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Children's Views of Mental Illness: A Review of the

Literature
a
Otto E Wahl
a
George Mason University
Published online: 18 Jan 2011.

To cite this article: Otto E Wahl (2002) Children's Views of Mental Illness: A Review of the Literature, Psychiatric
Rehabilitation Skills, 6:2, 134-158, DOI: 10.1080/10973430208408430

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 134 PSYCHIATRIC SKIU 2002 Vol. 6, No. 2. 134- 158
REHABILITATION

Children’s Views of Mental Illness:

A Review of the Literature

Otto F: Wahl
George Mason University

This paper reviews research since 1980 on children’s

knowledge of and attitudes toward mental illness. This
research has involved many different methods, including use
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of vignettes, projective drawings, storytelling, and direct

questioning. Findings suggest that younger children do have
clear knowledge of what mental illness is and that their
understanding becomes more sophisticated as they age. At
the same time, however, even younger children have been
found to view people with mental illnesses more negatively
than they do other groups. A small literature on depiction of
mental illnesses in children’s media revealed negative por-
trayals that may contribute to children’s attitudes. Numerous
limitations of the research are described and further research
is urged, with attention recommended to issues such as the
impact of language in designating someone as having a men-
tal health problem, possible differing reactions to peers and
adults, and incorporation of the perspectives of children
with mental disorders.

A substantial body of research has established that

adults hold stereotyped and largely negative views of mental
illness. Studies in the 1950s and 1960s found that people
viewed those with mental illnesses as dirty, dangerous, and
unpredictable, were reluctant to have them as neighbors or co-
workers, and would likely not hire them or rent them an apart-
ment if their mental health treatment history were revealed.
(Farina, 1982; Nunnally, 1961; Rabkin, 1974; Fink & Tasman,

Address Correspondence to: Otto Wahl. Ph.D., Dept. of Psychology 3F5, George Mason
University, Fairfax. VA, 22030. Email: owahl@gmu.edu.

Copyright 2002 Psychiatric Rehabilitation Skills

All rights Reserved.
 Children's Views of Mental Illness 135

1992). More recent studies have found that this situation has
changed little over the past 50 years (Clements, 1993; Fraser,
1994). The public still associates mental illness with anti-social
behavior-even more so than 50 years ago according to infor-
mation from the Indiana Consortium of Mental Health Services
Research (Phelan, Link, Stueve, & Pescosolido, 2000). First
hand reports from mental health consumers indicate that they
continue to experience rejection, avoidance, and discrimina-
tion from those around them when their mental illnesses
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become known (Wahl, 1999).

Attention has also been paid to one of the sources of
continued misconceptions about mental illness-mass media
depictions. Research has established that films, newspapers,
and, particularly, television routinely depict those with mental
illnesses in stigmatizing ways (Diefenbach, 1997; Gerbner,
1995; Wahl, 1995; Wahl & Roth, 1982). Signorielli (1989), for
example, reported that over seventy percent of the time a char-
acter with mental illness appeared in prime time television
drama, that character was shown as violent. Moreover, this vio-
lence is often more graphic and more frightening than that of
other, non-mentally ill villains (Defleur & Dennis, 1981).
Research has also confirmed fears that these dramatic media
associations of violence with mental illness can influence the
ways the public thinks about and reacts to people with psychi-
atric disorders (e.g., Philo, Secker, Platt, Henderson,
McLaughlin, & Burnside, 1994; Thornton & Wahl, 1996;
Wahl & Lefkowits, 1989). Depictions of those with mental ill-
nesses as distinctly different from others and as humorous and
worthy of ridicule have also been noted as likely contributors
to persistent negative attitudes toward mental illness (Wahl,
1995)
Few, if any, of those concerned with the problem of
mental illness stigma believe that the negative attitudes and
problematic stereotypes they find emerge full-blown in adult-
hood. Rather, it seems likely that these ideas and attitudes are
acquired gradually over a lifetime and that their roots are
 136 Otto Wahl

established in childhood. Mental health advocates, in consid-

ering strategies to combat stigma, have come to realize that
efforts directed toward children may be particularly beneficial
and that shaping attitudes before they are well-formed may be
easier than challenging and modifying attitudes that are
already firmly entrenched. Children’s views of mental illness,
however, have received far less research attention than the
views of adults, particularly in recent years. There has been a
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similar dearth of consideration of the representation of mental

illness in children’s media, despite suggestions that these are
sources through which children may derive their preliminary
understanding of psychiatric disorders (Scheff, 1966, 1999;
Wahl, 1995).
The current article will examine the research literature
on children’s conceptions of mental illness, with an emphasis
on work completed within the past two decades. In addition, it
will review published work concerning the depictions of men-
tal illness in children’s media that may contribute to youthful
ideas about mental illness, as well as provide a few examples of
anti-stigma programs targeting children.

Children’s knowledge of mental illness.

One set of questions that have been asked concerns
children’s understanding of psychiatric disorders. We can
expect that children may not have the same understanding of
what a mental illness is or what might cause it as do mature,
experienced, and better educated adults. What children know
or believe about psychiatric disorders, their causes, and their
possible treatments, then, has been the focus of several
research investigations. Roberts, Beidleman, & Wurtele ( 1981)
presented vignettes of imaginary peers with medical and psy-
chological disorders to 34 fifth and sixth grade children, aged
9-13. Four vignettes were presented, representing mild med-
ical problems (sniffles and coughing), severe medical problems
(missing school, staying in the hospital), mild psychological
disturbance (screaming and kicking other children), and
 Children’s Views of Mental Illness 137

severe psychological disturbance (believing in monsters from

outer space). The researchers asked each child to read a
vignette and then asked the child to write answers to questions
such as “What do you think is wrong with [the character]?”
and “What do you think made [the character] this way?”
Responses were rated blindly by two independent raters in
terms of categories established by the researchers. Results indi-
cated that the children viewed psychological disorders as being
a function of reality distortion (e.g., “He has too big imagina-
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tion.”) or innate aggressive tendencies (“He can’t control his

temper.”). Children also suggested that too much media expo-
sure was a likely contributing factor to the severe psychologi-
cal disorder, while they saw the mild disorder as a product of
family mistreatment. Despite gender-neutral names, both psy-
chologically disordered characters were perceived as male.
Roberts, Johnson, & Beidleman (1984) expanded their
study to 105 fifth grade students in order to examine the
potential influence of socioeconomic status (SES) on children’s
views of mental illness. Using their four vignettes and ques-
tions similar to those used in Roberts et a1.k (1981) study, they
compared high and low SES students with respect to their
judgments about causes and prevention of the disorders pre-
sented. The researchers found more similarities than differ-
ences across socioeconomic status. Both groups, for example,
tended to view the psychologically disordered characters as
male, to believe that self-control was necessary to avoid
becoming like those characters, and to be pessimistic about the
likelihood of recovery from psychological problems.
Poster (1992) also used vignettes to study the knowl-
edge about mental illness of 168 school children in third
through sixth grades. Her vignettes included three involving
adults with symptoms of depression, anxiety, and schizophre-
nia and three involving children with symptoms of those same
disorders; three vignette characters were male and three were
female. Following the reading of each vignette, children were
asked to write answers to seven questions, such as “What is the
 138 Otto Wahl

name for the way hdshe is acting?” and “How do you think
this person got to be the way hdshe is?” Among Poster’s find-
ings were that only 27% of the children assigned mental illness
labels (such as “crazy,” “phobic,” and “depressed”) and even
fewer (11%)prescribed psychiatric interventions (e.g., “take to
a head doctor”). Poster also reported that that children’s
responses vaned with the type of vignette problem. In particu-
lar, children were more likely to assign psychiatric labels to
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vignette characters with schizophrenia symptoms, to ascribe

external causes for those characters, and to recommend psy-
chiatric interventions for them (e.g., “take to the nut house”).
A number of interactions between vignette problem, gender of
vignette character, and grade of respondents were reported, as
well, but no overall analyses were provided of the effects of
gender or age of vignette character.
Adler & Wahl (1998) used a combination of methods
to explore children’s beliefs about people labeled as having
mental illness. They first asked 104 third-grade students to
make up stories about neutral pictures of an adult male. One
group of children was told that the “target” character was men-
tally ill; another group was informed the target character was
physically disabled; and a third group was given no label for
the figure. Stories were later scored by trained raters in terms
of the psychological characteristics of the target figure in the
stov. The children were also asked to indicate their agreement
or disagreement with a series of questions about the expected
behaviors of a “physically disabled person,” a “mentally ill per-
son,” and a “regular grown-up.” Adler and Wahl found few
specific characteristics that consistently differentiated mental-
ly ill, physically disabled, and unlabeled persons in either the
stories or the direct statements. Mentally ill persons were dis-
tinguished from physically disabled persons primarily by the
expectation that they would be less likely to be able to help the
child with hidher homework and less likely to smile a lot.
Spitzer and Cameron (1995) also sought to clarify chil-
dren’s understanding of mental illness. Similar to the work of
 Children’s Views of Mental Illness 139

Roberts, they presented vignettes to 90 children in grades 1 , 4 ,

and 7 and asked them questions about each. Questions includ-
ed both open-ended items (e.g., “What do you think about this
boy/girl?”) and 34 questions, from a semi-structured, inter-
view-administered questionnaire, relating to definitions,
causality, and treatment for the conditions represented in the
vignettes. Spitzer and Cameron reported, first of all, that
younger children had little familiarity with the term mental ill-
ness, but used instead terms like “crazy” and “weirdo.” They
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also found that the children in their sample had difficulty cor-
rectly identifying children in the vignettes as having psychi-
atric problems; children more readily recognized psychiatric
disturbance in adults, leading the researchers to conclude that
“children did not perceive craziness as an illness in children”
(p. 413).
Attempts to assess children’s understanding of mental
illness have occurred in the United Kingdom as well. Bailey
(1999) asked 106 children, aged 11-17, to answer several
open-ended questions, such as “What causes mental illness?”
and “What happens to people with mental illness?” She report-
ed, first of all, that responses to most questions tended to be
quite diverse-i.e., there was seldom a specific response that
was given by more than half of the children participating. The
most frequently cited causes of mental illness were stress (by
41% of the children), genetics (27%), and bad childhood expe-
riences (26%). The most common expectations about what
happens to people with mental illnesses were that such indi-
viduals would go to mental hospitals (23%) and nursing
homes (8%)and that they would lose control of their behavior
(7%). Consistent with this, children reported that they thought
people with mental illness should be treated in a hospital
(46%) and receive their help from doctors (22%) and psychia-
trists (19%).When asked what names they had heard someone
with mental illness being called, the children evidenced some
misunderstanding of mental illness by most commonly citing
terms such as “retarded” (19%) and “spastic” (15%). Terms
 140 Otto Wahl

such as “psychopath” (17%), “mental” (lo%), “crazy” (lo%),

and “lunatic” (9%)were also offered.

Children’s attitudes toward mental illness.

The attitude of children toward others with psychiatric
disorders has also been of interest to investigators. The ques-
tion here is not so much what children know about psychiatric
disorders as how they appraise and react to them. Wilkins and
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Velicer (1980), for example, used the Semantic Differential to

determine third and sixth graders’ attitudes toward the con-
cepts Person, Crippled, Retarded, and Crazy. Each of 20 chil-
dren (10 male and 10 female) in each grade was asked to tell
what they thought an average person in each category was like.
Wilkins and Velicer reported that the Crazy person was rated
less positively than any of the other concepts and rated as less
understandable (more unpredictable), as well, with half of the
children ascribing dangerous behaviors to the Crazy person.
The concepts Crazy and Person were also rated as more active
and more potent than the concepts Retarded and Crippled.
Thus, the researchers pointed out, Crazy persons may be par-
ticularly frightening in the eyes of children, who see them as
active and powerful as well as dangerous and unpredictable.
Roberts, Beidleman, & Wurtele (1981) included in
their study a request to their child participants for a rating of
the attractiveness of imaginary peers described in vignettes.
Their results revealed 9-13 year old children to be equally
accepting of an imaginary peer with severe psychological dis-
turbance as peers depicted with mild and severe medical dis-
orders. Children perceived the depicted peers as moderately
attractive as playmates except for the mildly psychologically
disturbed one. Greater rejection of the mildly psychologically
disturbed peer, however, is probably not surprising given that
the vignette behaviors involved aggressive and antisocial acts
toward others-playmg mean tricks on other children and
screaming and kicking others. Although the researchers did
not provide data on the absolute level of attractiveness in this
 Children’s Views of Mental Illness 141

study, the follow-up study (Roberts, Johnson, & Beidleman,

1984) indicated that the lack of statistically significant differ-
ences between the severely mentally disordered character and
the physically ill characters did not indicate a positive attitude
toward the character with the severe psychological disorder.
Rather, children tended to perceive all target characters as rel-
atively unattractive, but with the mildly psychologically disor-
dered one much more unattractive than the others; the charac-
ter with severe psychological disorder was the second least
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attractive.
Poster, Betz, McKenna, & Mossar (1986) attempted to
assess attitudes toward mental illness among 168 third to sixth
graders in Southern California utilizing a modified version of
the Human Figure Drawing Test and accompanying written
stories. The study involved three tasks. First, students were
asked to draw a picture of a person doing something and write
a brief story about the picture. Then, following the presenta-
tion of vignettes describing persons with psychiatric problems
(including anxiety disorder, schizophrenia, and depression),
the students were asked to draw a picture of “a crazy person”
and to write a story about what the character was doing. The
researchers reported no differences between the two sets of
drawings in traditional scoring indicators for Human Figure
Drawings (e.g., line discontinuity, erasure, and body shading).
However, there were differences in the content of stories
attached to the drawings. Both male and female students were
more likely to identify the person in the second drawing (“the
crazy person”) as male than in the first drawing. The most
common themes of the first drawing involved play and work.
In contrast, the most common themes of drawingdstories
about the “crazy person” were inappropriate behaviors, sui-
cide, self-abuse, and hostile aggressive actions-themes that
were rare in the initial drawings. Although, as the authors
noted, some of the children’s stones about the “crazy person”
may have been influenced by the vignettes they had read (one
of which, for example, involved someone contemplating sui-
 142 Otto Wahl

cide), the researchers felt that the negative behaviors projected

by the children transcended the vignette cues.
A1though finding few specific descriptors consistently
used by children to characterize a person with mental illness,
Adler & Wahl (1998) nevertheless concluded that there was
evidence in their findings for a more general negative attitudi-
nal view of mental illness among their elementary school sam-
ple. In particular, they found that children’s stories about pre-
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sented neutral figures ascribed more overall negative attributes

and behaviors to those characters labeled “mentally ill” than to
characters labeled “physically disabled” or “regular grown-up.”
Children, the authors concluded, may not be able to articulate
concrete trait differences at young ages, but, even by third
grade, they seem to know that those labeled mentally ill are
somehow ‘‘worse”than others.

DeveIopmentaI progression of knowledge and attitudes.

A number of studies have been concerned with devel-
opmental aspects of children’s conceptions and attitudes
toward mental illness. Children’s ability to make generaliza-
tions and conceptualize people in terms of discreet and endur-
ing traits is thought to change over time, and it is possible that
conceptualizations of people with mental illnesses undergo a
similar evolution as children age. Several studies have
addressed questions of how children’s conceptions change with
age and at what point negative stereotypes of mental illness,
such as are found with adults, begin to crystallize in children’s
thinking.
Wilkins & Velicer (1980) reported few differences
between third graders and sixth graders in their Semantic
Differential assessment of children’s attitudes. Children in both
grades, they concluded, shared similar negative attitudes
toward “crazy” persons. Most other studies, however, have
found significant grade and age differences. Dollinger, Thelen,
& Walsh (1980) asked 1051 children in grades 5-12 what kind
of problems are handled by clinical psychologists and sorted
 Children’s Views ol Mental Illness 143

child responses into five categories-External, Internal, Social,

Labels, and Other. Primary findings included increasing cita-
tion of “internal” conceptions of psychological problems (dis-
turbed thoughts and feelings rather than overt behaviors) with
advancing grade and less citation of social problems (difficul-
ties with other people) among high school juniors and seniors
than among elementary school students. The researchers inter-
preted these findings as evidence of an external to internal pro-
gression in the conceptualization of psychological problems,
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with older children having a greater appreciation of the impor-

tance of individual thoughts and feelings in determining psy-
chological difficulty.
Conant & Budoff (1983) interviewed 103 nondisabled
children from primary grades, junior high, and high school
concerning their awareness of five different kinds of disabili-
ties-blindness, deafness, orthopedic disabilities, mental retar-
dation, and psychological disturbance. Participating children
were asked whether they knew anyone with the disability and
whether they had ever seen such a person (including on tele-
vision). The children were also asked their ideas about the
nature, causes, and prognosis of the disability. Based upon the
child’s rated ability to describe aspects of the disability accu-
rately, comparisons of “awareness” of the disability were made.
Conant & Budoff concluded that psychological disturbance
was the most difficult disability for younger children to be
aware of, followed by mental retardation. They suggested that
this result reflects both the more conceptual and more invisi-
ble natures of mental disabilities. Grasping the concept of
mental disabilities, they argued, involves an understanding of
abstract concepts, social norms, and relative degrees of differ-
ence that are undeveloped in younger children. Moreover, they
noted, younger children may not yet have the exposure to or
instruction about mental disabilities that is provided for more
visible disabilities like blindness and orthopedic limitations.
Royal & Roberts (1987) investigated students’ percep-
tions of 20 different disabilities, including mental illness and
 144 Otto Wahl

mental retardation. One hundred fifty-one students in grades

three, six, nine, and twelve, along with 25 college students,
were supplied brief descriptions of each disability and then
asked to rate the disability in terms of visibility, severity,
acceptability, and familiarity, Blindness, cancer, mental illness,
and paraplegia were consistently rated as the most severe dis-
abilities. Mental illness and mental retardation were rated as
least acceptable at all grade levels, with acceptability defined as
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the answer to the question, “How much would you like to have
this person as a friend?” Overall, students were more accepting
of disabilities as they matured-with one exception, mental ill-
ness. Third graders were found to be more accepting of mental
illness than ninth graders or college students.
As noted previously, Poster (1992) noted grade differ-
ences in children’s written responses to questions about
vignettes presented to them. For example, she found that fifth
and sixth graders attributed mental illness to vignette charac-
ters’ behaviors, recommended psychiatric treatments more fre-
quently, and suggested punitive interventions less frequently
than did third and fourth graders. Older students were also
more likely to attribute vignette behaviors to internal causes
than were younger students.
Spitzer and Cameron (1995) also reported differences
between children of different grade levels based on qualitative
appraisal of responses to vignettes of psychiatric disorder; no
quantitative data was presented. Spitzer and Cameron
observed that first graders tended to define mental illness as
simply a very serious physical illness; they seemed to under-
stand “mental” as an indication of degree of severity. Children
in fourth grade, according to the researchers, began to make
connections between mental illness and the brain or head, a
connection that was voiced even more strongly by seventh
graders. First graders associated “being crazy” with being
weird, wild, and hyperactive. Fourth graders added violation of
rules of behavior, and, by seventh grade, propensity for vio-
lence became a central element. Beliefs about the causes of dis-
 Children’s Views of Mental Illness 145

turbed behavior reportedly changed from having little or no

idea about etiology to emphasis on traumatic childhood
events, although there were also suggestions from fourth and
seventh graders of biological explanations such as head trau-
ma. All groups of children reportedly cited alcohol and drug
use as potential causes of mental illness as well. Finally, first
graders seemed to favor general medical care for the disturbed
individuals; fourth graders advocated psychological help such
as teaching and counseling; and seventh graders settled on
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hospitalization in psychiatric institutions, citing both the care

of the individual and the protection of society as rationales for
such treatment.
The most extensive consideration of developmental dif-
ferences in conceptions of mental illness comes from a series of
studies by Marc Weiss. In an initial study, Weiss (1985) admin-
istered a graphic version of the Opinions About Mental Illness
scale (OMI) to 512 children from second, fourth, sixth, and
eighth grades. The graphic adaptation involved using happy
and sad faces for agree and disagree options and matching the
size of the check box to the intensities of Likert-type respons-
es. Weiss’ results suggested that children have more negative
attitudes when younger. In .particular, he reported that children
showed increasingly less Authoritarianism and Social
Restrictiveness and greater Benevolence in their attitudes with
increasing grade, perceiving “mental patients” as less threaten-
ing, less in need of restriction and control, and more in need of
sympathy and paternalistic assistance in higher grades. These
changes, Weiss reported, were greatest between grades two and
four, with attitudes becoming relatively stable between grades
6 and 8.
Weiss ( 1986) also assessed children’s attitudes toward
mental illness using a child-oriented social distance measure.
Weiss presented stick figures of seven “attitude objects” (con-
vict, mentally retarded person, normal person, mentally ill,
crazy person, physically handicapped, and emotionally dis-
turbed) to 577 children from kindergarten, second, fourth,
 146 Otto Wahl

sixth, and eighth grades. Children were asked to draw a stick

figure, representing themselves, at a distance from the target
object at which they would feel most comfortable. Social dis-
tance preferences were then judged according to the relative
distances from the named object. Overall, Weiss found that
convict and crazy person produced the greatest social distance,
and physically handicapped and normal the least social dis-
tance, for children in all grades. The main change with advanc-
ing grade was that, between sixth and eighth grades, crazy per-
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son replaced convict as the least preferred.

Weiss (1994) also has contributed the only longitudinal
study of children’s attitudes toward mental illness found in the
literature. He managed to find and re-examine 34 of the 65
kindergarten children who participated in his 1986 study.
These seventh and eighth grade students repeated the stick fig-
ure placement task described previously. The main change
observed was significantly reduced social distance from the
person described as mentally retarded between kindergarten
and advanced grades. Otherwise, results were strikingly simi-
lar to those obtained earlier. In particular, convict and crazy
person induced the greatest social distance, with crazy person
displacing convict as the most unacceptable by eighth grade.

Overview offindings.
Overall, then, there is some consistency to findings. For
example, there are repeated suggestions from research results
that younger children do not have clear knowledge of what
mental illness is and that their understanding becomes more
sophisticated as they progress in age and grade. Younger chil-
dren were unable to describe specific traits, and they confused
mental illness somewhat with physical illness and mental
retardation. Older children were better able to understand
mental illnesses as disturbances of thoughts and emotions
rather than just behavior and showed a broader conception of
the causes and treatments of these disorders.
 Children’s Views of Mental Illness 147

On the other hand, negative attitudes toward mental ill-

ness were apparent at even the earliest ages studied. Children
perceived people with mental illnesses as less attractive than
those with other kinds of disabilities, described them less pos-
itively in stories and ratings, and sought social distance from
those identified as “crazy.”As Weiss concluded: “Crazy people
are apparently regarded with the same fear, distrust, and dislike
and are perceived as a threat by young and older children and
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adults alike” (Weiss, 1986, p. 18), with a clear (and lasting)

preference hierarchy established as early as kindergarten. As
Adler & Wahl (1998) noted, even if young children do not
know the precise definitions or characteristics of people with
mental illnesses, they seem to know that they are undesirable
and to be avoided. Moreover, most of the studies found that, if
anything, unfavorable attitudes toward mental illness
increased, rather than decreased, with age.
Conclusions about children’s conceptions of mental ill-
ness and their developmental progression must be made with
caution, however, due to significant limitations in the research
accomplished thus far. First of all, the techniques used to
assess children’s knowledge and/or attitudes toward mental ill-
ness have varied greatly, including interview responses to
vignettes, questionnaires of various types, Semantic
Differential ratings, stick figure drawings, and storytelling.
Vignette studies ask children to respond to behavioral descrip-
tions that they may or may not consider mental illness while
other studies ask for response to labeled mental illness; the
extent to which both assess children’s beliefs and attitudes
about “mental illness” (as opposed to undesirable behavior) is
uncertain. Moreover, the disorders represented in behavioral
descriptions differ across different vignette studies, as do the
behaviors chosen to represent similar disorders.
While the varied techniques reflect laudably creative
efforts to develop measures suited for the cognitive and com-
munication skills of children, they make comparisons between
studies difficult. Moreover, the techniques that have been used
 148 Otto Wahl

have seldom been subject to psychometric scrutiny. Rarely

were reliabilities reported, for example, in the studies
described above. In particular, test-retest and inter-rater relia-
bilities were typically not reported, raising questions about the
stability and validity of findings. For adults, there are a few
instruments, such as the Opinions about Mental Illness scale
(Cohen & Struening, 1962) and the Community Attitudes
toward Mental Illness scale (Taylor & Dear, 1981), which have
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been widely used. There are no similarly standardized mea-

sures of children’s attitudes toward mental illness. Work is
under way to produce a revised version of the Opinions about
Mental Illness scale for children (Struening, personal commu-
nication), with empirical verification of factors, but no such
validated instrument is currently available.
Existing studies also show considerable variation in the
language used to indicate or refer to mental illnesses. Some
children were asked about mental illness, others about “crazy”
people or people who might need the services of a clinical psy-
chologist. Again, the variability among studies in language
used makes comparison and generalization difficult, particu-
larly since different labels appear to generate different respons-
es. For example, a peer labeled “emotionally disturbed”
appears to be more acceptable than one labeled “mentally ill”
who is, in turn, less to be avoided than a child described as
“crazy.” Data from several studies, moreover, suggest that use
of more formal terms for mental disorder may fail to reveal the
attitudes of younger children who know mental disorder by
informal labels (such as “crazy”). The nature of children’s atti-
tudes toward mental illness and the ages at which such atti-
tudes appear will be difficult to determine if researchers do not
speak to children in language those children understand.
There is further variation in the studies completed in
terms of the age and gender of the stimuli to which children
have been asked to respond. Some studies, seeking to under-
stand children’s reactions to their mentally ill peers, have pro-
vided vignettes of children with different forms of psychiatric
 Children's Views of Mental Illness 149

disorder. Other studies have been more concerned with overall

stereotypes and attitudes toward mental illness, and, consistent
with suggestions-such as those of Spitzer & Cameron (1995)
and Roberts, Beidelman, & Wurtele (1981)-that children
associate mental illness with male gender and adult status,
these studies have utilized adult and/or male figures for
response. A few studies did not specify the age or gender of
their stimulus characters. Both the attitudes toward mentally
ill peers and the general views about mental illness are impor-
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tant to investigate, but it may be misleading to try to compare

results from studies with different goals and different target
stimuli. Future research will need to be clear on which set of
attitudes is of primary interest, select target stimuli according-
ly, and specify those target stimuli in reports of results. In addi-
tion, the extent to which children do indeed think differently
about psychiatric symptoms in males and females and in adults
and peers needs clarification. Analyses of the possible impact
of varied target characteristics are needed.
What is also needed is the inclusion of the perspectives
of children who experience mental illness-and the stigma
that may attach to it. Adult research on stigma has begun to
recognize the importance of investigation of the experiences of
the people who may have encountered stigma. There is recog-
nition that responses to attitude surveys may be colored by
social desirability and that such responses may reflect learning
about what is appropriate to say about mental illness rather
than the individual's true attitudes. Stigma research, then, has
added the reported experiences of those with mental illnesses
to the assessment of stigma (Wahl, 1999; Link, Struening,
Rahav, Phelan, & Nuttbrock, 1997). N o such efforts have been
reported with children-i.e., efforts to find out from children
with mental illnesses how they have been treated by their
peers. This would be an important contribution to the litera-
ture.
 150 Otto Wahl

Depiction of mental illness in chiIdren3 media.

Another way to understand how those with mental ill-
nesses are viewed is to examine the ways they are presented
and described (Hinshaw & Cicchetti, 2000; Wahl, 1995). As
noted previously, examinations of media depictions of mental
illness reveal numerous negative stereotypes that may fuel stig-
ma. Media depictions of mental illness, however, not only
reveal beliefs about mental illness but they also communicate
and instruct. U.S. citizens report that they receive more infor-
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mation about mental illness from mass media than from any
other sources (DYG, 1990). It is likely that children are even
more reliant on mass media as primary sources of information
about psychiatric disorder. Indeed, Scheff, in articulating how
the societal stigma of mental illness is created and perpetuated
specifically singles out mass media, noting that “the stereo-
types [ of mental illness] receive almost continual support from
the mass media” (Scheff, 1999, p. 76). George Gerbner also has
suggested that mass media, television in particular, have
become the chief socializing agents, replacing family and trib-
al storytelling as conveyers of mores and attitudes and leading
to stereotypes of groups of people that are closer to the por-
trayals of those people in prime time television than to their
characteristics in real life (Gerbner, Gross, Morgan, &
Signorielli, 1980).
There has been little empirical investigation of the
depiction of mental illness in children’s media, despite its sus-
pected importance in shaping children’s views of mental ill-
ness. In fact, this author was able to find only two studies
addressing depiction of mental illness in children’s media. One
study comes from the ongoing Cultural Indicators Project of
George Gerbner and his colleagues. Gerbner has been examin-
ing the content of television programming for over 20 years.
His work has looked at a variety of aspects of television pre-
sentations, not primarily at the depiction of mental illness.
However, his work on violence and on depiction of minorities
has inevitably led to discoveries about mental illness portrayal.
 Children’s Views of Mental Illness 151

Gerbner’s work also has focused on prime time, adult pro-

gramming, but he has recently added some samples of
Saturday morning children’s programs (Gerbner, 1995).
Among his findings were that mentally ill characters on
Saturday morning fail (i.e., do not achieve their stated aims)
twice as often as any other kind of character (similar to their
fates in adult programming). They are also, along with elderly
women, highly likely to be killed, injured, or exploited, lead-
ing Gerbner to conclude that, “At the bottom of fate’s ‘pecking
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order’ are characters portrayed as old women and as mentally

ill” (Gerbner, 1995, p. 134). Specific figures for the failure and
victimization rates for characters with mental illnesses in chil-
dren’s programs have not been provided, however, in Gerbner’s
published reports.
By far the most extensive examination of depiction of
mental illness in children’s media was conducted in New
Zealand. Wilson, Nairn, Coverdale, and Panapa (2000) sam-
pled a full week of television on two New Zealand television
channels during the early morning (6:30 AM - 9 AM) and mid-
afternoon (2 - 4:30 PM) timeslots (designated for children’s
programming. Altogether, they examined approximately 58
hours of children’s shows (128 programs). They looked at both
the attributes of the characters designated as having mental ill-
ness and the vocabulary used to refer to those characters.
Wilson et al. reported that 59 (46%) of the episodes contained
one or more references to mental illness, the majority of these
(47) occurring within animated cartoons rather than in shows
with human actors (12). The most common terms for mental
illness were “crazy” (28), “mad” (19), and “losing your mind”
(13). Similarly disrespectful slang terms like “nuts,”
“bananas,” “twisted,” “deranged,” “wacko,” and “looney” were
also common.
Wilson et al. found six recurring characters consistent-
ly identified as having a mental illness. Three appeared in
mainly comic roles and three were shown as evil villains. All
were male. These characters, the researchers noted, often had
 152 Otto Wahl

distinct (and unattractive) physical features, such as rotting

teeth, unruly hair, heavy eyebrows, narrowed eyes, and bad
breath. Comic characters behaved in illogical and irrational
behaviors that were amusing to other characters. Mentally ill
villains were “determined and obsessive” (p. 442) and engaged
in criminal acts such as kidnapping and attempted murder.
The authors reported further that they “looked for, but did not
find, any positive attributes” (p. 442). They also noted that
more than half of the programs they reviewed were produced
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in the United States and that specific (professional) diagnoses

of the mentally ill characters were seldom provided.
The two studies above certainly suggest that children’s
media present the same negative stereotypes as do adult media.
Specifically, they suggest that those with mental illnesses are
depicted as physically distinct, unattractive, unsuccessful, vio-
lent, and villainous. They are also commonly referred to in dis-
respectful ways, using many of the terms children seemed to
prefer in studies of their knowledge of mental illness. The find-
ing that mentally ill characters tended to be male is also con-
sistent with children’s ascription of male gender in studies
where gender has not been specified. In short, examination of
children’s television programming supports concerns that chil-
dren may be learning unfavorable stereotypes and disrespectful
attitudes related to mental illnesses from their own special
media.
It is obvious, however, that the available research on
depiction of mental illness in children’s media, is very limited.
Not only is there a dearth of studies from which to draw con-
fident conclusions, but the published studies themselves have
substantial gaps in their methodologies. Neither study, for
example, provided information about rating criteria, proce-
dures, training, or reliability. Both omitted quantitative infor-
mation about many of their results (e.g., proportions of men-
tally ill characters who fail, percentage of characters given spe-
cific diagnoses). Both also focused exclusively on television,
leaving us with no information about the variety of other
 Children’s Views of Mental Illness 153

media from which children may develop impressions about

mental illness-films, books, music, and even video games.
There are only a very few studies that have attempted to
assess the hypothesized impact of media presentations of men-
tal illness on adult attitudes (Wahl, 1995). There have been
none that look at the impact on children. Given the minimal
number of studies even looking at what children’s media pre-
sent, the lack of studies examining a connection between those
depictions and children’s developing attitudes is not surpris-
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ing. However, it will not be sufficient simply to establish the

prevalence of negative depictions of mental illness in children’s
media to conclude such depictions are contributors to negative
attitudes. Empirical demonstrations of connection are needed.

Education of children about mental illnesses.

The prominent discussions of mental illness stigma in
the 1999 White House Conference on Mental Health and in the
subsequent Report ofthe Surgeon General on Mental Health have
contributed to renewed efforts to educate the public about
mental illness as a means to combat stigma and misunder-
standing. Most of these, and previous, efforts are aimed at the
adult population. However, recognition that the stigmatization
of children by their peers may be a significant barrier to treat-
ment-seeking have led to efforts to better inform children
about psychiatric disorders as well (U.S. Public Health Service,
2000).
The United States has begun a National Mental Health
Awareness Campaign, and its initial efforts have targeted
teenagers. The Campaign uses brochures, an internet web site,
and public service announcements on MTV to reach adoles-
cents with its encouragement to teens to “Change Your Mind”
and be more willing to seek psychiatric help. Another effort
involves curricula for schools. The Breaking the Silence pro-
gram, developed by NAMI-Queens County (NY), features writ-
ten teaching guides for upper elementary, middle school, and
high school teachers, with lesson plans about mental illness
 154 Otto Wahl

that include exercises for students, discussion questions, hand-

outs, posters, and even games appropriate for each age level. A
similar program, called Stamp Out Stigma, has been promoted
to schools in Ohio. Also in Ohio is the Generation Y program
that utilizes children to educate other children about mental
illness. In this program, children who have relatives with men-
tal illnesses speak to groups of other children (and to adults as
well) about mental illness and about their experiences. In addi-
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tion to direct education of children, there are national and local

Stigma Watch programs intended to decrease inaccurate nega-
tive media portrayals of mental illness. In these programs, par-
ticipants monitor and respond to stigmatizing depictions of
mental illness in order to educate media professionals and
reduce the occurrence of negative stereotyping. While Stigma
Watch programs usually are not directed specifically to chil-
dren’s media, targets of protest have frequently included toys,
video games, music, and other youth-oriented presentations
(Wahl, 1995).
As important, innovative, and promising as the above
programs may be, however, they are limited by the lack of an
adequate research base on which to develop materials. Without
a clearer idea of what children’s conceptions and misconcep-
tions of mental illness are, it remains unclear what specific
ideas to target in childhood education efforts. Lack of research
on the possible sources of children’s beliefs (such as media
depictions) and lack of demonstration of a connection between
those sources and attitudes weaken both demands for change
and support for specific change efforts. In addition, with little
or no research on the effectiveness of stigma reduction endeav-
ors-either child education efforts or media change efforts-
the value of such interventions remains a matter of belief
rather than fact.
It will be important to improve our understanding of
how children perceive their mentally ill peers and of how and
when they acquire the attitudes about mental illness that may
carry over into adulthood. While completed studies suggest
 Children’s Views of M e n d Illness 155

that negative attitudes toward mental illness emerge early in

childhood and that children’s media may present images that
fuel those negative attitudes, the relative paucity of research and
the vaned approaches used to gather information prevent con-
fident generalizations. Continued research on these topics is a
necessity for expanding our understanding of children’s con-
ceptions of mental illness and for the establishment of a core of
knowledge on which to base efforts to help children develop
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more accurate and sympathetic views of mental illness.

Adler, A. K., & Wahl, 0. F: (1998). Children’s beliefs about people labeled
mentally ill. Journal of the American Orthopsychiatric Association,
68, 321-326.
Bailey, S. (1999). Young people, mental illness, and stigmatization.
Psychiatric Bulletin, 23, 107-110.
Clements, M. (October 31,1993). What we say about mental illness. Parade
Magazine, 3-6.
Cohen, J., & Struening, E. L. (1962). Opinions about mental illness in the
personnel of two large mental hospitals. journal of Abnormal and
Social Psychology, 64, 349-360.
Conant, S., & Budoff, M. (1983). Patterns of awareness in children’s under-
standing of disabilities. Mental Retardation, 21, 119-125.
Defleur, M. L., €3Dennis, E. E. (1981). Understanding mass communications.
Boston: Houghton Mifflin.
Diefenbach, D. L. (1997). The portrayal of mental illness on prime time
television. Journal of Community Psychology, 25, 289-302.
Dollinger, S. J., Thelen, M. H., & Walsh, M. L. (1980). Children’s concep-
tions of psychological problems. Journal of Clinical Child
Psychology, 9, 191-194.
DYG, Inc. (1990). Public attitudes toward people with chronic mental ill-
ness. Report prepared for the Robert Wood Johnson Foundation
Program on Chronic Mental Illness.
Farina, A. (1982). The stigma of mental illness. In A.G. Miller (Ed.) In the
eye of the beholder (pp. 305-363). New York Praeger.
Farina, A. Fisher, J. D., & Fischer, E. H. (1992). Societal factors in the prob-
lems faced by deinstitutionalized psychiatric patients. In I? J. Fink
& A. Tasman (Eds.) Stigma and mental illness (pp. 167-184).
Washington, DC: American Psychiatric Press.
 156 Otto Wahl

Fink, l? J. & Tasman, A. (Eds.). (1992). Stigma and mental illness.

Washington, DC: American Psychiatric Press.
Fraser, M. E. (1994). Educating the public about mental illness: What will
it take to get the job done? Innovations and Research, 3, 29-31.
Gerbner, G. (1995). Casting and fate: Women and minorities on television
drama, game shows, and news. In E. Hollander, C. van der Linden
& l? Rutten (Eds.) Commuication culture community (pp. 125-135).
Bohn: Stafleu von Loghum.
Gerbner, G., Gross, L., Morgan, M., & Signorelli, N . (1980). The “main-
streaming” of America: Violence Profile No. 11. Journal of
Downloaded by [University of West Florida] at 22:26 29 December 2014

Communication, 30, 10-29.

Hinshaw, S. F!, & Cicchetti, D. (2000). Stigma and mental disorder:
Conceptions of illness, public attitudes, personal disclosure, and
social policy. Development and Psychopathology, 12, 555-598.
Link, B. G., Cullen, E T., Mirotznik, J., & Streuning, E. L. (1992). The con-
sequences of stigma for persons with mental illness: Evidence from
the social sciences. In F! J. Fink & A. Tasman (Eds.). Stigma and
mental illness (pp. 87-96). Washington, DC: American Psychiatric
Press.
Link, B. G., Struening, E. L., Fbhav, M., Phelan, J. C., & Nuttbrock, L.
(1997). On stigma and its consequences: Evidence from a longitu-
dinal study of men with dual diagnoses of mental illness and sub-
stance abuse. Journal of Health and Social Behavior, 38, 177-190.
Nunnally, J. C.(1961). Popular conceptions of mental health. New York Holt,
Rinehart, & Winston.
Phelan, J. C . , Link, B. G., Stueve, A., & Pescosolido, B. (2000). Public con-
ceptions of mental illness in 1950 and 1996: What is mental illness
and is it to be feared? Journal of Health &JSocial Behavioc 41, 188-
207.
Philo, G., Secker, J., Platt, S., Henderson, L., McLaughlin, G, & Bumside, J.
(1994). The impact of the mass media on public images of mental
illness: Media content and audience belief. Health Education
Journal, 53, 271-281.
Poster, E. C. (1992). Children’s concepts of the mentally ill. Journal of Child
and Adolescent Pediatric and Mental Health Nursing, 5, 28-36
Poster, E. C., Betz, C., McKenna, A., & Mossar, M. (1986). Children’s atti-
tudes toward the mentally ill as reflected in human figure drawings
and stories.]ournal ofthe American Academy of Child Psychiatry, 25,
680-686.
Rabkin, J. (1974). Public attitudes toward mental illness: A review of the lit-
erature. Schizophrenia Bulletin, 10, 9-33.
Roberts, M. C., Beidleman, W. B., &I Wurtele, S. K. (1981). Children’s per-
ceptions of medical and psychological disorders in their peers.
Journal of Clinical Child Psychology, 10, 76-78.
 Children’s Views of Mental Illness 157

Roberts, M. C., Johnson, A. Q., & Beidleman, W. B. (1984). The role of

socioeconomic status on children’s perceptions of medical and psy-
chological disorders. Journal of Clinical Child Psychology, 13, 243-
249.
Royal, G. I?, &Roberts, M. C. (1987). Students’perceptions of and attitudes
toward disabilities: A comparison of twenty conditions. Journal of
Clinical Child Psychology, 16, 122-132.
Scheff, T. J. (1966). Being mentally ill: A sociological theory. Chicago: Aldine
Publishing.
Scheff, T. J. (1999). Being mentally ill: A sociological theory (third edition).
Downloaded by [University of West Florida] at 22:26 29 December 2014

New York: Aldine De Bruyter.

Signorielli, N. (1989). The stigma of mental illness on television. Journal of
Broadcasting 6 Electronic Media, 33, 325-333.
Spitzer, A., & Cameron, C. (1995). School-age children’s perceptions of
mental illness. Westein Journal of Nursing Research, I 7, 398-415.
Taylor, S. M., & Dear, M. J. (1981). Scaling community attitudes toward the
mentally ill. Schizophrenia Bulletin, 7, 225-240.
Thornton, J. A., & Wahl, 0. E (1996). Impact of a newspaper article on atti-
tudes toward mental illness. Journal of Community Psychology, 24,
17-25.
U.S. Department of Health and Human Services. (1999). Mental health: A
report of the Surgeon General. Rockville, MD: U.S. Department of
Health and Human Services, Substance Abuse and Mental Health
Services Administration, Center for Mental Health Services,
National Institutes of Health.
U.S. Public Health Service (2000). Report ofthe Surgeon General’s Conference
on Children’s Mental Health: A national action agenda. Washington,
D.C.
Wahl, 0. E (1995). Media madness: Public images of mental illness. New
Brunswick, NJ: Rutgers University Press.
Wahl, 0. E (1999). Telling is risky business: Mental health consumers confront
stigma. New Brunswick, NJ: Rutgers University Press.
Wahl, 0. E, & Lentowits, J. Y. (1989). Impact of a television film on atti-
tudes toward mental illness. American Journal of Community
Psychology, 17, 521-527.
Wahl, 0. E, & Roth, R. (1982). Television images of mental illness: Results
of a metropolitan Washington Media Watch. Journal of
Broadcasting, 26, 599-605.
Weiss, M. E (1985). Children’s attitudes toward mental illness as assessed
by the Opinions About Mental Illness scale. Psychological Reports,
57, 251-258.
Weiss, M. E (1986). Children’s attitudes toward the mentally ill: A devel-
opmental analysis. Psychological Reports, 58, 11-20.
 158 Otto Wahl

Weiss, M. E (1994).Children's attitudes toward the mentally ill: An eight-

year longitudinal follow-up. Psychological Reports, 74, 5 1-56.
Wilkins, J. E., & Velicer, W. E (1980). A semantic differential investigation
of children's attitudes toward three stigmatized groups. Psychology
in the Schools, 17, 364-371.
Wilson, C., Nairn. R., Coverdale, J., & Panapa, A. (2000). How mental ill-
ness is portrayed in children's television. British Journal of
Psychiatry, 176, 440-443.
Downloaded by [University of West Florida] at 22:26 29 December 2014