Stigma towards Peers with Mental Health Disorders in Childhood & Adolescence: An Investigation into Explicit & Implicit Stigma & Social Reasoning about Exclusion

xxi Abstract Children and adolescents with mental health disorders are widely reported to have problems with peer relationships; however, few studies have explored the way in which their peers regard these young people. The literature that exists exclusively focuses on explicit measures to evaluate stigma and provides an incomplete assessment of the many aspects of stigma. The aim of this body of research was to provide a comprehensive insight into mental health disorder stigma in childhood and adolescence by exploring how young people perceive peers with mental health problems. Specifically, this research assessed all known dimensions of stigma (stereotypes, prejudice, discrimination, power and social status) and implicit attitudes towards peers with disorders. In addition, it also investigated how young people reason about the exclusion of peers with disorders. In doing so, this research programme consisted of two studies. In the first study, patterns of explicit and implicit stigmatisation of peers with depression and attention deficit hyperactivity disorder (ADHD) were explored. The sample was 385 children (M = 10.21 years) and adolescents (M = 15.36 years). Questionnaire data indicated that the peer with ADHD was perceived more negatively than the peer with depression on all dimensions of stigma, except perceived dangerousness and fear. In contrast, the implicit data, detected by the Implicit Association Test (IAT), suggested that some participants had more negative views of the peer with depression than the peer with ADHD. Specifically, the findings demonstrated that adolescent males exhibited significantly stronger negative implicit evaluations of depression compared to younger males and adolescent females. Overall, the findings of Study One demonstrated that the nature and extent of stigmatising responses depends on the type of clinical disorder, the type of measure used and also the perceivers’ age and gender. In Study Two, group interviews with 150 children (M = 10.76 years) and adolescents (M = 15.5 years) were conducted to investigate evaluations of dyadic and group exclusion scenarios involving peers with ADHD and depression. Abstract ! xxii Explanations for why the target peers were rejected were also explored. Thematic analysis of the data showed that evaluations of peer exclusion were often multi-faceted, with participants frequently explaining that legitimacy of exclusion hinged on many factors. In general, young people believed that such peers were rejected because their disordered behaviour violated the expectations that they apply to their friendships. Overall, Study Two provided an insight into the reasons why young people with mental health problems are likely to be excluded by their peers. The findings from this body of research provide a valuable insight into how children and adolescents with mental health disorders are perceived by their peers. This information can be used in the development of anti-stigma interventions. Chapter 1: Overview ! 1 Chapter 1: Overview of the Thesis 1.1 Aim of Chapter Chapter One sets the scene for this body of research. It briefly addresses the current status of the existing literature and outlines the principle aims of this research programme. A summary of the chapters contained in this thesis is also provided. 1.2 Current Status of the Research Literature The stigmatisation of mental disorders is one of the most important and challenging issues facing all who are attempting to understand, prevent and treat mental illness (Crisp, Gelder, & Rix, 2000; Sartorius, 1998; US Department of Health and Human Services, 1999). Stigmatisation is a phenomenon that overcomes cultural and national boundaries and creates significant barriers to both personal development and treatment access (Tsan, Tam, Chang, & Cheung, 2003; World Health Organisation, 2001). In adult populations, stigmatised individuals face many social and emotional challenges, including social withdrawal, loss of productivity, lowered self-esteem, and increased levels of negative affect (Heatherton, Kleck, Hebl, & Hull, 2000). Although the nature and consequence of stigma has been studied in-depth in adulthood, stigma during childhood and adolescence is relatively under-researched. The data that does exist suggests that stigma is a widespread problem (Walker, Coleman, Lee, Squire, & Friesen, 2008), with young people with mental health problems not only experiencing stigma from their peers, but also from adults (Pescosolido, Fettes, Martin, Monahan, & McLeod, 2007). Young people with mental health problems often report experiencing teasing or harassment from their peers for having a disorder or for receiving treatment (Moses, 2010). Consistent with findings in the adult literature, stigma contributes to the under! Chapter 1: Overview ! 2 utilisation of mental health services and treatment non-adherence among adolescents (Ghaziuddin, King, Hovey, Zaccagnini, & Ghaziuddin, 1999; Hack & Chow, 2001; Kazdin, 1996). In addition, it may cause feelings of shame or embarrassment and fear of being rejected by their peers (Moses, 2009). Thus, the indirect effects of stigma have far reaching social, emotional, and health consequences. Future research needs to develop sophisticated interventions that change misconceptions about mental disorders and promote positive cognitive, emotional, and behavioural responses to all persons with mental health problems. However, the development of such interventions cannot be done without a comprehensive understanding of stigma. Although the available research provides important evidence on peer stigmatisation there are some notable empirical gaps in the literature. Hinshaw (2005) highlights some methodological shortcomings including the need to explore stigma towards specific mental health problems and not towards the general term mental illness. Assuming that all mental health problems are stigmatised in the same manner limits our knowledge of how stigma may operate across disorders. Hinshaw also notes that addressing the lack of research that utilises implicit measures to assess stigma is a priority. The wider social cognitive literature has witnessed a surge in research on implicit attitudes towards outgroups. This trend has trickled into the adult mental health stigma literature (see Lincoln, Arens, Berger, & Rief, 2008; Teachman, Wilson, & Komarvoskaya, 2006); however, no published research has assessed implicit attitudes towards peers with mental health problems in childhood and adolescence. Furthermore, stigma is a complex construct, consisting of cognitive, emotional, and behavioural elements, that is a challenge to empirically measure in its entirety in psychological research. For stigma to be comprehensively understood the cognitive dimension of stereotypes, the emotional dimension of prejudice and the behavioural dimension of ! Chapter 1: Overview ! 3 discrimination need to be thoroughly investigated. The multi-dimensional make-up of this construct ensures that research frequently fails to operationalise and measure stigma sufficiently (Hinshaw, 2007). Study One will aim to address these limitations. A further area of study that has been notably absent from the mental health stigma literature is research that explores young people’s social reasoning about the exclusion of peers with mental disorders. Research investigating social reasoning about exclusion has received much attention in the racial and gender stigma literature, providing an insight into the types of considerations young people attend to when determining whether to exclude or include a target peer. Killen, Mulvey, and Hitti (in press) suggest that this approach is useful as it permits an exploration of stigma from an intergroup perspective; it provides an insight into whether social conventional issues, such as norms, rules, and identity are involved in determining exclusion. Given that in childhood and adolescence, peer exclusion is the most salient form of discrimination (Brown & Bigler, 2005), adapting this research approach to the domain of mental health disorders is likely to provide a novel perspective on stigma towards peers with mental disorders. Overall, the body of research presented in this thesis aims to enhance our general understanding of stigma towards peers with ADHD and depression in childhood and adolescence. Investigating young people’s perceptions of peers with ADHD and depression will provide an insight into the unique or shared ways in which peers with externalising and internalising disorders are stigmatised. ADHD and depression were chosen as the disorders to be investigated, as they are two of the most common externalising and internalising mental health disorders in childhood and adolescence (CAMHS, 2008; Goodman, Meltzer & Ford, 2000; Lynch, Mills, Daly, & Fitzpatrick, 2006), and therefore are most socially relevant to young people. Chapter 1: Overview ! 4 Specifically, Study One consists of a quantitative study concerned with comprehensively investigating stigma by exploring stereotypes, prejudice, and discrimination. This study is also the first study, to the researcher’s knowledge, that explor