Associations between child mental health,carer worry and help-seeking

Abstract

Carers may not always express child mental health concerns to health professionals. Therefore, identifying factors delaying help-seeking is important. The aim of this study was to examine the relationship between carer affect and help-seeking. In a secondary analysis of data collected from school-aged children (N = 1,857, mean age = 9.85 years, 51% female), we used logistic regression to examine the associations between carer worry, help-seeking and child mental health. Regarding worry, higher levels of emotional problems (OR = 1.42, 95% CI = 1.33–1.52), conduct problems (OR = 1.24, 95% CI = 1.12, 1.36), peer problems (OR = 1.17, 95% CI = 1.05–1.27) or functional impairment (OR = 1.37, 95% CI = 1.2–.56) were associated with higher levels of carer worry. Regarding help-seeking, higher levels of functional impairment were associated with higher levels of help-seeking (OR = 1.51, 95% CI = 1.09–2.11). After controlling for mental health problems, carers who reported being worried about their child’s mental health were less likely than other carers to seek help (OR = 0.13, 95% CI = 0.05–0.35). Knowledge of these factors may inform early interventions. Alongside implications for future research and practice, limitations of the study are discussed.

Keywords

Child adolescent parents and carers help-seeking behaviour mental health

A high prevalence of young people experience mental health problems at some point during childhood and adolescence (Oh et al., 2015; Rickwood et al., 2005). However, only a proportion of young people experiencing mental health problems will receive mental health support (Mitchell et al., 2017; Oh and Bayer, 2015). In the extant literature, several theoretical explanations have been proposed for help-seeking, albeit these are predominantly for adults (Gulliver et al., 2010). For example, the theory of planned behaviour has been used to demonstrate the mediating effect of attitudes on psychological help-seeking intentions (Ajzen, 2011). Similarly, the health belief model posits that help-seeking is determined by the individual’s appraisal of the perceived threat of the illness, its severity and barriers and benefits of help-seeking (Rosenstock, 1977). A meta-analysis has found that perceived barriers and perceived benefits are strong predictors of help-seeking behaviour, although perceived threats and severity were not consistent predictors (Carpenter, 2010).

Parents and carers are key to identifying when their child is experiencing mental health problems and critical to the help-seeking process (Haine-Schlagel and Walsh, 2015). The gateway provider model posits that carers’ decision to seek help may be influenced by a range of internal and external factors, such as perceived need, demographic characteristics and awareness and availability of resources (Stiffman et al., 2004). In particular, limited awareness of formal help-seeking processes, carers’ stress levels and carers’ perception of the severity of the child’s mental health problem are barriers to help-seeking (Bonis, 2016; O’Brien et al., 2016; Reardon et al., 2017; Reardon et al., 2019). Previous studies also highlight that carers experience additional barriers due to negative attitudes towards seeking help, concerns about trust and fear of being stigmatised or judged (Andershed et al., 2017; Bradby et al., 2007; Coogle and Hanline, 2016).

Quantitative studies thus far have mainly focused on families already accessing specialist mental health care (Oh et al., 2015; Rickwood et al., 2005; Skylstad et al., 2019). Further, studies in the United States (US) have shown that higher levels of carer worry were associated with accessing formal help-seeking (Ellingson et al., 2004; Godoy et al., 2014). This is not mirrored in findings from qualitative studies in the United Kingdom (UK), where higher levels of carer worry, and perceiving a child’s mental health problems as being more severe, were sometimes barriers to help-seeking (Bradby et al., 2007; Sayal et al., 2010). This pattern of findings can potentially be explained using the affective appraisal approach to decision-making in child mental health settings (Liverpool et al., 2021). This evidence-informed model posits that carer child mental health decision-making is a cyclical process, underpinned by affective states. Hence, high levels of worry and concern that a child is experiencing severe problems may contribute to negative affective states, which act as a barrier to formal help-seeking. Notwithstanding, carers may be more likely to access informal, rather than formal, support when their child is experiencing mental health difficulties (Reardon et al., 2019). These authors also highlighted that carers may feel a sense of blame and concern that they will be perceived to have failed as a carer, placing further barriers to help-seeking. Despite the authors’ focus on anxiety, these findings highlight the importance of exploring carer worry, specific to the child’s mental health, which can be a potential underlying factor influencing barriers to recognising a problem and subsequently seeking help. This knowledge could further evidence the role of affective states in carer help-seeking and child mental health.

To improve the quality of care and early interventions for carers and their children, it would be important to further investigate the factors influencing help-seeking behaviours and identify possible predictors. In light of the current waiting periods to access child and adolescent mental health services (CAMHS) (NHS Digital, 2019), and only a subset of parents accessing and engaging with CAMHS, it is just as important to investigate the gap between service need and service access in a non-clinical population. It is important to extend the literature further to understand how these same factors affect help-seeking from both informal and formal sources. Additionally, by exploring help-seeking experiences of parents in a non-clinical population (i.e. pre-CAMHS), we can identify (1) areas suitable for early interventions; (2) families who are less likely to access early intervention or carer support and (3) areas to target that will require further investigation.

Aims

Consequently, the aim of the present research was to examine characteristics associated with carer help-seeking and child mental health, using a secondary analysis of data collected from school-aged children in the UK. In particular, we examined the associations between carer worry, help-seeking and their child’s mental health. We expected that carers would have higher levels of worry when their child’s mental health problems were more severe. We also expected that carers would be less likely to seek help when they had higher levels of worry and when their child’s mental health problems were more severe.

Methods

Data source

A secondary analysis was conducted on data collected from carers of children 8–12 years from primary to secondary schools in the UK who participated in the 2008–2011 Targeted Mental Health in Schools (TaMHS) programme. All families were eligible to participate in the study. Further details of the TaMHS programme have been reported elsewhere (Department for Education, 2011). Taking into account the length of time it generally takes for data to be released for further analysis (Johnston, 2017), the authors recently received permission to analyse and publish the findings from the baseline data. Nonetheless, owing to the limited knowledge on carer help-seeking for child mental health, the dataset was deemed valid for exploratory purposes. The original TaMHS study received ethical approval for collection and analysis of the primary data. However, this secondary data analysis included no identifiable data, and permission was granted for further use and analysis (Tripathy, 2013).

Measures

Demographic characteristics

The demographic profile of the sample included relationship to the child, the child’s age and sex and the families’ first language. Relationship to the child, as reported by the carer, was categorised as mother, father, guardian or others. The child’s age was calculated based on the child’s date of birth, and the child’s sex, based on available data, was categorised as male or female. The family’s first language was categorised as ‘English’ or ‘Others’. Self-report ethnicity was recorded using the superordinate categories of the 2011 Census: Asian, Black, mixed-race, ‘others’ or White (Office for National Statistics, 2012).

Child mental health problems

To capture child mental health problems, carers completed the Strengths and Difficulties Questionnaire (SDQ), which consists of 25 items divided into five subscales (emotional problems, conduct problems, hyperactivity, peer relationship problems and prosocial behaviour), in addition to the impact supplement (Goodman et al., 2003). Higher scores indicate higher levels of mental health difficulties, except for the prosocial subscale where lower scores indicate higher levels of prosocial behaviour difficulties (Goodman et al., 2003). Items required parents to respond on a Likert scale (not true, somewhat true or certainly true) based on the child’s behaviour (e.g. Constantly fidgeting or squirming) or the child’s mood (e.g. Many worries or Often seems worried) within the previous 6 months. A total difficulties score, including emotional problems, conduct problems, hyperactivity and peer relationships problems, can also be calculated ranging from 0 to 40, with an increased score corresponding to an ‘increase in the risk’ of developing a mental health disorder. The SDQ displayed adequate internal consistency (Cronbach’s alpha = 0.74) for the current sample.

Carer worry about their child’s mental health

Worry has been defined as a state of feeling anxious or troubled about a person or situation (Hirsch and Mathews, 2012). Carer worry was assessed using a binary item based on a modified version of the General Help-Seeking Questionnaire (Wilson et al., 2005). Carers were asked ‘Have you ever been worried because your child seemed to be unhappy or disruptive?’ to which they responded ‘Yes/No’. Similar to the Health Anxiety Questionnaire (Lucock and Morley, 1996) and the Health Anxiety Inventory (Salkovskis et al., 2002), which are used to report on an individual’s worry about their own physical or mental health, the current measure aimed at capturing carer worry about their child’s mental health.

Carer help-seeking for child mental health problems

Based on the modified version of the General Help-Seeking Questionnaire, a brief measure was used to capture carer help-seeking behaviours. Experts encourage that where possible the use of such measures is necessary to reduce burden and ease of interpretation (Bowling, 2005). Carers were asked ‘Did you try to get help from any of the following: A family member/A friend/A form/class teacher/A family doctor?’ to which they responded ‘No’ or ‘Yes, but not helpful’ or ‘Yes, a little helpful’ or ‘Yes, and helped a lot’. To address our research questions, the responses were coded as ‘Yes’ or ‘No’ responses. It was important to note that only a subset of our sample (n = 529) responded to this question. Differences between completers and non-completers were statistically significant only in relation to prosocial behaviour: χ² (17) = 1998.19, p < .05. Carers reporting higher prosocial scores for their children were less likely to complete the help-seeking item.

Design and statistical analysis

First, an exploration of the variation among carer help-seeking between schools was conducted to investigate if carers at the same schools displayed similar help-seeking behaviours. The intraclass correlation coefficient was <.05, suggesting that the school level accounted for less than 5% of the variation in carer help-seeking behaviour. Therefore, logistic regressions were acceptable (LeBreton and Senter, 2008).

Once all assumptions were tested and confirmed, binary logistic regression analysis was conducted to explore the associations between child mental health with carer worry, controlling for demographic variables. Similarly, binary logistic regression analysis was conducted to explore the associations between child mental health and carer worry with carer help-seeking behaviour, controlling for demographic variables. Odds ratios (ORs) and corresponding 95% confidence intervals (CI) were used as estimates of the associations. Statistical analyses were conducted using SPSS (version 24), and p-values <0.05 were considered significant (Du Prel et al., 2009).

Results

Participants

The included sample comprised N = 1857 children (Mean Age = 9.85, SD = 1.56; 950 or 51.2% girls). The sample was predominantly English-speaking mothers of White ethnic origins. The overall sample had ‘close to average’ scores on all subscales of the SDQ (Goodman et al., 2003). The majority of carers (1352, 73%) reported feeling worried about their child’s mental health, of whom less than half (529, 39%) had complete data on seeking help from formal (teachers or general practitioners) and/or informal sources (family members or friends). See Table 1 for a descriptive summary of the sample.

Table 1.

Demographic and clinical characteristics of the total sample.

Characteristics	Frequencies
Child’s age, M (SD)	9.85 (1.56)
Child’s sex, n (%)
Boy	907 (48.8%)
Girl	950 (51.2%)
Family’s first language
English	1683 (90.6%)
Others	174 (9.4%)
Ethnicity
Asian	134 (7.2%)
Black	44 (2.4%)
Mixed race	45 (2.4%)
Others	11 (0.6%)
White	1623 (87.4%)
Relationship to child
Father	275 (14.8%)
Mother	1560 (84%)
Guardian	18 (1%)
Others	4 (0.2%)
Child mental health problems, Mdn (IQR)
Hyperactivity and inattention	3 (4)
Emotional problem	2 (3)
Conduct problems	1 (2)
Peer problems	1 (2)
Prosocial behaviours	9 (3)
Impact score	0 (1)
Total difficulties score	7 (8)
Carer worry
Yes	1352 (72.8%)
No	505 (27.2%)

Note. N = 1857. Continuous variables were described by the mean (M) and standard deviation (SD) or median (Mdn) and interquartile range (IQR). Categorical variables were described by count (n) and percentages (%).

Associations between carer worry and child mental health

The logistic regression model was statistically significant: χ² (16) = 576.54, p < 0.05. Asian carers were about 3.9 times less likely to report being worried about child mental health than White parents (OR = .258, 95% CI [0.107, 0.624]). Guardians were about 11 times less likely to report being worried than mothers (OR = .092, 95% CI [0.011, 0.941]). As the carer ratings of their child’s emotional problems (OR = 1.418, 95% CI [1.326, 1.516]), conduct problems (OR = 1.237, 95% CI [1.123, 1.363]) and peer problems (OR = 1.172, 95% CI [1.084, 1.268]) increased, they were more likely to indicate that they were worried about their child’s mental health. As functional impairment increased (i.e. impact score), carers were about 1.4 times more likely to indicate that they were worried (OR = 1.371, 95% CI [1.202, 1.563]). The child’s age, gender, first language, hyperactivity and inattention problems and prosocial behaviours were not independently significant in predicting carer worry (see Table 2).

Table 2.

Logistic regression with demographic and clinical characteristics predicting carer worry.

Variable	OR	95% CI
Child’s age	0.994	[0.918, −1.076]
Child’s sex (Ref: girl)
Boy	1.279	[0.987, 1.657]
Language (Ref: English)
Others	0.564	[0.264, 1.207]
Ethnicity (Ref: White)
Black	0.817	[0.332, 2.012]
Asian	0.258	[0.107, .624]*
Mixed	1.584	[0.719, 3.490]
Others	0.340	[0.058, 1.999]
Relationship to child (Ref: mother)
Father	0.690	[0.472, 1.007]
Guardian	0.092	[0.011, .941]*
Others	0.594	[0.053, 6.694]
Psychosocial difficulties
Hyperactivity	1.020	[0.960, 1.085]
Emotional problems	1.418	[1.326, 1.516]**
Conduct problems	1.237	[1.123, 1.363]**
Peer problems	1.172	[1.084, 1.268]**
Prosocial behaviours	0.932	[0.858, 1.013]
Impact score	1.371	[1.202, 1.563]**

Note: N = 1852. OR = odds ratio; CI = confidence interval; Ref = reference group was selected as per the larger percentage of the sample.

* = p < .05, ** = p < .001.

Associations between child mental health and carer worry with help-seeking

Analyses were conducted for the sample of carers who completed the help-seeking measure (n = 529). The logistic regression model was statistically significant, χ² (17) = 45.94, p < 0.05. Fathers were about 2.6 times less likely to report seeking help than mothers (OR = 0.386, 95% CI [0.163, 0.915]). Carers who reported being worried about their child’s mental health were about 7.5 times less likely to seek help than carers who did not report being worried (OR = 0.134, 95% CI [0.051, 0.349]). However, as functional impairment increased (i.e. impact score), carers were about 1.5 times more likely to seek help (OR = 1.514, 95% CI [1.085, 2.114]). None of the other variables were independently significant in predicting carer help-seeking (see Table 3).

Table 3.

Logistic regression with demographic and clinical characteristics and carer worry predicting help-seeking.

Variable	OR	95% CI
Child’s age	0.973	[0.792, 1.197]
Child’s sex (Ref: girl)
Boy	0.787	[0.404, 1.535]
Language (Ref: English)
Others	0.601	[0.088, 4.092]
Relationship to child (Ref: mother)
Father	0.386	[0.163, .915]*
Psychosocial difficulties
Hyperactivity	1.045	[0.899, 1.227]
Emotional problems	0.891	[0.768, 1.033]
Conduct problems	0.885	[0.716, 1.095]
Peer problems	1.124	[0.921, 1.372]
Prosocial behaviours	1.016	[0.832, 1.240]
Impact score	1.514	[1.085, 2.114]*
Parental worry (Ref: No)
Yes	0.134	[.051, .349]**

Note: N = 529. OR = odds ratio; CI = confidence interval; Ref = reference group was selected as per the larger percentage of the sample.

*p < 0.05, **p < 0.001.

Discussion

The aim of the present research was to examine characteristics associated with carer help-seeking and child mental health, using a secondary analysis of data collected from school-aged children in the UK. In particular, we examined the associations between carer worry, help-seeking and their child’s mental health. The findings from the logistic regressions suggest that carer perceptions of their child’s mental health difficulties and carer worry play important roles in help-seeking.

Regarding carer worry, higher levels of emotional problems, conduct problems, peer problems and functional impairment were associated with increased likelihood of worry. These findings are in line with previous studies suggesting that carers’ appraisal of their child’s mental health is associated with their level of worry (Godoy et al., 2014). The findings of the present research also add to the evidence-base indicating that carer worry may go beyond the activities involved in help-seeking (e.g. concerns about stigma and lack of resources) and be specific to the child’s condition or its impact.

Regarding help-seeking, higher levels of functional impairment were associated with increased likelihood of help-seeking. This is in line with previous research suggesting that higher levels of functional impairment for children were associated with higher levels of help-seeking for carers (Ellingson et al., 2004; Godoy et al., 2014). This finding is also in line with previous evidence suggesting that individuals are more likely to seek help when mental health difficulties impair functioning in education, work, training and interpersonal relationships (DosReis et al., 2010; Patel et al., 2007). Nevertheless, previous research suggests that problem severity in addition to functional impairment is associated with help-seeking, which was not the case in the present study as problem severity was not associated with help-seeking (Reardon et al., 2017, 2019). The impact of the mental health problem was significant in our model, but the severity of the individual problems was not, therefore, implicating a need for further investigations to differentiate between presence and impact of the child’s mental health on the carers’ decision to seek help.

This study further adds to the literature highlighting carer worry as a potential influencing factor that may be a barrier to the help-seeking process. This finding may be partly explained by the perceived level of burden the mental health problems may have on the family (Angold et al., 1998) or the level of blame parents place on themselves (Reardon et al., 2019). However, this finding is contrary to similar US-based studies that reported a positive association between carer worry and help-seeking (Ellingson et al., 2004; Godoy et al., 2014). The contrary findings may be explained by differences in the studies’ samples. Previous studies targeted carers of younger children (<5 years), carers seeking formal support and included smaller samples (<300). Nonetheless, based on raw scores, previous studies highlighted that less than one-third of carers actually spoke to a healthcare provider about the problem (Ellingson et al., 2004; Oh and Baker, 2015; Sayal and Taylor, 2004). This raises a further question about which problems carers consider as atypical in pre-teens and therefore warrants seeking help. Taken together, this finding underscores the importance of the carers affective states as an influencing factor to help-seeking and the need for further investigations (Liverpool et al., 2021). The future findings can further inform existing help-seeking models (e.g. Gateway Providers Model) by explicitly acknowledging and accounting for carers emotional states.

The current findings also reflect potential demographic disparities. Asian carers and guardians were less likely to worry about their child’s mental health, and fathers were less likely to seek help. The results partly support previous qualitative findings suggesting British-Asian carers are worried about being ‘gossiped’ about or stigmatised which prevented them from seeking help (Bradby et al., 2007). Similarly, although studies show that fathers do worry about their child’s mental health (Skylstad et al., 2019), the current findings added that they are less likely to seek help. Although these findings may help to identify socially defined groups for targeted interventions, these groups were represented in less than 15% of the total sample and therefore need to be interpreted with caution.

Limitations

The strength of this exploratory study lies in its ability to provide some insight into carer worry about child mental health problems and their decision to seek help. However, potential limitations should be considered when interpreting the findings of the present research. This was a study about parents’ decision to seek help and not a formal preference trial or evaluation of the depth of services received, so no conclusions about the effectiveness of the support or which support carers prefer can or should be drawn from these findings. The authors only accessed available data from 2008 of the TaMHS dataset, with majority white English-speaking mothers, to represent a cross section of the population, and as a result, causality and generalisability cannot be inferred. In acknowledging the time of data collection, this study acts as an exploratory study to support findings from more recent studies and inform future research. The authors also take caution when comparing the current findings to studies involving data more recently collected as there have been many advancements in the field.

Owing to the limitations of secondary data analysis (Johnston, 2017), the available dataset only provided a single item measure to assess carer worry. Due to carers interpretation of worry, and the subjective nature of the question, participants may have selected to express their first or most recent recall of their child being unhappy or disruptive, therefore neglecting other instances or lack thereof. Similarly, parents may not have reported being worried when their children experienced other mental health challenges.

Another limitation is that the data collected were based on self-report data from carers. Due to self-report bias, some parents may have reported underestimated or inflated scores on psychosocial difficulties (Cheng et al., 2018). Further, less than half of the total sample (n = 529) responded to the help-seeking measure. Moreover, help-seeking from online resources, traditional mental health services (e.g. psychologist) or other sources (e.g. charities) were not reflected in the measure. Further, investigations into the differences in completers and non-completers of the help-seeking measure showed that increased prosocial scores were associated with completion. Therefore, the current findings may not be generalisable to families reporting higher prosocial scores.

Implications for future research

Further studies on effectiveness and preference on various sources of support in child mental health are warranted as satisfaction has an important influence on help-seeking and whether carers go on to seek further help (Gulliver et al., 2010), or to accept the support offered. Recognising the need for help can be challenging as carers’ perceptions of their child’s mental health differ from that of the children, teachers and health professionals (Cleridou et al., 2017; Hawley and Weisz, 2003). These disagreements may develop into a cycle of deciding to seek help then deciding to not seek further help. More rigorous and up to date studies in this area controlling for the views of others and any previous experience carers have had with accessing support would be beneficial to update the theories outlined in the help-seeking literature.

Implications for practice

Results from this study are useful in identifying possible areas of shortcomings. Carers of school-aged children may have regular contact with schools and therefore continuing to establish stronger links between mental health services and education providers may lead to more children receiving appropriate support. In addition, carers do access informal support, and therefore, these support systems should be provided with the knowledge base to offer the necessary support. Consequently, information about identifying child mental health disorders, ways to access help and treatment and early-stage interventions should be widely disseminated and accessible to the public. Additionally, embedded in practice, should be the necessary emotional support guidelines for working with carers of children accessing child mental health support. It may also be important to consider lowering carers’ worry through routine screening and education about child mental health problems.

Conclusion

Although these findings could be viewed as exploratory, they suggest that carers’ perception of child mental health problems and carer worry may influence their decision to seek help. Knowledge of these factors may improve development and access to early carer-targeted interventions and further inform theories of pathway to CAMHS. Involving informal support systems in the development and dissemination of information resources and interventions may help reach those carers who are less likely to access CAMHS.

Footnotes

Acknowledgements

The authors would like to thank Dr. Mohammed Moinuddin and Thomas Bardsley for guidance and advice on data analysis and interpretation. We would also like to thank Professor Miranda Wolpert, Professor Jessica Deighton and Professor Peter Fonagy for guidance and support at various points throughout this study. Lastly, we would like to thank Miles Weekes for his support at the time of writing the manuscript.

Author contributions

All authors contributed to the conception and design of the study. Analysis and interpretation of the data was conducted by the first author. All authors contributed to the drafting and refinement of the article before submission.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: H2020 Marie Skłodowska-Curie Actions, Grant No. 722561.

ORCID iD

Shaun Liverpool

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