about both the constituent behaviors and labels signifying mental illness. Regarding families, when parents suffer from mental illness, stigma may have great impact on their parenting and, in turn, the development of their children. In addition, parents have typically been blamed for their childrens mental disturbances, limiting the pursuit of assessment and treatment. Because stigma operates at multiple levels individuals, families, schools, communities, public media, and social policy overcoming stigma will require change efforts spanning these interacting spheres of inuence. For huge numbers of individuals and families worldwide, mental illness is a harsh reality that yields considerable impairment (Murray & Lopez, 1996). Compounding the considerable suffering emanating from mental disorders is the stigma surrounding the various forms of mental illness. Despite real progress in terms of scientic knowledge regarding causal factors for mental disorders, the development of empirically supported treatment strategies, and increased public knowledge of the concept of mental disorder, mental illness particularly its most severe forms continues to be engulfed in stereotype, prejudice, and stigma, promoting

shame and silence and perpetuating a vicious cycle of ignorance, distancing, and punitive societal responses (Corrigan, 2005; Hinshaw, Cicchetti, & Toth, in press; Phelan, Link, Stueve, & Pescosolido, 2000). Understanding the processes related to the stigmatization of mental illness is a major priority, as stigma limits research funding, access to treatment, family unity, and attainment of personal relationships and educational/vocational goals (Sartorius, 1998). Not only is mental illness emerging into far greater public awareness and discussion, but the stigmatization of individuals with mental disorders is also a growing area of inquiry. Social psychological concepts, sociological theories, and evolutionary psychological models are increasingly directed toward the topic of the stigmatization of mental disorder (e.g., Crocker, Major, & Steele, 1998; Kurzban & Leary, 2001; Link, Cullen, Struening, Shrout, & Dohrenwend, 1989). Empirical research on stigma processes and provocative theoretical accounts of stigmatization continue to mount (e.g., Corrigan, 2004; Link & Phelan, 2001). Medical and psychological professions, as well as policy makers, are taking note. For example, in 1998 the eminent journal Lancet published a special section on the topic of stigma and mental illness (Stigma of Mental Illness, 1998). The following year, the Surgeon General of the United States, David Satcher, emphatically stated that stigma is the most important problem facing the entire mental health eld (US Department of Health and Human Services, 1999). At the same time, interventions designed to overcome stigma have proliferated. From 19982003 the Royal College of Psychiatrists implemented an antistigma campaign in the United Kingdom, entitled Changing Minds: Every Family in the Land (Crisp, 2000). Currently, the World Psychiatric Association is embarking on a cross-national effort to abolish or at least reduce the stigma that surrounds serious mental illnesses (Thompson et al., 2002). Destigmatization efforts are increasingly based on core social psychological principles (Corrigan & Penn, 1999). Overall, stigma related to mental illness is emerging into full scientic and public view. Although considerable literature now exists on the stigmatization related to mental disorders of adult-

Association for Child Psychology and Psychiatry, 2005. Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA

Stigma and mental disorders

715

hood, a much smaller body of research has appeared regarding (a) the stigmatization of child/adolescent mental illness and (b) the ramications of prejudice and stigma when a parent has a mental disorder. Both of these are essential topics. First, rates of treatment utilization for children and adolescents with mental disorders are distressingly low (US Department of Health and Human Services, 1999), and this is especially the case for youth from ethnic/ racial minority groups (Yeh, McCabe, Hough, Pupuis, & Hazen, 2003). Several types of barriers are relevant, some economic and policy-related (i.e., lack of insurance coverage) and others more psychological (e.g., lack of parental awareness that certain child problems may reect mental disorder). Tellingly, for much of the 20th century, the predominant theoretical views in the mental health elds were that child mental disturbance was directly linked to faulty parenting. With such professional blame rmly in place, the shame of admitting a childs mental disorder also served to limit help-seeking. Thus, stigmatization of child disorders and the blame of parenting practices as causally responsible for them are important considerations for child mental health. Second, parental mental illness is clearly a risk factor for psychiatric disturbance in offspring (e.g., Beardslee, Versage, & Gladstone, 1998), operating through a variety of genetic, psychological, and interactive mechanisms. In addition, when families do not seek treatment for a parents mental disturbance or adequately support their children who experience the effects of such mental illness, self-blame on the part of the child may accentuate these other risk mechanisms to produce vulnerability (Hinshaw, 2004). In short, it is quite conceivable that stigma related to parental mental disorder limits helpseeking on the part of the parents and prevents open family discussion and provision of support to the offspring, further exacerbating the childs risk. Thus, I rst review general issues and mechanisms related to the stigmatization of mental illness, and follow this encapsulated review with information regarding what is known about stigma in relation to childrens mental disorders, including material on youths awareness of and responses to mental illness. I then attempt to provide understanding of the inuence of stigma on families when a member of the family has a mental disorder either a parent, a sibling, or a child. Throughout, I highlight that (a) the applicability of adult conceptions of stigma to child and adolescent mental conditions is an open question and (b) the implications of stigmatization of parents for either their own mental disorders or for having caused their childrens disorders are only beginning to receive research attention. I conclude with recommendations for research on child and family stigma processes as well as a summary of potential avenues for intervention to counter stigmatization.

Core concepts
Dening stigma
Stigma is a term originating with the ancient Greeks, denoting a visible mark placed or branded on members of tainted groups such as traitors or slaves (Goffman, 1963). All members of society therefore knew instantly of the degraded status of the stigmatized individual. Currently, the term has more of a psychological meaning, signaling an invisible, internal mark of shame related to membership in a deviant or castigated subgroup. The insidiousness of stigmatization is evidenced by the fact that virtually all of the individuals attributes come to be interpreted in light of the mark or aw (Goffman, 1963). Stigma processes are universal, in that all human societies feature castigation of outgroups by ingroups. Yet they are also local, to the extent that different traits, conditions, and attributes are shunned in different cultures. Several related terms are salient. Stereotyping is a cognitive process whereby members of a group are viewed in terms of particular traits or attributes, applied in blanket fashion; prejudice connotes negative, emotion-laden pre-judgments of members of outgroups; and discrimination refers to behavioral actions that limit the power or rights of members of castigated groups (see Crocker et al., 1998). Stigma incorporates all of these processes but transcends them by including the strong likelihood that the castigated individual will internalize the degradation. Stigmatization therefore incorporates psychological as well as social processes. It also involves structural features in a given society, given that (a) conditions are stigmatized only if powerful members of society deem the trait in question to be deviant, immoral, or impermissible and (b) the blaming of castigated individuals for their plight tends to reinforce the status quo regarding social inequities (Link & Phelan, 2001). Sociologically, stigma has been viewed in relation to structural variables in various societies and cultures (i.e., fewer resources for members of disenfranchised groups, leading to system-justifying, denigrating attitudes on the part of majority-group perceivers). It has also been studied via modications of labeling theory (see Link et al., 1989, for crucial insights related to modications of the labeling theory of Scheff, 1966). Although the claims of primary labeling theory that labels essentially create disorders through the branding of deviance are likely to be overstated, denigrating labels do set in motion a set of expectancies and self-fullling prophecies that considerably worsen the initial deviance. From this perspective, stigma matters being ofcially diagnosed (or labeled) as being mentally ill results in a spoiled identity linked to negative outcomes in terms of employment, economic success, social functioning, and self-esteem (Wright, Gronfein, & Owens, 2000, p. 70).

716

Stephen P. Hinshaw

A host of social problems and individual traits are currently stigmatized, including (but not limited to) membership in racial and ethnic minority groups, gay or lesbian status, adoption, single parenthood, left-handedness, being overweight or otherwise physically unattractive, homelessness, and many more. Most work on stigma has focused on racial prejudice and stigma (Allport, 1954; Heatherton, Kleck, Hebl, & Hull, 2000). Overtly racist attitudes have attenuated in the last half-century, yet they appear to be expressed currently through more subtle attitudes (e.g., beliefs in self-determination) or through laissez-faire racism: beliefs that racial minorities are to blame for achievement gaps and failures of the majority to support policies designed to improve racist practices (Bobo, 1999). At present, stigmatization of mental illness is often quite direct, as there has not been a parallel set of social injunctions against ridicule or castigation in relation to mental disorders. Having a mental illness is one of the most overtly stigmatized attribute an individual can have, rivaled by substance abuse or homelessness (Link, Phelan, Bresnahan, Stueve, & Pescosolido, 1999; Pescosolido, Monahan, Link, Stueve, & Kikizawa, 1999; note that substance abuse itself is considered a form of mental disorder American Psychiatric Association, 2000). It is conceivable, however, that if social norms shift and overt stigmatization of mental illness becomes more proscribed, unconscious and indirect expressions of such bias may become normative. Overall, the degraded status of mental illness is likely to be related, in large measure, to the threat posed by many of the behavioral features of mental disorders (Stangor & Crandall, 2000) as well as the connotations emanating from the term itself e.g., violence, irrationality, unpredictability, and being out of control of ones faculties (Hinshaw et al., in press).

(Should I reveal my diagnosis?), including parents (What if the teacher or a neighbor nds out about my childs mental disorder?). (2) Chronicity: Long-lasting, negatively-laden traits are far more likely to be stigmatized than acute, short-lived characteristics, and mental disorders are typically assumed to be lifelong. Finding means of promoting the mutability and treatability of mental illness is an important objective. Hence, development and dissemination of empirically supported interventions for both children and parents are crucial, and emphasizing that genetic vulnerability does not imply immutability is essential (see Hinshaw et al., 2000). (3) Threat or peril: Media portrayals of mental illness are grossly biased toward depictions of violence and dangerousness (Wahl, 1995), playing a key role in the continuing stigmatization of mental disorders. This is clearly the case for childrens media as well, including cartoons (Wilson, Nairn, Coverdale, & Panapa, 2000). (4) Controllability: Attribution theory predicts that when negative behavioral displays are ascribed to non-controllable causes (e.g., seizure disorder, physical disability), compassion is likely, whereas ascription to personal control yields blame and anger. Supportive experimental research has supported this hypothesis, at least with college student populations, by showing that the symptoms of mental disorders are typically viewed as volitional and controllable (Weiner, Perry, & Magnusson, 1988). Such research and theory have provided impetus for the effort to brand mental disorder as the product of aberrant genes and biochemistry in order to reduce blame and stigma (Corrigan et al., 2000). However, the actual data are far more complex, as I discuss subsequently. In all, the dimensions underlying stigmatized conditions are of relevance to child, adolescent, and family mental disorder.

Key issues related to stigma

Given space limitations, I address several seminal points in abridged fashion (see Corrigan, 2005; Crocker et al., 1998; Heatherton et al., 2000; Hinshaw et al., in press, and Link & Phelan, 2001, for extended discussion).

Dimensions of stigmatization. As elucidated by Jones et al. (1984), stigmatized conditions vary across a number of dimensions, each of which predicts the response of social perceivers to the marked trait or attribute. Noting only in passing aesthetics (physical appearance) and disruptiveness (which may certainly pertain to externalizing disorders of childhood and adolescence), I highlight four dimensions of relevance. (1) Concealability: Racial status and physical disabilities are typically visible, but other castigated conditions such as having a history of mental illness can often be hidden, leading to considerable anxiety for individuals in question

Ingroups, threat, pervasiveness, and ambivalence. In all human societies, there are strong tendencies to form ingroups persons linked by family heritage, community, or shared values and for ingroup members to differentiate themselves from outgroups, dened as those persons existing outside such boundaries. Such tendencies are strongly ingrained, as evidenced by so-called minimal group research: Individuals will form strong ingroup identication and castigate those in the outgroup even if the initial selection is based on random choice, color of clothing, or other arbitrary means (for a summary, see Gaertner & Dovidio, 2000). Given additional reasons for ingroup formation, such as economic competition, the outgroups threat value is intensied, and stigmatization is even more likely (Stangor & Crandall, 2000). Threat is fueled by the connotations of labels, particularly when labels connote violence or loss of reason, as in the case of mental disorder. Children have strong proclivities to form ingroups and outgroups; indeed, these tendencies

Stigma and mental disorders

717

develop by the preschool years with regard to racial status (Aboud, 2003). As noted subsequently, little is known about child conceptions of mental illness and the relation of such views to youths proclivity to shun peers with behavioral deviance and/or labels. Both social cognitive processes (e.g., the outgroup homogeneity effect, whereby outgroup members are perceived as similar; see Myers, 1998) and strong cultural messages (media, word of mouth) result in the pervasiveness of communications and messages about mental disorder. Omnipresent negative messages about outgroup members tend to become overlearned and automatized, such that perceivers learn the castigating messages unconsciously. These types of implicit and automatic biases may be resistant to change, partly because they are not even recognized. They are also likely to be learned at early ages, given their widespread circulation throughout a given culture. Thus, childrens tendencies to stigmatize deviant peers are doubtless fueled by the pervasiveness of negative messages about mental illness. Although research on racial prejudice has shifted largely to examination of unconscious, implicit bias or prejudice, parallel developments with respect to physical conditions and mental disorders are just beginning to emerge (see Teachman, Gaspinski, Brownell, Rawlins, & Jeyeran, 2003). The extent to which children and adolescents develop such automatic, overlearned prejudices about mental illness is an important empirical question with almost no existing database. Finally, when one confronts an outgroup member, sympathy and concern are likely, related to perceptions of the difcult plight of stigmatized individuals, but distancing and derision are also salient, given the overlearned, biased associations just discussed. Thus, ambivalence is common in stigmatizing responses, marked by swings between acceptance and scorn (see Katz, 1981). Although such ambivalence is a hurdle in the battle to overcome stigma, it gives reason for hope: The presence of at least some empathy provides a foundation for acceptance.

Evolutionary principles related to stigmatization. Is there a deeper way in which humans are programmed to detect and shun persons with extreme forms of social deviance? Evolutionary psychology has entered the debate about stigma (Fishbein, 2002; Kurzban & Leary, 2001, with provocative implications. From an evolutionary point of view, humans have been selected not only for needed prosocial tendencies but also for certain limitations on social interchange, as indiscriminate afliations may pose a survival threat. The attributes most likely to engender naturally selected exclusion mechanisms are those that presumably posed universal threats to early human societies: (a) fellow humans who foster parasitic infestation, (b) those who

provide low social capital or exploitation of social partners, and (c) members of rival nationalities or cultures.1 Kurzban and Leary postulate that persons with mental disorder engender the rst two types of exclusion tendencies, in that dishevelment or obsessional features may signal contagion (as they appear to do in other animal species), and behavioral excesses and poor inhibition suggest both low social status and the potential for exploitation of others. Almost completely unknown, however, is the extent to which children utilize such automatic, naturally selected tendencies toward peers. To the extent, however, that such exclusion modules are naturally selected, it would be expected that initial display tendencies could emerge early in life. The specicity of predictions from evolutionary models is compelling: Fears of contagion are expected to yield the emotional response of disgust and behavioral exclusion, whereas the signs of exploitation or low social capital propel anger and the tendency toward punitive responses. Generally, however, it is assumed that mental disorders do not engender the third type of stigma noted above the form typically associated with members of different nationalities, tribes, or racial groups. Yet, in consonance with essentialist views of genetic ascriptions for mental disturbance, it is quite conceivable that that when mental disorders are attributed to reductionistic, biogenetic medical models that is, when they are viewed as the exclusive products of awed genes or biochemistry aficted individuals may come to be viewed as a separate, inferior, even subhuman group (for extended discussion, see Hinshaw, in press; Phelan, in press). Thus, despite the supposed attributional advantages of making medical model, non-controllable ascriptions for deviant behavior, it may be the case that simplistic or overly zealous ascriptions to medical/genetic causes could fuel a harsh and exploitative set of behavioral responses, at the level of tribal stigmas. Recent empirical evidence is provocative in this regard. At least some research indicates that benign attitudes can emanate from aspects of biological ascriptions to mental disorder (Corrigan et al., 2000; Martin, Pescosolido, & Tuch, 2000). Yet a recent, general attitude survey of a representative sample of the US population revealed that genetic ascriptions for mental disturbance do not yield the supposed advantages posited by attribution theory and that such ascriptions may, in fact, predict stigmatization of the aficted individuals relatives (Phelan, in
Intriguingly, these three types of stigma modules postulated by Kurzban and Leary (2001) map almost exactly onto the three classes of stigmatized individuals hypothesized by Goffman (1963): abominations of the body (disease or parasitic threat), character aws (individuals posing threats to social equity), and tribal stigmas (related to nationalistic or racial differences). Thus, the evolutionary psychology perspective on stigma has resurrected a sociological typology that had fallen out of favor in recent decades.
1

718

Stephen P. Hinshaw

press). Additional evidence suggests that exclusive genetic/biomedical attributions for mental disorder can fuel social distance and punitive attitudes (Dietrich et al., 2004; Read & Harre, 2001), with actual behavioral responses denoted by marked punishment (Mehta & Farina, 1997). Thus, the supposed advantage of attributing mental disorder to a genetic or exclusively illness-based model is not at all clear. Indeed, views emphasizing the essentialist perspective that genes are the sole and exclusive causal agents of mental illness may promote the view that aficted individuals are fundamentally different from the rest of humanity. A developmental, transactional perspective on mental disorder, emphasizing genetic/biological interplay with environmental risk and triggers, is more accurate, with the added advantage that it may also be linked with greater acceptance. Finally, whereas the evolutionary perspective is pessimistic to the extent that there may be inherent human tendencies to exclude, shun, and even punish other persons with certain forms of behavioral deviance, even advocates of evolutionary models agree that such proclivities do not inevitably portend that humans will act on these exclusionary modules and tendencies (Kurzban & Leary, 2001; Fishbein, 2002). Humans have the power to overcome stigma.

mental and contextual research on the responses of children and adolescents to peers and adults deemed mentally ill (Wahl, 2002).

Historical perspectives
As detailed in Hinshaw et al. (in press) and Zilboorg (1941), throughout recorded history persons with mental illnesses have received neglect, abandonment, and punishment. Although humane reform efforts have been mounted on many occasions, such attempts have often been met with cynicism and retrenchment when the initial promise is countered by slow progress and the realities of dealing with serious mental illness (Grob, 1994). In addition, whereas inhumanity has been part of the legacy worldwide, non-Western cultures have often been marked by more humane care and better prognoses for serious psychopathology than industrialized, Western societies (Lin & Kleinman, 1988). Reform efforts in the current era must contend with the need for realistic expectations and sustained efforts if progress is to be maintained. Throughout much of human history, deviant behavior associated with mental illness has been attributed to possession by evil spirits or the devil (Zilboorg, 1941). Such demonologic views are typically linked with harshly punitive social responses, including torture and death. Yet in some instances religious and moral views of mental illness have been imbued with hopeful, humane care (Grob, 1994). Similarly, whereas naturalistic, medical-model perspectives on mental disorder have been associated with bursts of reform and humane treatment beginning with Hippocrates and his humoral theory in classical Greece and continuing to the present day biological views (often simplistic or misguided) have also led to the perception of mental illness as permanent, hopeless, and predetermined, fostering cruel treatments such as bloodletting, purging, and psychosurgery. Thus, there is no simple, one-to-one association between etiologic views of mental illness and humane versus cruel social responses. In addition, history is cyclic and complex rather than linear and simplistic; even during historical periods tainted by portrayals of cruelty (e.g., the Middle Ages), attempts were made to effect more rationale and humane means of assessment and intervention (e.g., Allderidge, 1979). Likely to be crucial in the future is the promotion of multifaceted views of mental disorder emphasizing biological vulnerabilities and underpinnings along with personal and family responsibility for ultimate outcome. The 20th century was marked by increasingly secular views of mental illness, as evidenced by the expansive growth of psychology and psychiatry. Although these perspectives tended to rid mental illness of demonologic overtones, for much of the century they directly implicated poor parenting as

Summary. Sociological theories of deviance emphasize the social reactions that may form when behavior is labeled as deviant, particularly in terms of mental illness, which connotes loss of reason and irrational, out-of-control behavior. Social psychological and evolutionary psychological frameworks for the understanding of stigma suggest that human tendencies to form ingroups and to castigate and stigmatize outgroups are fundamental parts of our cultural backgrounds and even our naturally selected heritages. Given their irrational and at times threatening nature, the behaviors that constitute serious mental disorder tend to be universally stigmatized. Stigma is likely to be fueled by traits and conditions that are believed to be stable, threatening, and controllable, attributes often ascribed to mental disorder. Pervasive social messages convey the negative attributes of stigmatized subgroups. Although such images tend to be overlearned and automatic, learned at early ages, compassion for social underdogs fuels sympathy and ambivalence and provides hope that mental illness need not always receive stigmatization. Furthermore, individuals possess the power to overcome prejudice and stigma by utilizing effortful control, by concentrating on empathic responses to members of stigmatized groups, and by making ascriptions for mental illness that are not reductionistic in terms of either exclusively psychosocial or exclusively biomedical origins. The relevance of these points to childrens mental illness is speculative at present, given the dearth of develop-

Stigma and mental disorders

719

responsible for most forms of mental disturbance. In fact, disorders like autism, schizophrenia, and depression (and, more recently, attention-decit/ hyperactivity disorder, or ADHD) were believed to emanate from faulty, unresponsive, or awed parenting, according to the central theoretical formulations of the eld (e.g., Bettelheim, 1967). Stigmatization of families and parents was therefore rampant. More recently, biomedical/genetic frameworks have strongly re-emerged, fostered by major advances in neuroscience, neuroimaging, biological psychiatry, and genetics (Hyman, 2000; Kandel, 1998). These views have prompted the perspective that mental illnesses are diseases like any other, beyond volitional control, with a resultant reduction in personal and family blame (Johnson, 1989). Yet as discussed above, reductionistic, unidimensional, and essentialist biomedical/genetic views may well be associated with punitive responses, probably because they cast persons with mental illnesses as chronically awed, deviant, and even subhuman.2 Though complex, transactional perspectives on deviance could serve as an antidote. What of children and, in particular, children with mental disturbances? Throughout history, relatively few children have survived childbirth, infancy, and childhood, delimiting parental attachment and investment in young children (Aries, 1962; Donohue, Hersen, & Ammerman, 1995). Also, childhood has often been seen as a relatively short period of time before youngsters were, of necessity, brought into agricultural work or the labor force. As a result, childrens rights have been virtually nonexistent (Phares, 2003). Only in the last several hundred years has childhood been viewed as a distinct developmental phase, and only in the past century and a half have movements to curtail child labor and mandate education been in place. Thus, until extremely recently, children have had little in the way of protected status. Indeed, it is only since the 1960s that child abuse has been ofcially recognized and mandatory reporting laws have been instituted (see Helfer & Kempe, 1968). Overall, when children have displayed behavioral and emotional deviance, adult tolerance has typically been quite limited. Stigmatization of childrens mental aberrations has been strongly present, even at the level of infanticide and child murder (Donohue et al., 1995). Despite the explosive growth of child psychology and child psychiatry during the 20th century, research on childrens mental disorders has lagged behind parallel efforts for adults (Donohue et al., 1995). Although the current biological zeitgeist has replaced earlier environmental views of etiology, tempering family and parental blame for mental
In addition, it should not be forgotten that the eugenics movement of the initial half of the 20th century had its origins in reductionistic, genetic accounts of mental illness (Black, 2003; Kevles, 1985).
2

disorders of youth, it has not ended the stigma and shame encountered by far too many families who cope with mental disturbance (Leey, 1992) nor the extremely low rates of service utilization for such families (US Department of Health and Human Services, 1999). Furthermore, the underfunded and inadequately planned nature of the deinstitutionalization movement in the past few decades has undoubtedly promoted stigma for both adults and children. For instance, the absence of communitybased services has allowed severely mentally ill adults, adolescents, and children to exist in the kinds of underfunded community residences or even on the streets that are the legacy of cost-cutting measures (e.g., Appelbaum, 2002; Grob, 1994). Stigma is likely to be increased by community care models that emphasize cost-savings over integrated programs. In short, whereas mental disorder has received banishment and harsh treatment throughout history, the plight of children and adolescents has been even worse, given the low status and lack of power afforded to youth. Stigma of child and adolescent mental disorders must contend with a dual struggle: The effort for childrens rights in general and the attempt to provide services to persons with mental illness in particular.

Evidence for stigma

What is the specic evidence for the stigmatization of mental illness in present times? In this section, I provide a headline review of the considerable literature on stigma that pertains to mental disorders, from the perspective of the general public, mental health professionals, family members, and childrens own views. I then consider general indicators of stigma in common cultural practices for example, portrayals in the media, usage of everyday language, discriminatory policies, and narratives of families particularly regarding children with mental disorders and their caregivers.

General public
Research on public attitudes toward mental illness began in earnest during the 1940s and 1950s. Initial attitude surveys were large in scope; they revealed that the public (a) knew quite little about mental illness and (b) showed strong tendencies toward exclusion and distancing (e.g., Nunnally, 1961; Rabkin, 1972). In fact, mental illness was devalued to such an extent that attitudes were comparable to those regarding leprosy from earlier time periods. Dependent measures utilized in such research included semantic differentials (e.g., persons with mental illness were typically branded as dirty vs. clean), attitude scales, and measures of social distance (through which respondents indicate willing-

720

Stephen P. Hinshaw

ness vs. unwillingness to interact with a person with mental illness in increasingly close forms of contact). Across all such instruments, mental illness was consistently rejected and rated pejoratively (see review in Hinshaw et al., in press). Although attitudes showed an apparent improvement during the 1970s and 1980s (see Crocetti, Spiro, & Siassi, 1974), an alternative interpretation is that the general public was becoming more sophisticated and more socially desirable in their questionnaire responses. In fact, actual behavioral reactions to persons with mental illness, or histories of mental hospitalization, continued to be marked by considerable discrimination (e.g., Farina, Fisher, & Fisher, 1992; Page, 1995). Furthermore, recent attitude surveys reveal continuing stigmatization on the part of the general public and negative consequences of such stigma for individuals with mental disorders (Hinshaw et al., in press; for a review of current measures of stigma processes, see Link, Yang, Phelan, & Collins, 2004). Overall, despite general improvement in knowledge about mental illness, mental disorder continues to receive a great amount of prejudice, discrimination, and stigma from the public (Crisp, 1999; Phelan et al., 2000; Sartorius, 1998; Wahl, 1999). The scope of stigmatization is international (Angermeyer & Matschinger, 1997; Desipriya & Nobutada, 2002; Guimon, Fischer, & Sartorius, 1999; Ohaeri & Abdullahi, 2001; Thara & Srinivasan, 2000). Crucially, when respondents rate their attitudes toward mental illness in contrast to their views of other conditions, mental disorder (including substance abuse) consistently comes out as the most stigmatized condition a person can have (e.g., Tringo, 1970; see review in Hinshaw et al., in press). Furthermore, stigma has important, negative impact on the experiences and self-esteem of persons with mental disorders, fueling the effects of continuing social rejection they experience (Wright et al., 2000). Which receives the greater stigmatization: The constituent behaviors of mental disorder or the mental illness label per se? When experimental research directly compares these two potential sources of stigma, deviant behaviors emerge as the more salient feature. Yet labels are still powerful triggers of stigmatization, particularly when normal-range behavior patterns are labeled as mentally disturbed and crucially when respondents hold the general perception that mental disorder is associated with violence and dangerousness (Link, Cullen, Frank, & Wozniak, 1987). Furthermore, in fascinating experimental research, when individuals (whether or not they actually suffered from mental disorders) were led to believe that an interaction partner knew of their status as mentally ill, such expectancies negatively inuenced the subsequent interaction, even though the partners had received no such information (e.g., Farina, Gliha, Boudreau, Allen, &

Sherman, 1971). Thus, even the potential for disclosure of mental illness was enough to disrupt the social interaction. Note also that behavioral patterns of the various forms of mental illness are extremely varied and that desire for exclusion or social distance varies with the type of mental disorder depicted (Link et al., 1999). Yet when the blanket label of mental illness or mental disorder is applied to such disparate patterns, common associations with the terms in use out of control, violent, irrational, hopeless may become invoked regardless of the specic behaviors exhibited, fueling greater stigmatization.

Families
Among the growing information base about families and their experience of mental illness (e.g., Leey, 1992; Tessler & Gamache, 2000), I make four key points. First, the types of suffering, sacrice, and burden that are central to familial experiences with mental disorder have been dichotomized as (a) objective burden, comprising the nancial costs, seeking of housing, and logistic negotiations needed to manage a relative with mental illness, and (b) subjective burden, constituting the psychological pain, embarrassment, and mental anguish related to caring for the family member. Families report that subjective burden is the stronger (Thompson & Doll, 1982; see review in Hinshaw et al., in press), providing evidence for continuing stigma. Second, as highlighted above, families dealing with the mental illness of an offspring or relative have frequently contended directly with the elds predominant views that mental disorders emanate from faulty parental discipline or socialization. Such professional attitudes are inherently stigmatizing; they emanate directly from theoretical views that became predominant during the middle of the 20th century (e.g., Bettelheim, 1967). Given that blaming of parents has been a major tenet of 20th-century conceptions of mental illness, it is not surprising that families have been and continue to be reluctant to seek evaluation or treatment for the emotional and behavioral abnormalities of their offspring (Hinshaw et al., in press). Third, the predominant coping mechanism for families in response to the mental disorder of a child, spouse, or other relative has been one of secrecy and concealment (Clausen & Yarrow, 1955; Leey, 1992; Wahl & Harman, 1989). Fear of stigmatization often renders the entire topic off-limits, so that needed social support is not available. Self-help and advocacy groups, greater education about mental illness, engagement in family therapy, and far greater promotion of personal and family disclosures will all be necessary to bring the family experience of mental illness into the open (e.g., Hinshaw, 2004). Treatment procedures that emphasize open family communication about mental disorder show promise in

Stigma and mental disorders

721

terms of current and future functioning of children (Gladstone & Beardslee, 2001). Finally, I note that whereas nearly all of the relevant literature has emphasized family burden related to the negative effects of coping with a relative with mental illness anecdotal evidence suggests that in at least in a subset of families, the experience has fostered sensitivity, courage, and a more positive outlook on life. Just as mental disorder itself may foster resilient responses, as discussed below, the experience of family coping may not inevitably be associated with despair, isolation, and silence. Research documenting this type of outlook could help to mitigate the stigma that tends to cling to the portrayal of families who deal with mental disorder on a daily basis.

Mental health professionals

A systematic survey in the US (Wahl & Harman, 1989) revealed that one of the primary sources of stigmatization perceived by persons with mental illness and their family members emanated from both demeaning attitudes and low expectations for improvement from professionals providing care. Although a great number of those in the mental health professions are genuinely committed to clinical care and the fostering of autonomy, the very models of training in psychology, psychiatry, and other helping professions often convey a superior attitude, promoting an us versus them mentality (Hinshaw & Cicchetti, 2000). In addition, the mental health professions have low status in comparison with other medical subdisciplines (for historical information, see Nunnally, 1961); and working with patients who have serious mental disorders can be stressful. As a result, staff burnout, use of inappropriate humor, and scapegoating of particularly difcult clients and diagnostic categories are realities (Wahl, 1999). Extant literature focuses almost exclusively on professional responses to adult forms of mental disorder; far less is known about the ways in which professional attitudes toward child and adolescent clients are exhibited. In short, at least a subset of mental health professionals may inadvertently foster stigmatization through attitudes of superiority, paternalism, and separation from persons with mental illnesses and through theoretical modes that fundamentally blame parents and family members for mental disorders of children and adolescents.

children frequently utilize terms denoting mental illness as some of their rst words to put down disliked peers, such as psycho, retard, and crazy. Efforts to investigate young childrens attitudes must often incorporate such terms, as the phrase mental illness is often not recognized (Wahl, 2002). Relatedly, lyrics to popular songs, in both childrens and adults music, explicitly include terms related to mental disorder (Psycho Killer). Such usage is sufciently commonplace as to be hardly noticed, revealing the utter pervasiveness of stigma related to mental illness. Second, public media are extremely prone to promote stereotyped, negative depictions of mental illness (Wahl, 1995). Commercials, soap operas, prime time dramas, and newspaper/magazine accounts portray persons with mental illness as deranged, violent, and unpredictable with alarming frequency (Coverdale, Nairn, & Claasen, 2002; Diefenbach, 1997). Even childrens cartoons are quite likely to depict mental illness in characters, with such portrayals exhibiting extremes of stereotypes and pejorative features (Wilson et al., 2000). Short of stereotyped depictions of violence and utter irrationality, media portrayals still depict incompetence, unemployment, and grossly disturbed affect (Nunnally, 1961; see also Wahl, Ward, & Richards, 2002, for perspective on slowly emerging positive trends in media coverage in recent years). Such omnipresent images are perhaps the primary vehicle for fostering and maintaining stigma in the current era.3 Third, a host of discriminatory policies are still in place. Of great signicance is the lack of full parity of insurance coverage for mental, as opposed to physical, illnesses. Not only is there a lack of recognition, in many cases, that behavioral and emotional problems emanate from mental disorders, but inadequate funding for treatment also adds to abysmally low rates of treatment seeking for persons with mental disorders (Wang, Demler, & Kessler, 2002). In addition, independent housing for persons with mental illness is extremely difcult to nd, related in part to the fact that public assistance benets in several US states are not enough to cover the cost of a monthly rental, much less food or other necessities. Persons with histories of mental illness have difculties in obtaining a drivers license or maintaining child custody (Wahl, 1999). All of these indicators of discrimination constitute prima facie evidence of continuing stigmatization.
Is there an actual link between mental illness and propensity toward violence? Steadman et al. (1998) showed that there is a real association between severe, psychotic forms of mental disorder and risk for violent behavior, risk that is clearly fueled (and actually outweighed) by substance abuse. Still, overall rates of violent behavior in the US have little to do with mental illness. In short, whereas it is not veridical to make a claim of no association between mental disorder and risk for danger or violence, the linkage is clearly distorted and exaggerated throughout media coverage.
3

Evidence from everyday life

Beyond empirical research in the form of experiments, surveys, and interviews, what are signs from the general culture that stigma processes are operative? First, everyday language is revealing. Many words in common use as indicators of scorn are related to mental illness (e.g., what an insane statement! are you crazy?). Even preschool aged

722

Stephen P. Hinshaw

Fourth, increasing numbers of disclosures from individuals with mental illness, as well as their family members, provide poignant testimony to not only the vicissitudes and ravages of mental disorder but also to the pernicious effects of stigma (e.g., Hinshaw, 2002; Jamison, 1998; Neugeboren, 1997). Beard and Gillespie (2002) provided testimonials from many families in which a child has been diagnosed with a mental disorder, revealing considerable evidence of stigma. To the extent that such narratives become more accessible, compelling evidence for stigmatization can emerge for more of the general public. All of these problems are present worldwide. Indeed, harshly punitive practices toward those with mental illness exist in diverse nations and cultures (e.g., Guimon et al., 1999; Thara & Srinivasan, 2000). Overall, evidence from a range of everyday indicators reveals a substantial degree of stigmatization pervading many aspects of the general culture.

Children and adolescents Courtesy stigma. As noted at the outset of this article, research on the stigmatization of child and adolescent mental disorders is far less prevalent than investigations of stigma related to adult conditions. Some of the evidence for stigma regarding children is indirect. Goffman (1963) invoked the notion of courtesy stigma as a form of social disapproval for persons who are associated with a stigmatized individual (e.g., wife of a prison inmate). Spouses, parents, relatives, or even neighbors and acquaintances may therefore receive courtesy stigmatization when a child has a mental illness. When mental disorder exists in a family, courtesy stigma may extend in either direction. That is, parents of a child with a mental disorder may be blamed, rebuffed, and stigmatized, particularly in light of the elds tendencies to blame parents directly for causing mental disturbance; and when a child has a parent with a mental illness, the child may, by extension, be viewed as part of a deviant, disturbed family. Empirical evidence suggests that the concept of courtesy stigma applies, to some extent, to parents of youth with ADHD (Norvitilis, Scime, & Lee, 2002). Furthermore, Phelan (in press) recently found that when mental illness is presented in terms of genetic causation, the general public is likely to voice tendencies toward social distancing of biological relatives of the individual in question. Hence, courtesy stigma may be fueled by genetic ascriptions for mental disorder. Labeling effects. Do the labels and diagnoses related to mental disturbance in children promote stigmatization? A number of investigations reveal negative effects of labeling on stigma-related processes. For example, through careful quasi-experi-

mental research, Farrington (1977) showed that the labeling of youth displaying antisocial behavior as delinquent had negative effects on eventual outcome (see also Adams, Robertson, Gray-Ray, & Ray, 2003; Ray & Downs, 1986). In addition, Holguin and Hanson (2003) demonstrated the negative consequences of the label of sexual abuse for individuals so termed. What about the effects of labels on peer behavior? In a fascinating experimental investigation, Harris et al. (1992) had children in 3rd through 6th grades interact dyadically with an agemate. Experimentally manipulated were both (a) the actual diagnostic status of the peer, who either did or did not have ADHD; and (b) the childs expectation for the peer interaction partner, in the form of the label of behavior problem or no label. Both factors interacting with a peer with ADHD and holding the expectancy that the partner would have a behavior problem negatively inuenced the subsequent interaction, with the labeling effect strongly suggestive of stigma processes at work. Thus, not only are children with behavioral and emotional disorders highly likely to receive peer rejection in response to the symptoms of their conditions (e.g., Erhardt & Hinshaw, 1994), but agemates perceptions of labels related to mental illness appear to fuel denigration and castigation (see also Milich, McAninch, & Harris, 1992). Negative effects of labels extend downward in age to infancy: Labeling videotapes of infants as cocaine exposed yielded more negative adult ratings of the behaviors displayed than did no label (Woods, Eyler, Conlon, Behnke, & Webie, 1998). Similarly, labeling infants as depressed increased negative paternal ratings, particularly if the parents (fathers, in this case) showed symptoms of depression themselves (Hart, Field, Stern, & Jones, 1997). Yet different investigations suggest that labeling of child behavior problems is not always pejorative and may even have positive effects. MacDonald and MacIntyre (1999) showed that altering labels of mental disability and attention-disordered behavior did not inuence adult participants evaluations of the behavior patterns that were depicted. In addition, Klasen (2000) found that for parents of children with ADHD, the diagnosis of the child was actually empowering, as it reduced parental blame and increased the likelihood of obtaining treatment. Thus, whereas stigmatization may be fueled by the diagnosis and labeling of child behavior patterns, appropriate diagnosis may also relieve guilt and provide important empowerment for some parents. To the extent that the general public becomes better educated about the nature and causes of mental disorders as well as effective treatment strategies, and to the extent that professional guidelines for appropriate diagnosis are followed, accurate diagnosis and labeling may eventually confer more positive effects.

Stigma and mental disorders

723

Childrens perceptions of mental disorder. A small literature has emerged on the important topic of how children view the concept of mental illness, including their attitudes toward persons with mental disorders (see Wahl, 2002, for a review of investigations from the past two decades). A key question is whether developmental trends exist in the understanding children display about this concept or in their acceptance versus rejection of deviant behavior in peers or adults. Research on these important questions is difcult to appraise, given not only the small number of relevant investigations but also the methodologic differences cutting across the extant literature. For example, studies vary in the independent variables utilized (e.g., vignettes of children vs. adults with psychiatric problems; use of the term mental illness vs. more child-familiar terms like crazy) as well as the measures of stigma that constitute the dependent measures e.g., open-ended responses, questionnaire ratings, age-adapted social distance measures, projective drawings (see Hinshaw, in press). One important nding is that children have more difculty recognizing youth portrayed in vignettes as exemplifying psychological problems or mental illness than they do in recognizing adults as having such difculties (Spitzer & Cameron, 1995). Thus, mental illness in another child appears to be a difcult concept to comprehend prior to adolescence (see above, however, for clear behavioral evidence that the label of behavior problem can inuence peer interactions in childhood). In addition, evidence for a general age trend exists: From the elementary grades through adolescence, youth display greater and more accurate knowledge about mental illness (Wahl, 2002). In particular, from ages 5 through 12 years, children are increasingly likely to state that internal, psychological problems (thoughts and feelings), rather than overt behaviors, are appropriate subject matter for treatment (Dollinger, Thelen, & Walsh, 1980). Note that the slim database here comprises cross-sectional research (Wahl, 2002). Prospective longitudinal investigations of the same children across time with respect to their understanding of mental illness have not been performed. Although tentative evidence therefore exists for developmental trends in knowledge about mental illness, even relatively young children (3rd grade) are more likely to attribute negative qualities to neutral behavioral descriptions that are given a mentally ill label than to physically disabled or normal grown up labels (Adler & Wahl, 1998). Furthermore, developmental improvements in such attitudes about persons with mental illness have not been demonstrated in existing research; pejorative responses appear to exist from early childhood onward. In fact, a small longitudinal investigation noted that whereas attitudes toward mental retardation became more benign from early elementary grades to early

adolescence, the desire for social distance from a crazy person actually increased by middle school, such that this depiction replaced convict as the least acceptable category by eighth grade (Weiss, 1994). In short, whereas knowledge of mental illness increases across childhood, pejorative and stigmatizing attitudes show no comparable improvement and may, in fact, worsen. Thus, the stigmatization of mental disorder appears to begin in early in development, without substantial amelioration across time. A new generation of sophisticated research on developmental trends in childrens understanding and acceptance of mental illness both the label and the constituent behaviors would be extremely welcome (for parallels with a developmental perspective on the development of childrens racial attitudes, see Doyle & Aboud, 1995). For example, over and above cognitive appraisals and models that may unfold, what kinds of language and socialization practices do parents employ when discussing deviant behavior or mental illness with their children? It is hard to escape the possibility that negative media images (see above), as well as prejudice throughout the general culture, serve to drive this early display of fear and intolerance. In addition, the interaction of familial socialization and cultural messages is virtually unexplored. Finally, two points remain. First, there is an absence of research on the impact of stigma on children and adolescents who have experienced it themselves. This is a crucial omission, given the importance of documenting the internal effects of stigmatization on its victims (Wahl, 2002). Indeed, this perspective is essential to understanding the developmental ramications of both the experience of mental illness and the additional effects of prejudice and discrimination (Hinshaw, 2002). Second, it is quite conceivable that stigmatization of childhood disorders this time from the perspective of adults may be fueled by the state of the art of child and adolescent diagnostic assessment. That is, despite considerable progress in recent decades, the validity of many forms of child and adolescent diagnostic entities is far from fully established (see, e.g., Mash & Barkley, 2003). The publics condence in the viability of childrens mental health problems will be predicated on the continuation of strong scientic efforts to establish diagnostic and predictive validity.

Parental mental illness. Mental disorder in a parent is a crucial issue with respect to stigma. Indeed, having a parent with a major mental illness is a key risk factor for disorder and impairment in offspring (see, for example, Beardslee et al., 1998). The mechanisms underlying this association are variegated, including genetic mediation, lack of parental responsiveness, and modeling of emotional dysregulation, to name just three (see Goodman & Gotlib,

724

Stephen P. Hinshaw

2002; Hinshaw, 2004). The risk factor of parental mental disturbance is particularly complex, such that biological/genetic risk both correlates and interacts with environmental difculties in shaping the psychiatric problems in offspring (Rutter & Silberg, 2002). A variable seldom considered, however, is the problems parents are likely to have in communicating directly and clearly with their children about the nature of their own mental disorders and otherwise engaging support for their offspring. In the presence of stigma, available evidence indicates that the predominant parental tendency is concealment and silence (Leey, 1992). When no information is forthcoming about parental absence or disruption, however, children will tend to blame themselves, compounding other sources of risk for disorder and dysfunction (Hinshaw, 2004). Thus, one key antidote to stigma within families would appear to be the promotion of family communication to children and adolescents about the mental disorders of parents or close relatives (Beardslee, 2002). Such communication has the potential not only to demystify the mental condition itself but also to open the door for deployment of various coping responses on the part of both parents and offspring. Beardslee and colleagues have developed a form of therapy for families in which a parent suffers from a mood disorder where a key ingredient is the promotion of narrative accounts by parents, in understandable language for the child, about their mood-related problems. This treatment shows both short and long-term effects in enhancing coping and may even delay the emergence of mood disturbance in offspring (Beardslee, Wright, Rothberg, Salt, & Versage, 1996). The key point is that stigma may prevent parents from communicating openly about their own mental disturbance and that enhancement of such communication appears to play a role in mental health enhancement of children and adolescents.

for much of the last century, fostering a great deal of family blame and castigation. Furthermore, children with mental illness receive low status from both child and adult informants. Labeling and diagnosing children incurs risk for castigation, particularly from agemates; but in some cases, empowerment and access to services may be promoted through appropriate diagnosis (e.g., Klasen, 2000). Young children have limited knowledge of the concept of mental illness, often confusing it with mental retardation or physical illness; yet negative attitudes toward peers or adults deemed crazy or mentally ill appear to exist across childhood and adolescence without substantial improvement over time (Wahl, 2002). Although family stigma may prevent parents from discussing mental disorder with their children, such communication may yield important preventive benets. In all, stigma limits openness about mental illness, curtails access to needed assessments and treatments, and places funding efforts and legal rights as low priorities. The cost of failing to assess, treat, and rehabilitate children, adolescents, and parents with mental disorders is extremely high, so that work on stigma reduction is thus a high priority.

Developmental issues
What are some key issues, across the lifespan, related to the stigmatization of mental illness? After highlighting several of the most salient concerns here, I comment on core themes from developmental psychopathology that pertain to stigma.

Stigma across the lifespan

Stigma pertaining to disorders of infancy and toddlerhood may at rst appear to be a minor issue, given the lack of language skills and self-reective abilities in very young children. Yet the stigma of mental illness may be particularly intense for parents, caregivers, and relatives when the child is young, because the attributions made for the causation of such conditions will nearly always be faulty parenting, bonding, or attachment, given the childs lack of maturation (for the example of autistic disorder, see Bettelheim, 1967). Alternately, the ascription may be to extreme genetic aws, which may also carry stigmatizing messages, particularly for relatives (Phelan, in press). Accurate screening, diagnosis, and treatment of the earliest child mental disorders such as autism, other pervasive developmental disorders, very early onset depression, or ADHD are essential in order to prevent the accumulation of skill decits and negative feedback from the environment (e.g., Hinshaw, 1994). Yet (a) lack of education about the potential for serious mental disorders at this age and (b) the stigma of having a young child with mental illness may well serve to curtail the pursuit of early assessment and detection.

Summary
Mental illness continues to receive major stigmatization, whether measured through attitudes, behaviors, indicators in the general culture, discriminatory policies, or the continued lack of engagement in treatment of far too many persons with mental disorders. The overwhelming majority of research focuses on adults with mental disturbance, whose stigmatization is undoubted with respect to overt negative attitudes, desire for social distance, and actual behavioral discrimination. Both the constituent behaviors related to mental illness and the label of mental disorder receive stigma; the label incurs stigmatization particularly when behavior is ambiguous and when respondents associate mental disorder with dangerousness and violence. In terms of children and adolescents, parents were often blamed for the mental disturbances of their offspring

Stigma and mental disorders

725

During the preschool and school-aged years, attaining educational competence is a major objective, given the salience of academic achievement for success in employment and productivity. Because the presence of a mental disorder may hamper the ability to focus on school curricula and master educational material (for information on the linkage between ADHD, disruptive behavior disorders, and underachievement, see Hinshaw, 1992), it may be essential for families to obtain an assessment in order to document special needs, leading to accommodations that can facilitate academic attainment. But if stigmatization leads to reluctance to acknowledge a childs emotional and behavioral difculties, appropriate accommodations can never be put into place. At the same time, the adversarial nature of many attempts to procure special services can only accentuate frustration and add to the effects of stigmatization. In short, stigma may therefore limit important life opportunities during years that are crucial for gaining academic as well as social skills. Adolescence is well known as a time period of identity consolidation and the gradual gaining of autonomy (Feldman & Elliott, 1990). A mental illness that takes place during adolescence may be particularly devastating for ones self-esteem, independence, and sense of fundamental normality in the world (Hinshaw, 2002). If the illness is severe and hospitalization is required, it is essential that institutional staff convey a sense of that the individual still has agency and that his or her integrity is assured. Likewise, psychotherapists and pharmacotherapists must facilitate a strong therapeutic alliance while simultaneously maintaining their belief in the ability of the adolescent to make reasonable decisions. Stigmatization, which may include demeaning attitudes from therapists or dehumanizing hospital experiences, can thus have lifelong implications. Furthermore, social policies currently in place in the US convey both stigmatizing and fragmenting messages for families of adolescents. For example, parents of adolescents with serious behavioral or mood disturbances may be able to obtain needed day-treatment or residential services only if they relinquish custody of their youth to the courts or the state (see Hinshaw et al., in press). This practice reects the critical shortage of needed (a) residential facilities and (b) community supports as an alternative to residential care for children and adolescents with severe problem behavior. It also emphasizes the inherently stigmatizing messages regarding family unity in current policy. Legislation under consideration by the US Congress may be an important means of ending this policy of family dissolution in the service of obtaining necessary intervention. Finally, in adulthood stigmatization is associated with a primary strategy of secrecy and concealment regarding mental disturbance (see Link, 1987).

Whereas optimal coping does not mandate that an individual with a history of mental illness disclose his or her life story indiscriminately, if fear of rejection dictates that silence is the only option, life adjustment and social supports will be compromised. Recall the particularly devastating implications of silence and shame when an adult with mental illness is also a parent: Children are likely to internalize blame for their parents conditions if silence is the modal response, and lack of parental treatment may have crucial consequences for the childs eventual development (Hinshaw, 2004). Another issue pertaining to stigma for adults with mental disorders is the pervasiveness of social attitudes toward mental illness namely, that they tend to permeate all aspects of the persons life. Such a view is quite likely to foster the individuals becoming identied with the disorder. In other words, when professionals, neighbors, and families come to view the aficted individual as a schizophrenic, a manic depressive, or an autistic, the persons entire worldview is prone to be colored by the diagnostic label. Children, adolescents, and adults with mental illnesses are rst and foremost human; it is essential to cast the disorder as a set of symptoms the person has rather than a blanket ascription of his or her core being (American Psychiatric Association, 2000; Hinshaw & Cicchetti, 2000). Stigma processes, however, are by denition pervasive and globalizing, so that the battle to retain the individuals identity and humanity in the face of a mental illness diagnosis is likely to be an uphill battle. Across the lifespan, then, stigma has important implications for the attainment of competence, the development of independence and agency, and the ability to receive social supports and acceptance. The pain and impairments that emanate from mental disorders are often quite severe. When stigma and discrimination are added to the mix, chances for life success are markedly diminished. The effects of stigma on children may multiply during subsequent development, and family stigma can curtail the seeking of needed services at crucial developmental points for offspring (US Department of Health and Human Services, 1999). Overall, stigma is not a static entity but rather a process with major developmental implications.

Developmental psychopathology issues related to stigma

Many core issues are central to the enterprise of developmental psychopathology, the eld that explicitly links normal and atypical development (Cicchetti & Cohen, in press; Rutter & Sroufe, 2000). For example, continuities and discontinuitites in development and in the boundaries between normal and abnormal functioning are core considerations. I note three key additional points of particular relevance to stigma.

726

Stephen P. Hinshaw

Ecological models. Developmental psychopathology models emphasize the linkages between individuals and their environments, such that pathology and coping are hypothesized to reside in the interface between persons and settings (Bronfenbrenner, 1977). Stigma itself is an inherently relational construct, as it constitutes a mark of degradation-related membership in a group believed to be evil, awed, or contagious. Furthermore, stigma is inextricably linked with social power, in that only socially devalued attributes tend to be stigmatized (Link & Phelan, 2001). For children and adolescents, stigma processes occur in families, schools, and communities; the notion of t between child and setting is crucial to the diagnosis of the child as mentally disturbed. Hence, community tolerance and acceptance of developmental disorders and community facilitation of accommodations for youth with special educational needs are essential components of fostering academic, social, and life competence. Reciprocal determinism and transaction. Strongly emphasized in developmental psychopathology are accounts of the etiology of mental disorder that posit interactive linkages between individual-level constructs, such as genotypes or temperament, relational variables, including attachment and parenting styles, and wider systems inuences, like school or neighborhood settings, in shaping typical as well as atypical development (Rutter & Sroufe, 2000). Indeed, recent evidence points to the key role of interactions between genotypes and environments in molding psychopathological functioning (see Caspi et al., 2003). When such interactions unfold over time, the construct of transactional inuences is salient (Sameroff & MacKenzie, 2003). In light of such dynamic models, it becomes far more difcult to make reductionistic arguments that mental disorder is a sole product of either genes or dysfunctional environments. What is the relevance for stigma? As emphasized earlier, stigmatization of families is likely to occur when parenting is viewed as the primary cause of mental illness, and derogation and punishment are clear possibilities when deviant genetic makeup is indicated as the primary determinant of mental disorder (e.g., Mehta & Farina, 1997). As discussed earlier, traditional attribution theory emphasizes that ascriptions of personal control for deviant behavior tend to foster rejection and intolerance, whereas noncontrollable attributions should lead to more benign appraisals and responses (e.g., Weiner et al., 1988). Indeed, when adult respondents attribute mental illness to biological causal factors as opposed to personal aws, there is at least a small tendency toward reductions in social distance (Martin et al., 2000). Yet it may well be the case that extreme, reductionistic, and essentialist attributions to biological/genetic abnormalities can trigger a propensity for punitive and stigmatizing responses, as

well as restrictions of reproductive rights (see discussion in Phelan, in press), related to the underlying view that the deviant individual is separate from the rest of humanity awed at his or her biological core. On the other hand, appreciation of the interactional and transactional nature of mental disorder can give appropriate consideration to the complexity of causal pathways. It may therefore serve to mitigate blame directed toward awed parenting styles, character blemishes, or deviant genetic substructures as the sole loci of mental disturbance. Given, however, societys increasing penchant for eitheror, sound-bite perspectives on social and personal problems, interactive models may be difcult to comprehend. Furthermore, the current biological zeitgeist may help to shape attributions and stigmatizing responses. For instance, it may be the case that current clinical trials emphasizing the preferential response to medication treatments for child conditions like ADHD (see MTA Cooperative Group, 1999) add to the sense that only biological factors are relevant for etiology and treatment. Note, however, that this same clinical trial yielded important evidence that despite the substantial heritability of ADHD, changes in parental discipline styles by families particularly those who received multimodal treatment integrating medication and psychosocial treatment were a key explanatory factor for childrens improvements in social skill and normalization of disruptive behavior in the school setting (Hinshaw et al., 2000). In other words, conditions with substantial biological risk may be treatable via psychosocial, environmental processes. Overall, promoting the notions of interaction and transaction across biological and environmental inuences may help to reduce the stigmatization associated with extremes of either exclusively genetic or exclusively personal/familial causal models of mental disorder in children, adolescents, and adults.

Resilience. Views of serious mental disorder as chronically debilitating and devastating are modal in both the psychological/psychiatric literature and lay views of mental illness (e.g., Kraepelin, 1921/1987). Although the pain and impairment related to mental disability are undoubted, it is also the case that the symptoms of many mental disorders wax and wane over time, that periods of relatively normal functioning are prevalent, and that many persons with severe mental disturbances can make unexpectedly good life adjustments. In other words, resilience or recovery is a real possibility for individuals with mental disorders (Hinshaw, 2002), particularly among children and adolescents. Dened as the attainment of positive outcomes in the presence of risk for maladjustment (Luthar, Cicchetti, & Becker, 2000; Masten & Coatsworth, 1998), resilience is a construct that requires far greater promotion and

Stigma and mental disorders

727

understanding with respect to mental disturbance. That is, when it is understood that mental illness is not inevitably lifelong nor exclusively associated with despair and degradation, stigmatizing attitudes may begin to remit. There are signs of a greater proneness to portray positive images of persons with mental illness in the media (e.g., Wahl et al., 2002; see also the lm A Beautiful Mind, despite its inaccuracies), although progress is slow. The extension of these views to children and adolescents with autism, ADHD, learning disorders, conduct problems, depression, and other childhood disorders is a needed step to overcome stigma. However, falsely optimistic portrayals may lead to overzealous expectations and a subsequent backlash (Grob, 1994). Required are realistic, rather than sensationalized, depictions of child and family functioning that reveal, for example, the parenting skills and sensitivity of adults with serious mental disorders (Hinshaw, 2002); the potential for friendship, strength, and courage in children, adolescents, and adults with various mental conditions; and the chances for success in social and occupational roles despite severe symptoms (Jamison, 1995). The more human the portrayals, the greater the chances for stigma reduction (Beard & Gillespie, 2002). In short, counter-stereotypic portrayals of the realities of personal and familial mental illness may go a long way toward promoting the views that mental illness is a common reality in our culture and worldwide, that it is not inevitably associated with deterioration and despair, and that active coping efforts on the part of individuals and families have the potential to yield important short- and long-term benets. Resilience is thus an important construct for the elds conceptual models and for promoting more realistic and optimistic views in the wider culture.

Research questions and issues

The stigmatization of mental disorders raises a host of issues related to empirical research efforts for adults, children, and families alike. The listing here is representative but not exhaustive; see Hinshaw (in press) for a more comprehensive discussion. First, investigators of stigma need to pay close attention to the core meaning of the term, which involves not just stereotypic beliefs, negatively tinged attitudes and prejudices, or discriminatory acts but also reciprocal, internalized, negative perceptions on the part of the stigmatized individuals in question. In other words, measuring stigma by means of a single attitude scale completed by social perceivers may not do justice to the complex, interactional nature of the construct (see Fife & Wright, 2000, for research on the multidimensionality of stigma). In adult research, work by Farina and colleagues has approached the ideal of considering the joint

perspectives of perceivers and recipients of stigmatizing messages (see Farina et al., 1992). For children and adolescents, the difculty of the task is multiplied by the problems inherent in obtaining measures of behaviors and self-perceptions of young participants who lack the sophistication or verbal abilities of adults. The work of Harris et al. (1992) provides an excellent example of the behavioral manifestations of stigma when children are led to believe that an interaction partner has a behavioral problem. Future research needs to pay even greater attention to the cognitive and emotional responses of labeled children and their social partners. In short, much extant research on stigma captures a small portion of the network of cognitions, attitudes, and behaviors displayed by social perceivers and the counterpart network of responses and reactions of the castigated subgroup. Second, at the same time that investigators need to pay close attention to the dependent variable of stigma, they also need to measure accurately the independent variable of mental disorder in children and adolescents. That is, far too much work on adults has utilized extremely global measures of the mentally ill or ex-mental patients as the stimulus of interest, neglecting to consider the high levels of variation across the many types of mental disturbance known to exist (e.g., American Psychiatric Association, 2000). Current research reveals marked differences in both knowledge and attitudes regarding the various forms of mental disorder in adults (Link et al., 1999). Of note, however, it is still important to probe societal responses to the general label of mental illness a label that still carries harshly negative connotations (see Link et al., 1989, for discussion of a modied labeling theory of mental illness). Yet the assumption that public attitudes will be similar across such categories as substance abuse, depression, schizophrenia, and obsessivecompulsive disorder or ADHD, eating disorders, and conduct problems on the childhood side may itself be stigmatizing, as it makes the tacit presumption that such conditions are fundamentally similar. In short, knowing how adults, family members, teachers, and peers respond to different kinds of mental disturbance is an important goal for subsequent research efforts. Third, nearly all of the work on stigma in relation to both adult and child disorders focuses on selfreported attitudes (adjective checklists, social distance scales, semantic differentials) or behavioral rejection, both of which tap overt responding. In research on racial prejudice, it is well known that much of the current-day expression of bias is not overt and explicit. Changing social norms have made it relatively unlikely that a respondent will express overtly bigoted views (see Gaertner & Dovidio, 2000, for a review); the constructs of modern racism and aversive racism are invoked to describe the kinds of unconscious, overlearned, and largely hidden pre-

728

Stephen P. Hinshaw

judices still held by many individuals. Thus, measures of implicit attitudes and biases have come to the fore (e.g., Greenwald & Banaji, 1995), in which respondents reaction times to associated images (e.g., black-good vs. black-bad) are the dependent measures. As noted earlier, implicit attitudes toward persons with physical problems or mental disorders are just beginning to be measured (Teachman et al., 2003). A major research agenda is to understand the ways in which prejudice and bias toward mental illness may be underestimated by exclusive reliance on overt, explicit measures and the ways in which interventions to reduce stigma can affect implicit as opposed to purely explicit outcome measures. In particular, work on childrens implicit vs. explicit biases is a priority. Furthermore, it is essential to include measures of actual behavioral discrimination in addition to attitudinal measures per se, whether the latter are overt or covert. Fourth, despite theoretical speculations that stigmatization will inuence development across the lifespan of a child or adolescent, there is virtually no prospective, longitudinal research that deals with stigma of mental disorders (for an exception, see Weiss, 1994). This is an important gap, given the importance of understanding (a) how stigmatizing attitudes from social perceivers change with age and (b) what the specic impacts of stigmatization will be on the future development of those stigmatized. Furthermore, the conclusion of Wahl (2002) regarding the almost complete lack of empirical data on the topic of the experiences of youth who have experienced stigma is sobering. A core issue in this regard is to separate the effects of stigma from those related to prior levels of mental disturbance per se. Several adult investigators have begun to disentangle such constructs in mini-longitudinal research, by measuring the effects of stigmatization on subsequent functioning while taking into account baseline levels of psychopathology. Indeed, such research demonstrates the lasting effects of stigma, over and above pre-existing psychopathology (e.g., Link, Struening, Rahav, Phelan, & Nuttbrock, 1997). This kind of sophistication will be important for child and adolescent stigma research. Fifth, I have highlighted the major controversies related to attribution theory and its predictions regarding stigmatization in particular, that ascription of negative behavior to non-controllable causes like biomedical or genetic factors should lessen punishment and stigma. In fact, however, empirical evidence is not uniformly supportive of this position, and some investigations reveal a paradoxical tendency for biogenetic ascriptions to receive harsh punishment and castigation (Dietrich et al., 2004; Mehta & Farina, 1997; Read & Harre, 2001). What is it about mental disorder that appears to circumvent the supposed protective value of attributions to noncontrollable factors? It may well be that some of the negative response to stigma occurs immediately

upon perception of deviant, troubling, even threatening behaviors, prior to attributional processing; it is also possible that it is the reductionistic and exclusive attribution to defective biology or genes that promotes a kind of tribal stigma against an inherently awed, subhumanized subgroup (i.e., persons with mental disorders). Discovering more about the balance of social cognitions and attributions toward those with mental illness, and the linkage of such perceptions and beliefs affective and behavioral responding, will be an important yet difcult task. Sixth, individuals with mental disorder, and their families, are characterized by vastly different kinds of coping strategies in response to stigmatization (Corrigan & Watson, 2002). That is, some persons internalize stigmatizing messages deeply, with resultant devastation of self-esteem, whereas others appear to ignore castigating responses and still others mount protest measures or other types of problem-focused coping. Yet almost nothing is known about the kinds of children, adolescents, and families, who deploy these (or other) coping strategies in reaction to being stigmatized. Intervention efforts will benet greatly from the basic information about response to prejudice and stigma on the part of persons with mental disorders and the kinds of coping responses that are benecial for different kinds of individuals and families. Finally, an important research question relates to whether stigma has decreased in recent decades or whether it may actually be on the rise, particularly given the rising rates of identication and treatment of child psychiatric disorders. As noted earlier, conclusions of the 1970s and 1980s that public attitudes toward mental illness had dramatically shifted toward improvement were premature, relying as they did on the results of overt attitude scales reecting social desirability in responding. Phelan et al. (2000) replicated paradigms from the 1950s and found that, with respect the most severe forms of mental illness, desire for social distance had actually increased, related to the far-greater tendency for the general public to associate mental disorder with dangerousness and violence. (It is unknown, however, whether this nding also applies to children and adolescents with mental health problems.) Sartorius (1999) contends, in fact, that greater urbanization and education around much of the world has produced a consequent press for conformity, fueling rather than abating the stigmatization of persons with mental illness. It is certainly possible that other secular trends (e.g., homogenization of mass culture, increased technological sophistication that breeds lack of acceptance of those without requisite education or skills) may also be producing less, rather than greater, tolerance for mental illness. Creative research and cultural analysis could help to address this perplexing and fascinating issue.

Stigma and mental disorders

729

Solutions: overcoming stigma

Given the long historical legacy of stigmatization of mental disorders, nding strategies to overcome stigma will not be quick or easy. For example, given that increased knowledge of mental illness does not ve always translate into improved attitudes, it is na to think that public education programs alone will solve the problem of stigmatization. Because stigma processes operate in individual perceivers (whose social cognitions, stereotypes, and implicit biases are relevant), families (who may internalize messages to conceal and deny mental disorder in a relative), communities (where ingroup and outgroup processes occur), cultures (in which, for example, stereotyped media portrayals of mental illness are promoted), and broad social policies (for example, through legislation that fails to mandate parity of insurance coverage for mental disorders), change strategies to overcome stigma will need to operate at multiple, interacting levels (Hinshaw et al., in press; Link & Phelan, 2001). Furthermore, to the extent that some of the more egregious forms of prejudice and discrimination against persons with mental disorder are countered in the coming years via policy changes, what may be left are more subtle, implicit forms of stigma, resulting from the lingering cultural messages and the naturally selected exclusionary tendencies discussed above. Parallel to the laissezfaire types of racism discussed by Bobo (1999), these forms may be particularly resistant to change. Beginning with broad levels of intervention, a number of policy changes may help to limit the discriminatory aspects of the stigmatization of mental disorder among both children and adults. For instance, parity of insurance coverage would appear to be a crucial goal; without it, physical illnesses can be treated to a far greater extent than devastating mental illnesses. General health-care reform (given the huge numbers of uninsured in the US) is also a priority, as is enforcement of access to housing and employment. Sensible rights (e.g., for obtaining or renewing a drivers license; for maintaining or regaining custody of ones children if adequate caregiving can be demonstrated) need to be upheld and enforced. Specically with respect to children and adolescents, increased family understanding of the provisions of the Individuals with Disabilities Education Act (IDEA) might help to ensure adequate academic attainment for youth with mental disorders. Note that funding is a crucial issue here: At present, providing assessments and accommodations is mandated under this law, but federal funds support only a small fraction of the overall costs. Another policy-related suggestion is to include behavioral and emotional functioning as part of the medical check-ups that children receive each year from health-care providers. This kind of preventive approach could bring discussion of childrens social

and behavioral functioning into the everyday language of doctors and families and serve to deal with the precursors of mental disorders before they become entrenched (Hinshaw et al., in press). Also relevant is legislation to end the need for family dissolution or the giving up of child custody in order to obtain services for troubled youth as well as greater variety and quality of community-based services for children and adolescents with severe mental illness. In terms of public media, a different set of messages about mental illness needs to be transmitted. Information about mental disorder in the print and visual media continues to be related to danger, violence, and utter irrationality; all too little information about strength, courage, resilience, parent persistence in the face of adversity, and positive accomplishments is given. It may take a blend of protest by consumer groups, consciousness raising among writers and producers, and promotion of poignant and realistic disclosures by children and families who deal with mental illness on a daily basis to provide a different set of messages and images in the future (e.g., Leete, 1992; see discussion in Corrigan & Penn, 1999). Greater numbers of portrayals of the realities of such conditions as child autism, ADHD, and learning disorders as well as adolescent mood disorders and eating disorders might set the stage for openness and discussion, rather than silence and shame, about mental illness. At a community level, the predominant empirically based strategy for overcoming discrimination and stigma has been the contact hypothesis (Allport, 1954), through which it is held that attitudes and behaviors are most likely to improve through direct behavioral contact with members of outgroups. Kolodziej and Johnson (1996) found that contact between mental health personnel or students, on the one hand, and persons with mental disorder on the other generally facilitated better attitudes. However, research has made clear that it is the conditions of contact that are crucial for success. Specically, contact is most likely to lead to improved attitudes when ingroup and outgroup members have regular, informal contact on an egalitarian basis rather than contrived, articial contact in which the status differentials are great (see review in Gaertner & Dovidio, 2000). Improvements in child and adult mental health care and employment opportunities are clearly needed for contact to be more egalitarian than it often is today. Another prerequisite is locating persons with mental disorders in communities, rather than institutions or inner-city board-and-care residences isolated from the mainstream of society but only when adequate social and nancial supports are in place for community placements. In addition, when ingroup and outgroup members work toward common, superordinate goals and foster an expanded sense of ingroup identity (Gaertner & Dovidio, 2000; Sherif & Sherif, 1953), stigma is likely to

730

Stephen P. Hinshaw

diminish. Advocacy and support groups in which persons with mental disorders, parents, other family members, and the general public interact constitute examples of such collaboration. For families, education about the causes and realities of mental illness, social support from other families grappling with similar issues, and engagement in family-based therapies that give tools for coping with the difcult life issues presented by serious mental illness are all necessary steps toward reducing stigma and shame. Engaging families in treatment for the mental health problems of their children is an uphill struggle for several reasons psychological as well as economic and particularly for ethnic minority families (US Department of Health and Human Services, 1999). Along this line, a recent investigation revealed that that racial/ethnic minority parents in the US were less likely than Caucasian parents to attribute their childrens mental health problems to biological or psychological causal factors but more likely to ascribe such problems to social/political forces like prejudice (Yeh, Hough, McCabe, Lau, & Garland, 2004). A key conclusion here is that the lower rates of treatmentseeking in ethnic groups for childrens mental health services may relate, at least in part, to a lack of parental buy-in for the kinds of biopsychosocial models of etiology and treatment that are prevalent in middle-class, white culture. Furthermore, when a parent has a mental illness, children needed to be engaged in family discussion and treatment in such a way as to help them understand that they themselves are not to blame and that their parent is getting help (Beardslee, 2002). Self-help and advocacy groups can reduce isolation, provide needed information, and aid in family coping. Finally, for individuals with mental disorder, including children and adolescents, engagement in empirically supported treatments that can reduce symptoms and facilitate competent academic and social performance is an important means of stigma reduction. To the extent that interventions can lessen threatening and maladaptive symptoms, perceivers in society will have less reason to stigmatize those with mental disorders (Hinshaw, in press). This is a delicate issue: I am not advocating for a blaming-the-victim mentality in which stigma reduction is contingent on eliminating all signs of the disorder. Such a strategy would be tantamount to positing that the solution for racial prejudice is to have all members of racial/ethnic minority groups change their skin color or for members of sexual minorities to alter their sexual orientation. Yet mental disorder is unlike ethnicity, race, and sexual preference in that its signs and symptoms are maladaptive, and treatment may clearly enhance the independence and fulllment of the individual. Thus, successful treatment is one part but clearly not the only component of stigma reduction.

Beyond treatment strategies per se, nding means of bolstering the coping resources of children and adults with mental illness is needed. For example, if individuals encounter prejudice, it will be important that they learn to attribute such stigma to the limitations and biases of society rather than to inherent aws inside themselves. For children and adolescents in particular, parents and caregivers will also need to hear and internalize such messages. Given, however, that the nature of many forms of mental illness is to erode self-condence and a sense of agency, teaching such coping strategies is a formidable objective. One of the great challenges of the future will be to apply the basic principles of stigma reduction across the multiple levels of inuence that are operative for children, adolescents, and their families. The pervasive shame and silence that surround mental illness, the cyclic nature of reform and retrenchment throughout history, and the deep levels of stigma toward severe behavioral deviance present great challenges. The future for human society, however, depends on children and adolescents to reach their full potential, including those with mental disorders. Enacting change from the individual level to the systemic level is required for such human potential to be realized. Many forms of mental disorder may always receive some degree of social distance and castigation, particularly those at the most severe ends of the spectrum, but there is considerable hope that compassion can replace blame and silence, to reduce stigma and discrimination against those who most need the support of families, communities, and society at large children and youth.

Correspondence to
Stephen P. Hinshaw, Department of Psychology, Tolman Hall #1650, University of California, Berkeley, CA 94720-1650, USA; Email: hinshaw@socrates. berkeley.edu

References
Aboud, F.E. (2003). The formation of in-group favoritism and out-group prejudice in young children: Are they distinct attitudes? Developmental Psychology, 39, 4860. Adams, M.S., Robertson, C.T., Gray-Ray, P., & Ray, M.C. (2003). Labeling and delinquency. Adolescence, 38, 171186. Adler, A.K., & Wahl, O.F. (1998). Childrens beliefs about people labeled mentally ill. Journal of the American Orthopsychiatric Association, 68, 321326. Allderidge, P. (1979). Hospitals, madhouses, and asylums: Cycles in the care of the insane. British Journal of Psychiatry, 134, 321334. Allport, G. (1954). The nature of prejudice. New York: Addison-Wesley.

Stigma and mental disorders

731

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th edn: text revision). Washington, DC: American Psychiatric Press. Angermeyer, M.C., & Matschinger, D. (1997). Social distance towards the mentally ill: Results of representative surveys in the Federal Republic of Germany. Psychological Medicine, 27, 131141. Appelbaum, P.S. (2002). Response to the Presidential Address The systematic defunding of psychiatric care: A crisis at our doorstep. American Journal of Psychiatry, 159, 16381640. Aries, P. (1962). Centuries of childhood: A social history of family life. New York: Knopf. Beard, J.J., & Gillespie, P. (Eds.) (2002). Nothing to hide: Mental illness in the family. New York: New Press. Beardslee, W.R. (2002). Out of the darkened room: When a parent is depressed: Protecting the children and strengthening the family. Boston: Little, Brown. Beardslee, W.R., Versage, E.M., & Gladstone, T.R.G. (1998). Children of affectively ill parents: A review of the last 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 11341141. Beardslee, W.R., Wright, E., Rothberg, P.C., Salt, P., & Versage, E. (1996). Response of families to two preventive intervention strategies: Long-term differences in behavior and attitude change. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 774782. Bettelheim, B. (1967). The empty fortress: Infantile autism and the birth of the self. Oxford, UK: Free Press of Glencoe. Bobo, L.D. (1999). Prejudice as group position: Microfoundations of a sociological approach to racism and race relations. Journal of Social Issues, 55, 445472. Bronfenbrenner, U. (1977). Toward an experimental ecology of human development. American Psychologist, 32, 513531. Black, E. (2003). War against the weak: Eugenics and Americas campaign to create a master race. New York: Four Walls Eight Windows. Caspi, A., Sugden, K., Moftt, T.E., Taylor, A., Craig, I.W., Harrington, H., McClary, J., Mill, J., Morton, J., Braithwaite, A., & Poulton, R. (2003). Inuence of life stress on depression: Moderation by a polymorphism in the 5-HTT gene. Science, 301, 386389. Cicchetti, D., & Cohen, D. (Eds.), (in press). Developmental psychopathology (2nd edn). New York: Wiley. Clausen, J., & Yarrow, M.R. (Eds.). (1955). The impact of mental illness on the family. Journal of Social Issues, 11, No. 4. Corrigan, P.W. (2004). How stigma interferes with mental health care. American Psychologist, 59, 614 625. Corrigan, P.W. (Ed.). (2005). On the stigma of mental illness: Practical strategies for research and social change. Washington, DC: American Psychological Association. Corrigan, P.W., & Penn, D.L. (1999). Lessons from social psychology on discrediting psychiatric stigma. American Psychologist, 54, 765776. Corrigan, P.W., River, L.P., Lundin, R.K., Wasowski, K.U., Campion, J., Mathieson, J., Goldstein, H., Bergman, M., & Gagnon, C. (2000). Stigmatizing

attributions about mental illness. Journal of Community Psychology, 28, 91102. Corrigan, P.W., & Watson, A.C. (2002). The paradox of self-stigma and mental illness. Clinical Psychology: Science and Practice, 9, 3553. Coverdale, J., Nairn, R., & Claasen, D. (2002). Depiction of mental illness in print media: A prospective national sample. Australian and New Zealand Journal of Psychiatry, 36, 697700. Crisp, A.H. (1999). The stigmatisation of sufferers with mental disorders. British Journal of General Practice, 49, 34. Crisp, A. (2000). Changing minds: Every family in the land: An update on the Colleges campaign. Psychiatric Bulletin, 24, 267268. Crocetti, G., Spiro, H., & Siassi, I. (1974). Contemporary attitudes towards mental illness. Pittsburgh, PA: University of Pittsburgh Press. Crocker, J., Major, B., & Steele, C. (1998). Social stigma. In D.T. Gilbert, S.T., Fiske, & G. Lindzey (Eds.), Handbook of social psychology (4th edn, vol. 2, pp. 504553). Boston: McGraw-Hill. Desipriya, E.B.R., & Nobutada, I. (2002). Stigma of mental illness in Japan. Lancet, 359, 1866. Diefenbach, D.L. (1997). The portrayal of mental illness on prime time television. Journal of Community Psychology, 25, 289302. Dietrich, S., Beck, M., Bujantugs, B., Kenzine, D., Matschinger, H., & Angermeyer, M.C. (2004). The relationship between public causal beliefs and social distance toward mentally ill people. Australian and New Zealand Journal of Psychiatry, 38, 348354. Dollinger, S.J., Thelen, M.H., & Walsh, M.I. (1980). Childrens conceptions of psychological problems. Journal of Clinical Child Psychology, 9, 191194. Donohue, B., Hersen, M., & Ammerman, R. T. (1995). Historical overview. In M. Hersen & R.T. Ammerman (Eds.), Advanced abnormal child psychology (pp. 3 19). Mahwah, NJ: Erlbaum. Doyle, A.B., & Aboud, F.E. (1995). A longitudinal study of White childrens racial prejudice as a social-cognitive development. Merrill-Palmer Quarterly, 41, 209 228. Erhardt, D., & Hinshaw, S.P. (1994). Initial sociometric impressions of ADHD and comparison boys: Predictions from social behaviors and from nonbehavioral variables. Journal of Consulting and Clinical Psychology, 62, 833842. Farina, A., Fisher, J.D., & Fisher, E.H. (1992). Societal factors in the problems faced by deinstitutionalized psychiatric patients. In P.J. Fink & A. Tasman (Eds.), Stigma and mental illness (pp. 167184). Washington, DC: American Psychiatric Press. Farina, A., Gliha, D., Boudreau, L.A., Allen, J.G., & Sherman, M. (1971). Mental illlness and the impact of believing others know about it. Journal of Abnormal Psychology, 77, 15. Farrington, D.P. (1977). The effects of public labeling. British Journal of Criminology, 17, 112125. Feldman, S.S., & Elliott, G.R. (Eds.) (1990). At the threshold: The developing adolescent. Cambridge, MA: Harvard University Press. Fife, B.L., & Wright, E.R. (2000). The dimensionality of stigma: A comparison of its impact on the self of

732

Stephen P. Hinshaw

persons with HIV/AIDS and cancer. Journal of Health and Social Behavior, 41, 5067. Fishbein, H.D. (2002). Peer prejudice and discrimination: The origins of prejudice (2nd edn). Mahwah, NJ: Erlbaum. Gaertner, S.L., & Dovidio, J.F. (2000). Reducing intergroup bias: The common ingroup identity model. Philadelphia: Psychology Press. Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Englewood Cliffs, NJ: Prentice Hall. Gladstone, T.R.G., & Beardslee, W.R. (2001). The prevention of depression in at-risk adolescents: Current and future directions. Journal of Cognitive Psychotherapy, 14, 923. Goodman, S.H., & Gotlib, I.H. (Eds.). (2002). Children of depressed parents: Mechanisms of risk and implications for treatment. Washington, DC: American Psychological Association. Greenwald, A.G., & Banaji, M. (1995). Implicit social cognition: Attitudes, self-esteem, and stereotypes. Psychological Review, 105, 427. Grob, G.N. (1994). The mad among us: A history of care of Americas mentally ill. New York: The Free Press. Guimon, J., Fischer, W., & Sartorius, N. (Eds.). (1999). The image of madness: The public facing mental illness and psychiatric treatment. Basel, Switzerland: Karger. Harris, M.J., Milich, R., Corbitt, D.W., et al. (1992). Self-fullling effects of stigmatizing information on childrens social interactions. Journal of Personality and Social Psychology, 63, 4150. Hart, S., Field, T., Stern, M., & Jones, N. (1997). Depressed fathers stereotyping of infants labeled depressed. Infant Mental Health Journal, 18, 436 445. Heatherton, T.F., Kleck, R.E., Hebl, M.R., & Hull, J.G. (Eds.). (2000). The social psychology of stigma. New York: Guilford Press. Helfer, R.E., & Kempe, C.H. (1968). The battered child. Oxford, UK: University of Chicago Press. Hinshaw, S.P. (1992). Externalizing behavior problems and academic underachievement in childhood and adolescence: Causal relationships and underlying mechanisms. Psychological Bulletin, 111, 127155. Hinshaw, S.P. (1994). Attention decits and hyperactivity in children. Thousand Oaks, CA: Sage. Hinshaw, S.P. (2002). The years of silence are past: My fathers life with bipolar disorder. New York: Cambridge University Press. Hinshaw, S.P. (2004). Parental mental disorder and childrens functioning: Silence and communication, stigma, and resilience. Journal of Clinical Child and Adolescent Psychology, 33, 400411. Hinshaw, S.P. (in press). Stigma of mental illness: Developmental perspectives. In D. Cicchetti & D. Cohen (Eds.), Developmental psychopathology (2nd edn). New York: Wiley. Hinshaw, S.P., & Cicchetti, D. (2000). Stigma and mental disorder: Conceptions of illness, public attitudes, personal disclosure, and social policy. Development and Psychopathology, 12, 555598. Hinshaw, S.P., Cicchetti, D., & Toth, S. (in press). The mark of shame: Stigma of mental illness and an

agenda for change. New York, Oxford University press. Hinshaw, S.P., Owens, E.B., Wells, K.C., Kraemer, H.C., Abikoff, H.B., Arnold, L.E., Conners, C.K., Elliott, G., Greenhill, L.L., Hechtman, L., Hoza, B., Jensen, P.S., March, J.S., Newcorn, J., Pelham, W.E., Swanson, J.M., Vitiello, B., & Wigal, T. (2000). Family processes and treatment outcome in the MTA: Negative/ineffective parenting practices in relation to multimodal treatment. Journal of Abnormal Child Psychology, 28, 555568. Holguin, G., & Hansen, D.J. (2003). The sexually abused child: Potential mechanisms of adverse inuences of such a label. Aggressive and Violent Behavior, 8, 645670. Hyman, S.E. (2000). The millennium of mind, brain, and behavior. Archives of General Psychiatry, 57, 88 89. Jamison, K.R. (1995). An unquiet mind: A memoir of moods and madness. New York: Knopf. Jamison, K.R. (1998). Stigma of manic depression: A psychologists experience. Lancet, 352, 1053. Johnson, D.L. (1989). Schizophrenia as a brain disease: Implications for psychologists and families. American Psychologist, 44, 553555. Jones, E.E., Farina, A., Hastorf, A.H., Markus, H., Miller, D.T., & Scott, R.A. (1984). Social stigma: The psychology of marked relationships. New York: Freeman. Kandel, E.R. (1998). A new intellectual framework for psychiatry. American Journal of Psychiatry, 155, 457469. Katz, I. (1981). Stigma: A social psychological analysis. Mahwah, NJ: Erlbaum. Klasen, H. (2000). A name, whats in a name? The medicalization of hyperactivity, revisited. Harvard Review of Psychiatry, 7, 339344. Kevles, D.J. (1985). In the name of eugenics: Genetics and the uses of human heredity. New York: Knopf. Kolodziej, M.E., & Johnson, B.T. (1996). Interpersonal contact and acceptance of persons with psychiatric disorders: A research synthesis. Journal of Consulting and Clinical Psychology, 64, 13871396. Kraepelin, E. (1921/1987). Manic-depressive insanity and paranoia. Edinburgh: Livingston. Kurzban, R., & Leary, M.R. (2001). Evolutionary origins of stigmatization: The functions of social exclusion. Psychological Bulletin, 127, 187208. Leete, E. (1992). The stigmatized patient. In P.J. Fink, & A. Tasman (Eds.), Stigma and mental illness (pp. 17 25). Washington, DC: American Psychiatric Press. Leey, H.P. (1992). The stigmatized family. In P.J. Fink & A. Tasman (Eds.), Stigma and mental illness (pp. 127138). Washington, DC: American Psychiatric Press. Lin, K., & Kleinman, A. (1988). Psychopathology and the clinical course of schizophrenia: A cross-cultural perspective. Schizophrenia Bulletin, 14, 555567. Link, B.G. (1987). Understanding labeling effects in the area of mental disorders: An assessment of the effects of expectations of rejection. American Sociological Review, 52, 96112. Link, B.G., Cullen, F.T., Frank, J., & Wozniak, J. (1987). The social rejection of ex-mental patients:

Stigma and mental disorders

733

Understanding why labels matter. American Journal of Sociology, 92, 14611500. Link, B.G., Cullen, F.T., Struening, E., Shrout, P.E., & Dohrenwend, B.P. (1989). A modied labeling theory approach to mental disorders: An empirical assessment. American Sociological Review, 54, 400423. Link, B.G., & Phelan, J.C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27, 363385. Link, B.G., Phelan, J.C., Bresnahan, M., Stueve, A., & Pescosolido, B.A. (1999). Public conception of mental illness: Labels, causes, dangerousness, and social distance. American Journal of Public Health, 89, 13281333. Link, B.G., Struening, E.L., Rahav, M., Phelan, J., & Nuttbrock, L. (1997). On stigma and its consequences: Evidence from a longitudinal study of men with dual diagnoses of mental illness and substance abuse. Journal of Health and Social Behavior, 38, 177190. Link, B.G., Yang, L.H., Phelan, J., & Collins, P. (2004). Measuring mental-illness stigma. Schizophrenia Bulletin, 30, 511541. Luthar, S., Cicchetti, D., & Becker, B. (2000). The construct of resilience: A critical evaluation and guide for future work. Child Development, 71, 543562. MacDonald, J.D., & MacIntyre, P.D. (1999). A rose is a rose: Effects of label change, education, and sex on attitudes toward mental disabilities. Journal of Developmental Disabilities, 6, 1531. Martin, J.K., Pescosolido, B.A., & Tuch, S.A. (2000). Of fear and loathing: The role of disturbing behavior, labels, and causal attributions in shaping public attitudes toward people with mental illness. Journal of Health and Social Behavior, 41, 208223. Mash, E.J., & Barkley, R.A. (Eds.). (2003). Child psychopathology (2nd edn). New York: Guilford Press. Masten, A., & Coatsworth, J.D. (1998). The development of competence in favorable and unfavorable environments: Lessons from research on successful children. American Psychologist, 53, 205220. Mehta, S., & Farina, A. (1997). Is being sick really better? Effect of the disease view of mental disorder on stigma. Journal of Social and Clinical Psychology, 16, 405419. Milich, R., McAninch, C.B., & Harris, M. (1992). Effects of stigmatizing information on childrens peer relationships: Believing is seeing. School Psychology Review, 21, 400409. MTA Cooperative Group (1999a). Fourteen-month randomized clinical trial of treatment strategies for attention-decit hyperactivity disorder. Archives of General Psychiatry, 56, 10731086. Murray, C.J., & Lopez, A.D. (Eds.). (1996). The global burden of disease: A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge, MA: Harvard University School of Public Health. Myers, D.G. (1998). Social psychology (5th edn). New York: McGraw-Hill. Neugeboren, J. (1997). Imagining Robert: My brother, madness, and survival. New York: Henry Holt. Norvitilis, J.M., Scime, M., & Lee, J.S. (2002). Courtesy stigma in mothers of children with attention decit/ hyperactivity disorder: A preliminary investigation. Journal of Attention Disorders, 6, 6168.

Nunnally, J.C. (1961). Popular conceptions of mental health: Their development and change. New York: Holt, Rinehart, and Winston. Ohaeri, J.U., & Abdullahi, A. (2001). The opinion of caregivers on aspects of schizophrenia and major affective disorders in a Nigerian setting. Social Psychiatry and Psychiatric Epidemiology, 36, 403409. Page, S. (1995). Effects of the mental illness label in 1993: Acceptance and rejection in the community. Journal of Health and Social Policy, 7, 6168. Pescosolido, B.A., Monahan, J., Link, B.G., Stueve, A., & Kikazuwa, S. (1999). The publics view of the competence, dangerousness, and need for legal coercion of persons with mental health problems. American Journal of Public Health, 89, 13391345. Phares, V. (2003). Understanding abnormal child psychology. New York: Wiley. Phelan, J.C. (in press). Geneticization of deviant behavior and consequences for stigma: The case of mental illness. Journal of Health and Social Behavior. Phelan, J.C., Link, B.G., Stueve, A., & Pescosolido, B.A. (2000). Public conceptions of mental illness in 1950 and 1996: What is mental illness and is it to be feared? Journal of Health and Social Behavior, 41, 188207. Rabkin, J.G. (1972). Opinions about mental illness: A review of the literature. Psychological Bulletin, 77, 153171. Ray, M.C., & Downs, W.R. (1986). An empirical test of labeling theory using longitudinal data. Journal of Research in Crime and Delinquency, 23, 169194. Read, J., & Harre, N. (2001). The role of biological and genetic causal beliefs in the stigmatization of mental patients. Journal of Mental Health, 10, 223235. Rutter, M., & Sroufe, L.A. (2000). Developmental psychopathology: Concepts and challenges. Development and Psychopathology, 12, 265296. Rutter, M., & Silberg, J. (2002). Geneenvironment interplay in relation to emotional and behavioral disturbance. Annual Review of Psychology, 53, 463 490. Sameroff, A., & MacKenzie, M.J. (2003). Research strategies for capturing transactional models of development: The limits of the possible. Development and Psychopathology, 15, 613640. Sartorius, N. (1998). Stigma: What can psychiatrists do about it? Lancet, 352, 10581059. Sartorius, N. (1999). One of the last obstacles to better mental health care: The stigma of mental illness. In J. Guimon, W. Fischer, & N. Sartorius (Eds.), The image of madness: The public facing mental illness and psychiatric treatment (pp. 138142). Basel, Switzerland: Karger. Scheff, T.M. (1966). Being mentally ill: A sociological theory. Chicago: Aldine. Sherif, M., & Sherif, C.W. (1953). Groups in harmony and tension. New York: Harper & Row. Spitzer, A., & Cameron, C. (1995). School-age childrens perceptions of mental illness. Western Journal of Nursing Research, 17, 398415. Stangor, C., & Crandall, C.S. (2000). Threat and the social construction of stigma. In T.F. Heatherton, R.E. Kleck, M.R. Hebl, & J.G. Hull (Eds.), The social psychology of stigma (pp. 6287). New York: Guilford.

734

Stephen P. Hinshaw

Steadman, H.J., Mulvey, E.P., Monahan, J., Robbins, P.C., Appelbaum, P.S., Grisso, J., Roth, L.H., & Sikes, E. (1998). Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Archives of General Psychiatry, 55, 393401. Stigma of Mental Illness. (1998). Stigma of Mental Illness. (Special Section). Lancet, 352, 10471060. Teachman, B.A., Gaspinski, K.D., Brownell, K.D., Rawlins, M., & Jeyeran, S. (2003). Demonstrations of implicit anti-fat bias: The impact of providing causal information and evoking empathy. Health Psychology, 22, 6878. Tessler, R., & Gamache, G. (2000). Family experiences with mental illness. Westport, CT: Auburn House. Thara, R., & Srinivasan, T.N. (2000). How stigmatising is schizophrenia in India? International Journal of Social Psychiatry, 46, 135141. Thompson, A.H., Stuart, H., Bland, R.C., ArbodeleFlorez, J., Warner, R., & Dickson, R.A. (2002). Attitudes about schizophrenia from the pilot site of the WPA worldwide campaign against the stigma of schizophrenia. Social Psychiatry and Psychiatric Epidemiology, 37, 475482. Thompson, E.H., & Doll, W. (1982). The burden of families coping with the mentally ill: An invisible crisis. Family Relations, 31, 379388. Tringo, J.L. (1970). The hierarchy of preference toward disability groups. Journal of Special Education, 4, 295306. US Department of Health and Human Services. (1999). Mental health: A report of the surgeon general. Rockville, MD: Author. Wahl, O.F. (1995). Media madness: Public images of mental illness. New Brunswick, NJ: Rutgers University Press. Wahl, O.F. (1999). Telling is risky business: Mental health consumers confront stigma. New Brunswick, NJ: Rutgers University Press. Wahl, O.F. (2002). Childrens views of mental illness: A review of the literature. Psychiatric Rehabilitation Services, 6, 134158.

Wahl, O.F., & Harman, C.R. (1989). Family views of stigma. Schizophrenia Bulletin, 15, 131139. Wahl, O.F., Ward, A., & Richards, R. (2002). Newspaper coverage of mental illness: Is it changing? Psychiatric Rehabilitation Skills, 6, 931. Wang, P.S., Demler, O., & Kessler, R.C. (2002). Adequacy of treatment for serious mental illness in the United States. American Journal of Public Health, 92, 9298. Weiner, B., Perry, R.P., & Magnusson, J. (1988). An attributional analysis of reactions to stigmas. Journal of Personality and Social Psychology, 55, 738748. Weiss, M.F. (1994). Childrens attitudes toward the mentally ill: An eight-year longitudinal follow-up. Psychological Reports, 74, 5156. Wilson, C., Nairn, R., Coverdale, J., & Panapa, A. (2000). How mental illness is portrayed in childrens television: A prospective study. British Journal of Psychiatry, 176, 440443. Woods, N.S., Eyler, F.D., Conlon, M., Behnke, M., & Webie, K. (1998). Pygmalion in the cradle: Observer bias against cocaine-exposed infants. Journal of Developmental and Behavioral Pediatrics, 19, 283285. Wright, E.R., Gronfein, W.P., & Owens, T.J. (2000). Deinstitutionalization, social rejection, and the selfesteem of former mental patients. Journal of Health and Social Behavior, 41, 6890. Yeh, M., Hough, R.L., McCabe, K., Lau, A., & Garland, A. (2004). Parental beliefs about the causes of child problems: Exploring racial/ethnic patterns. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 605612. Yeh, M., McCabe, K., Hough, R.L., Dupuis, D., & Hazen, A. (2003). Racial/ethnic differences in parental endorsement of barriers to mental health services for youth. Mental Health Services Research, 5, 6577. Zilboorg, G., with Henry, G.W. (1941). A history of medical psychology. New York: W.W. Norton. Manuscript accepted 18 January 2005