How Parents Seek Help for Children with Mental Health Problems

Abstract

Parents seeking help for their child's mental health problem face a complicated system of services. We examined how parents navigate the various services available. Sixty parents contacting a children's mental health center were interviewed regarding their efforts and rationale in seeking help for their child. On average, in the year prior to the interview parents sought help for two different child problems, contacted five different agencies or professionals for help, and parents and/or children received two different treatments. One fifth of the time parents said they accepted treatments that they did not want. Almost all parents (87%) were simultaneously in contact with more than one agency at some point within the previous year. Future help-seeking models need to capture the iterative referral process that many parents experience.

Full text

ORIGINAL PAPER
How Parents Seek Help for Children with Mental Health
Problems
Dianne C. Shanley Æ Graham J. Reid Æ
Barrie Evans
Published online: 9 January 2007
Ó Springer Science+Business Media, LLC 2007
Abstract Parents seeking help for their child’s mental
health problem face a complicated system of services.
We examined how parents navigate the various
services available. Sixty parents contacting a children’s
mental health center were interviewed regarding their
efforts and rationale in seeking help for their child. On
average, in the year prior to the interview parents
sought help for two different child problems, contacted
five different agencies or professionals for help, and
parents and/or children received two different treat-
ments. One fifth of the time parents said they accepted
treatments that they did not want. Almost all parents
(87%) were simultaneously in contact with more than
one agency at some point within the previous year.
Future help-seeking models need to capture the
iterative referral process that many parents experience.
Keywords Parent  Child  Help-seeking  Service
utilization  Mental health  Access to care  Treatment
About 1 out of every 5 children and adolescents has a
significant mental health problem (Offord, Boyle,
Fleming, Blum, & Grant, 1989; Offord, 1998; Pavuluri,
Luk, & McGee, 1996; Costello et al., 1996). Yet only
about 20% of children with mental health problems
receive some form of help and just 5% receive
specialized mental health services (Offord et al.,
1987; Pavuluri et al., 1996; Verhulst & Van der, 1997;
Leaf et al., 1996; Angold et al., 1998).
Classic models of help-seeking assert that a person
must first recognize a problem, decide to seek help, and
then select a source for help (Gurin, Veroff, & Feld,
1960; Fischer, Weiner, & Abramowitz (1983). Rogler
and Cortes (1993) introduced the concept of a help-
seeking pathway to describe how people navigate
mental health systems. They defined pathway as ‘‘the
sequence of contacts with individuals and organiza-
tions prompted by distressed person’s efforts, and
those of his or her significant others, to seek help as
well as the help that is supplied in response to such
efforts’’ (p. 555). They suggested pathways have a
linear direction (i.e., individuals contact organizations
in a sequential manner), and specific duration (i.e.,
time lapses between help-seeking efforts).
Recent help-seeking models have been adapted to
describe a more detailed progression of the help-
seeking process. Srebnik, Cauce, and Baydar (1996)
presented a model that described how youth utilized
mental health services incorporating factors, originally
proposed by Anderson and colleagues (Andersen &
Newman, 1973), that impact the help-seeking process
including subjective need for services, predisposing
characteristics, and enabling and inhibiting factors.
Logan and King (2001) proposed an elaborate linear
progression of help-seeking for adolescents with men-
tal health problems. They suggested that parents must
first gain awareness of their adolescent’s distress,
recognize the problem as psychological in nature,
consider possible courses of action, develop the
D. C. Shanley (&)  G. J. Reid  B. Evans
Department of Psychology, University of Western Ontario,
7329 Social Science Center, London, ON, Canada N6A 5C2
e-mail: dhadley@uwo.ca
G. J. Reid
Department of Family Medicine, University of Western
Ontario, London, ON, Canada
B. Evans
Madame Vanier Children’s Services, London, ON, Canada
Adm Policy Ment Health (2008) 35:135–146
DOI 10.1007/s10488-006-0107-6
123

intention to seek mental health services, make an
active attempt to seek services, and obtain mental
health services. Progression through these stages is
facilitated or derailed by social, cultural, and systemic
factors. For example, physician referral increases the
likelihood of obtaining specialized mental health care
(Sayal, Taylor, Beecham, & Byrne, 2002).
Various elements in models of how parents access
mental health care for their children have empirical
support. Parental problem recognition is related to
help seeking (Pavuluri et al., 1996; Rawlinson &
Williams, 2000) and problems with transportation and
costs lead to decreased access (Benway, Hamrin, &
McMahon, 2003). However, some data are inconsistent
with a linear progression through specific stages.
Pavuluri, Luk & McGee (1996) identified 42 of 320
children with behaviour problems from community
preschools. Consistent with a linear progression, the
number of parents who recognized a problem (n = 19)
and sought help for the problem (n = 17) was much
greater than the number who finally obtained help
(n = 8). Interestingly, 50% of parents who sought help
(n = 4) ‘‘did not believe there was a problem but
sought help all the same’’ (p. 219). It would seem that
half of the parents who obtained help bypassed the
problem recognition stage, suggesting that the help-
seeking process is not always linear but may involve
multiple pathways.
Alternatives to a linear progression of help-seeking
include the family network-based model of access to
children’s mental health services (Costello, Pescoso-
lido, Angold and Burns, 1998), and the related gateway
provider model (Stiffman, Pescosolido, & Cabassa,
2004). These models propose that multiple influences
dynamically affect how children obtain mental health
services. Parents are seen as key ‘‘gateway providers’’
in terms of recognizing their child’s need for help, and
taking steps to obtain help. These models include
treatment system factors including organizational con-
straints related to accessibility (Costello, Pescosolido,
Angold, & Burns, 1998). The multiplicity of entry
points into mental health care and the mix of services
available have been identified in previous studies
(Farmer, Burns, Phillips, Angold, & Costello (2003).
Less is known about how parents navigate the systems
that provide mental health care for children and in
particular, how parents respond to problems in access-
ing services.
The present study examined the process of parental
help-seeking among families who were actively seeking
help for their child. Four issues were examined with a
focus on exploring whether the help-seeking process is
linear. (1) Do parents identify one single problem or
multiple co-morbid problems? A linear help-seeking
process would suggest that parents recognize a prob-
lem and seek help for that particular problem. (2) How
do parents choose the agencies they contact? (3) Do
parents simultaneously seek help from multiple agen-
cies, and receive services from multiple agencies? A
linear process would imply that parents seek help from
one location, and receive help from the same location
without accessing multiple services. (4) When treat-
ment is offered, do parents want what is offered to
them? Beyond commonly cited barriers for accessing
services (e.g., transportation, cost, etc.), we explored
parents’ agreement with the treatments they were
offered and whether they accepted the help offered to
them.
Methods
Participants
Parents who contacted a centralized intake serving
three publicly funded Children’s Mental Health
Centers in London, Ontario (population about
337,000, metropolitan area about 432,000) for help with
their child’s problems were recruited. The three centers
specialize in treating behavioural and emotional prob-
lems for children and adolescents up to age 18 in the
city and surrounding areas. Families seeking treatment
from these centers tend to have children with more
severe externalizing problems than internalizing prob-
lems. The mean T-score (age- and sex-based norms
based on a community population sample) for exter-
nalizing problems of all children receiving treatment
from the centers at the time of the study (M = 72.4,
SD = 12.2) was significantly higher than the mean
for internalizing problems [M = 64.1, SD = 14.7;
t(748) = 8.48, P
< .01].
1
Parents do not require a formal
referral to obtain services from the agencies.
Inclusion criteria were: (a) Parent or legal guardian
contacted the center regarding help for their child, (b)
child age 4–17 years old. Exclusion criteria were: (a)
crisis situations (i.e., an adverse event that was immi-
nent or had recently occurred and the family was given
immediate service by the center), (b) parents unable to
speak or read English, (c) parents communicated
with the center only through answering machines,
(d) doctors or other health/mental health care
1
These aggregate data were obtained from the participating
centers which may have included some of the patients partici-
pating in the current study.
123
136 Adm Policy Ment Health (2008) 35:135–146

professionals contacted the center for the parent, (e)
parents who were not the custodial guardian of the
child. The study was approved by the University of
Western Ontario’s Institutional Review Board. There
were no study incentives for participants.
During the 7 months of data collection, 487 parents
called for help with their child and 144 (30%) of these
parents agreed to be contacted about the study; the
remainder either did not meet study criteria or intake
workers neglected to ask them to participate. Of the
144 eligible parents who were asked and who agreed to
be contacted, 23 had more than a 2 month period
between the intake call and research contact and 34
could not be contacted despite repeated telephone
calls.
Of the 87 parents contacted, 60 (69%) agreed to
participate in the study. The primary reasons for
declining were lack of interest or not enough time. It
was not possible to compare parents who agreed to be
contacted with those who did not agree, nor was it
possible to compare parents who released their contact
information and who agreed to participate to those
who declined participation because intake staff collect
information only on families offered treatment and not
all families seeking help are offered treatment.
Children of parents who participated in the study
were 3–16 years old (M = 10.57, SD = 3.8); 40 (67%)
were male. Parents were 22–50 years old (M = 37.55,
SD = 7.02); there were 52 mothers and 8 fathers.
Parents reported their annual income in one of seven
categories. The modal annual income per family was
CA $10,000–$19,999 (US equivalent approximately:
$7,700–$15,500), which is in the low-income range for a
Canadian family in an urban setting (Statistics Canada,
2004). Of parents who participated in the study, 62%
went on to receive treatment from one of the three
treatment centers, the other 38% were not offered
treatment at one of these three centers. This is similar,
but slightly higher, than the total number of parents
who contacted the intake service and received treat-
ment from treatment centers during the study period
(52%). The severity of child problems among families
who participated in the study was not significantly
different from the severity of child problems in all
families receiving treatment from the centers during
the time the study was conducted [Externalizing
problems: t(433) = 1.6, n.s.; Internalizing problems:
t(433) = 0.4, n.s.].
Procedures
Intake workers completed a standard intake inter-
view and then asked all eligible parents if they
would be willing to be contacted about participating
in a research study. Parents were mailed a letter of
information about the study and were contacted for
the first time by the researcher over the telephone
approximately 1 week later. Parents who consented
completed a structured interview lasting about
one-hour that included the Brief Child and Family
Phone Interview (Cunningham, Pettingill, & Boyle,
2000) to assess the severity of children’s behaviour
problems, and questions designed for the present
study to assess parents’ decision-making processes
and experiences related to accessing mental health
services. The average length of time between the
parents contact with the intake worker and the
completion of the interview was 2.3 weeks
(Mdn = 2.1, SD = 1.5).
Measures
The Brief Child and Family Phone Interview
(BCFPI)
The BCFPI is a 30-minute standardized telephone
interview with 81 forced-choice questions (Cunning-
ham et al., 2000). It is the mandated intake measure
used by all children’s mental health centres in the
province of Ontario. The BCFPI is based on the
Ontario Child Health Study scales - Revised version
(OCHS-R) (Boyle et al., 1993). Parents report the
frequency of each child’s behaviour as ‘‘never’’,
‘‘sometimes’’, or ‘‘often’’. The present study used
three composite scales, which were based on nine
factor analytically derived subscales: (a) externalizing
(i.e., regulation of attention and activity; cooperation;
conduct), (b) internalizing (i.e., separation from
parents, managing anxiety and managing mood), and
(c) child functioning/impairment (i.e., social partici-
pation, quality of child’s social relationships, school
participation and achievement). Norms and reliability
were derived from community and clinic data from
the OCHS. Internal consistency for eight of the nine
BCFPI subscales in the community sample ranged
from .75 to .86 (Cronbach’s alpha) (Cunningham
et al., 2000). Internal consistency for the conduct
subscale was .56. The authors of the BCFPI, however,
considered this subscale to be too infrequent in a
community sample to produce reliable results.
Correlations between the BCFPI subscales and the
OCHS-R full-length scales range from .78 to .96. For
the present study, T-scores were computed using
the age and sex based norms from the community
sample.
123
Adm Policy Ment Health (2008) 35:135–146 137

Help-seeking and Health Care Utilization
Parents were asked the number of times they contacted
a list of 17 agencies/ professionals
2
in the past year; this
included 10 agencies from the OCHS-R health care
utilization schedule (e.g., physician, children’s mental
health centre) (Offord et al., 1989) and seven addi-
tional agencies providing children’s mental health care
in the surrounding community. For each agency
contacted, parents were asked the date of their first
and last contact, the number of times they contacted
the agency, how they chose the agency, what problem
they wanted to address, what kind of help was offered,
whether it was the help that they wanted, how long
they had to wait for the help, and if they were referred
anywhere. These questions were repeated for each
agency the parent encountered over the past year. In
addition, parents reported the impact of the child’s
problem upon themselves and their family.
Variables derived from the interview are outlined
below. Open-ended questions were coded for each
agency using a standardized coding manual. A research
assistant was trained to use the coding manual to a
kappa of at least .75 using data from 10 parents
(who together contacted 36 agencies). Disagreements
in the coding were resolved by discussion for these 10
interviews. Inter-rater reliability between the research
assistant and the interviewer (D.S.) was calculated on
data from 20% of the remaining interviews. All kappa
values were in the excellent range; across eight codes
kappa values ranged from 0.82 to 0.93 (M and
Mdn = 0.89).
Type of Problem
Parents’ statements about the problems they wanted to
address with each agency were coded into 26 symptom
categories that were consolidated into eight problem
areas: aggression/defiance, family functioning, anxious/
depressed, learning difficulties, attention/concentra-
tion, physical symptoms, social functioning, other. See
Table 1 for the definitions of each problem area.
Agencies Contacted
Two variables related to mental health agency con-
tacts were developed. (1) Number of agency contacts
past year. The total number of agencies parents
contacted in the past year for their child’s mental
health problem was computed. Some parents had
contacts with agencies prior to 1 year ago; only
contacts within the past year were discussed with
parents. (2) First agency contacted. Parents’ recollec-
tions of whom they chose to first speak with about
their child’s problems were documented. This repre-
sented parents’ very first contact with a professional,
and may have been prior to 1 year ago. Responses
were aggregated into the following categories: (a)
physician, (b) school, (c) child welfare, (d) children’s
mental health centre, (e) psychologist, (f) psychiatrist,
and (g) police.
Treatment History
The length of time parents had been accessing services
was documented by comparing when parents contacted
an agency for the first time and the date of the
interview. The length of time between their first
contact with an agency and the interview date was
coded as either (1) began accessing services more than
1 year ago, or (2) began accessing services within the
past year.
Choice of Agency
Parents were asked why they chose to contact each
agency. Responses were coded into seven categories:
(a) referred by professional, (b) referred by non-
professional, (c) personal knowledge of agency, (d)
current or past involvement with the agency, (e)
agency contacted the parent, (f) agency was most
accessible, or (g) other.
Services Offered
Parents were asked what services each agency had
offered them. Responses were coded and then catego-
rized into (a) treatment or (b) non-treatment services.
Treatments were coded in 13 categories and involved
any form of intervention aimed at resolving the child’s
problem (e.g., individual counselling with parent or
child, parent group, medication). Non-treatment
services were coded into nine categories and then
aggregated as referrals or other services (e.g., intake
appointments, assessment, listening or providing
support, parent respite). Referrals included formal
requisitions for specialized services by family physi-
cians, as is typically the case in the Canadian medical
care system (i.e., family physicians refer patients to
medical specialists) and recommendations by agency
staff (professionals or non-professionals) that parents
should seek services elsewhere.
2
For simplicity, the term agency will be used to refer to agency
and professional for the remainder of the article.
123
138 Adm Policy Ment Health (2008) 35:135–146

Treatment Received
Parents were asked about treatment from each agency.
If treatment had not been received from the agency it
was coded as (a) waiting or (b) other (e.g., professional
cancelled the treatment).
Simultaneous Agency Contacts
The most recent agency contacts were grouped by each
month prior to the interview. Simultaneous agency
contact was defined as having contact with more than
one agency within the same month. The total number
of agencies that parents were simultaneously in contact
with in each of the 12 months prior to the interview
was computed; simultaneously contacts 6–12 months
prior to the interview were averaged due to low
frequency of contact per month for this period. This
method was modeled after Farmer, Stangl, Burns,
Costello, & Angold (1999) who aggregated contacts
over a 3-month period.
Agreement with Treatment
Parents who were offered treatment were asked if they
wanted the treatment that was offered. Responses were
coded as (1) Treatment wanted, (2) Treatment not
wanted because of barriers (e.g., transportation, cost,
lengthy waiting, child refusal to attend treatment), or (3)
Treatment not wanted. Treatment not wanted refers to
times when parents disagreed with the type of treatment
offered; that is, they did not want the type treatment
offered either because they felt that they or their child
would not benefit from the treatment (e.g., offered
parenting classes but the parents felt they had taken
enough parenting classes already), or they felt that there
was a different treatment that was more suitable (e.g.,
offered an anger management group for the child, but
the parent wanted medication for the child).
Impact on Parent
The impact of the child’s problems on various aspects
of the parent’s life was measured using six questions
from the Child and Adolescent Impact Assessment
(CAIA) (Angold, Costello, Farmer, Burns, & Erkanli,
1999) and one question adapted from the Child Health
Questionnaire (CHQ) (Landgraf, Abetz, & Ware,
1996). Questions asked parents to rate on a scale from
1 to 5 (1 = not at all, 5 = very much so) the extent to
which the child’s problems had affected the parents’
emotions, energy, time for personal needs, and physical
health during the past 4 weeks.
Data Analyses
To calculate the reasons parents chose an agency as
well as the services offered to parents, data were
aggregated across parents or across agencies. This
allowed for an examination of the services delivered to
children from a systems perspective that could not be
examined from only analyzing the data at a parent-by-
parent level. T-tests were used to examine group
differences within the sample.
Table 1 Problem areas that parents identified when seeking help for their child
a
Problem areas Definition Percent of parents
endorsing problem area
Aggression/
defiance
Child acts out in anger or aggression; is argumentative or dishonest; talks back to adults;
refuses to do tasks or attend school; participates in illegal activities; or has frequent
conflicts with siblings
75% (n = 45)
Family
functioning
Parent is having difficulty with discipline or caring for the child; child has difficulty
adjusting to a new family member, the loss of a family member or divorce; parent
psychopathology is having a negative effect on parent-child relationship; parent
respite is needed; abuse within the family
40% (n = 24)
Anxious/
depressed
Child is anxious, fearful, has difficulty separating from parents, has lowered mood,
lack of interest, lack of energy, withdrawal or a sad affect
22% (n = 13)
Learning
difficulties
Child has difficulty due to a learning disability or has difficulty completing
school work
20% (n = 12)
Attention/
concentration
Child has difficulty paying attention, concentrating or focussing; child gets
easily distracted; has difficulty sitting still
12% (n =7)
Physical
symptoms
Child is having motor, hearing, developmental or speech difficulties 12% (n =7)
Social
functioning
Child is having difficulties appropriately socializing with peers, or displays odd social
behaviours (i.e., licking, smelling, pica)
12% (n =7)
Other Sleep problems, enuresis, sexual acting out, or problems with school administration 12% (n =7)
a
N = 60 parents.
123
Adm Policy Ment Health (2008) 35:135–146 139

Results
Help-Seeking History
Physicians were the most common first contact for help
with their child’s problem (42% of parents) and
schools were the next most common (22%). Parents
first sought help for their child an average of 3.1 years
ago (SD = 3.2; range = 0.1–12.8 years ago), when their
child was an average of 7.5 years old (SD = 4.3;
range = 1.2–15.5).
Thirty-seven percent of parents participating in the
study began contacting professionals for their child’s
mental health problem within the past year (n = 22);
63% had been in contact with at least one agency
more than 1 year before the interview. Parents who
began contacting agencies more than 1 year ago had
children with more severe externalizing problems
[t(58) = 2.34, P < .05], compared to those who began
looking for help within the past year; there were
no significant difference in terms of child age
[t(58) = .42, n.s.], socio-economic status [t(58) = .22,
n.s.], child internalizing problems [t(58) = .72, n.s.], or
the impact of the problem on the parent [t(58) = .03,
n.s.].
Parents’ Help-Seeking Experience: Past Year
Parents sought help for an average of two different
problems (SD = 1.15, Mdn = 2, range 1–6). Table 1
presents the percentage of parents seeking help for
each problem area. Parents contacted an average of
4.9 different agencies during the previous year for help
with their child’s problems (SD = 1.91, Mdn =5,
range = 1–11; this includes contact with the agency
from which the parents were recruited). Families had
contact with all service sectors including medical (e.g.,
family physician, pediatrician, psychiatrist, emergency
room), school (e.g., school psychologist, guidance
counsellor, school board, learning disability associa-
tion), mental health (e.g., child and adult mental
health center, private psychologist), child protection
agencies, justice (e.g., police, probation, courts), and
community and social services (i.e., local community
agencies).
‘‘Referral’’ (by professionals and non-professionals)
was the most common reason parents contacted an
agency (52% of all agency contacts, n = 159/303),
current or previous involvement with the agency and
personal knowledge of the agency (i.e., knew about the
agency from advertisements or other sources, such as a
relative employed there) were the next most common
reasons (see Table 2).
Simultaneous Agency Contacts
The vast majority of parents (87%) were simulta-
neously in contact with more than one agency at some
point within the past year (see Fig. 1). Parents were
involved with increasingly more agencies simulta-
neously over time. In the 6–12 months prior to the
interview parents were simultaneously in contact with
an average of less than one agency (M = 0.05) versus
2.6 agencies in the month prior to the interview. As one
parent stated, ‘‘I didn’t talk to any other places while I
was on the waiting list for the psychologist because I
was sure that the psychologist could help. He didn’t
help one bit, now I talk to more than one place at a
time or I never get anywhere’’.
Services Offered
During the previous year, parents sought help from up
to 11 different agencies and each agency offered up to
three services for each family. In total, 329 services
were offered to the 60 families. Thirty-six percent of
the services were treatments (n = 117), the remainder
mainly included services such as referrals (27%),
intake appointments (12%), listening/providing sup-
port but not treatment (e.g., at a physician’s office)
(10%), and assessments (3%).
Services Received
Over two-thirds of parents reported having received
treatment during the past year prior to contacting
the children’s mental health centre from which they
were recruited. In other words, over two-thirds of
parents had already received treatment and were
seeking additional treatment. Fifteen percent of
families had not yet received any treatments at the
time of the interview. Of the 85% who received at
least one treatment, parents contacted an average of
2.3 agencies prior to receiving that treatment
(SD = 1.7, Mdn = 2, range = 1–11), and they were
placed on a waiting list 50% of the time. During the
previous year, families received treatment from up to
seven different agencies (M = 2.0, SD = 1.6,
Mdn = 2). Within agencies, parents received up to
three different treatments at each agency (M = 1.3,
SD = 0.6 Mdn = 1).
Agreement with Treatment
Parents wanted the majority (66%) of treatment
services offered to them (see Fig. 2). As would be
123
140 Adm Policy Ment Health (2008) 35:135–146

expected, parents consented to participate in all
treatments that they wanted for their child. Ten
percent of treatments offered were not, or had not
yet been, received (7.5% on a wait list, 2.5% agency
cancelled treatment). A minority of treatments offered
(8%) were declined due to barriers. About one quarter
of the treatments offered (27%) were not wanted
because parents disagreed with the treatment
approach. Despite parents’ disagreement with the
treatment, parents declined only 5% of these treatment
services. Thus, out of all treatment services offered to
these families, 21% of the time parents agreed to
treatments that they did not want. In each of these
cases (20/25 treatments) families participated in the
treatments; for one treatment the family was still on a
wait list and in four cases the agency cancelled the
treatment.
We examined whether a small subset of parents
accounted for not wanting any of the treatments
offered. Of the 51 parents who were offered one or
more treatments during the past year, 55% (n = 28)
wanted all the treatments offered to them, 26%
(n = 13) did not want some treatments, 14% (n =7)
Table 2 Reasons parents chose to contact agencies
Sector Percentage of time each reason was endorsed by sector
Referred by
professional
Referred
by non-
professional
Knowledge
of agency
Involvement
with agency
(current/past)
Most
accessible
agency
Agency
contacted the
parent
Other
reason
Not enough
information
d
CMHC
a
(n = 99) 75 5 5 7 3 1 1 3
Medical (n = 51) 16 2 45 27 2 0 4 4
Community/social
services (n = 50)
62 12 8 6 4 2 0 6
School (n = 40) 18 0 13 33 2 20 0 15
CAS (n = 29) 14 3 14 10 3 4 10 7
Private
psychologist/
therapist (n = 11)
45 9 9 27 9 0 0 0
Psychiatrist (n =7) 71 14 0 14 0 0 0 0
Police/probation
(n =8)
50 0 13 13 0 13 0 13
Adult MHC
b
(n =4)
50 0 25 0 25 0 0 0
Occupational/
speech therapist
(n =2)
50 50 0 0 0 0 0 0
Other (n =2) 50 50 0 0 0 0 0 0
Total: across
sectors
(N = 303)
c
47 6 15 15 3 7 2 6
Note. Row percentages are shown
a
CMHC = children’s mental health center
b
MHC = mental health center
c
N = number of agencies contacted by all parents
d
Not enough information indicated that, despite interviewer prompts, parents did not provide enough information to allow for
accurate coding of the data
Fig. 1 Number of times a parent was simultaneously
a
in
contact with more than one agency in the previous year
b
.
a
Simultaneous agency contact was defined as having contact
with more than one agency within the same month. Plots show
the M as a dark bar, SD as shaded box, and range as error
bar.
b
N = 60 parents
123
Adm Policy Ment Health (2008) 35:135–146 141

did not want any, and 6% (n = 3) encountered barriers
to all treatments. Parents who did not want at least one
of the treatments (39%) did not differ from parents
who wanted all treatments in terms of child age
[t(46) = 0.6, n.s.], socio-economic status [t(46) = 1.6,
n.s.], child problem severity [internalizing: t(46) = 1.4,
n.s.; externalizing t(46) = 1.0, n.s.], family having
accessed services more than 1 year ago versus within
the past year [v
2
(1) = 1.0, n.s.], or the impact of the
problem on the parent [t(46) = 0.4, n.s.].
We also examined whether there was a specific type
of treatment that accounted for the treatment services
that parents did not want because they disagreed with
the treatment approach (see Table 3). Parenting clas-
ses, counselling for parents and medication were the
most common treatments with which parents dis-
agreed. In total, 11 different types of treatment were
not wanted by parents.
Discussion
Most families involved in professional services for their
child during the past year looked for help for multiple
Services offered
N=329
Non-treatment services
offered
64.4%
N= 212
Treatment services
offered
35.6%
N= 117
Treatment Wanted
65.8%
77/117
Treatment Not Wanted
due to Barriers
7.7%
9/117
Treatment Not Wanted
26.5%
31/117
Consented
65.8%
77/117
Declined
0%
0/117
Consented
21.4%
25/117
Declined
5.1%
6/117
Received
55.5%
65/117
Received
0%
0/117
Received
17.1%
20/117
Fig. 2 The distribution of services offered to parents. Services
offered to parents were divided into treatment services and
non-treatment services. Parents reported whether the treatments
offered were wanted or not wanted. The percentage of
treatments that parents consented to and the percentage that
parents received were documented. The total N for this figure
(N = 329) is greater than the number of agencies contacted by
parent (Table 2: N = 303) because some agencies offered more
than one service to each parent
Table 3 Treatments to which parents consented, but did not
want because of disagreement with the treatment approach
a
Type of treatment Number of
times
treatment not
wanted
Total number
of times
treatment
offered
Percentage
of time
treatment
not wanted
Parenting class 6 13 46%
Medication 7 16 44%
Counseling for
parent
4 9 44%
Anger
management
2 6 33%
Residency 1 4 25%
Counseling for
child
5 25 20%
Group for child 4 20 20%
Family counseling 1 5 20%
Counseling
undefined
1119%
Art therapy 0 4 0%
Play therapy 0 2 0%
Occupational/
physical therapy
02 0%
Marital counseling 0 0 0%
Note. Figure 2 shows the breakdown for all services offered
a
N = 31 treatments not wanted
123
142 Adm Policy Ment Health (2008) 35:135–146

problems in multiple places. The results of this study
support models of help-seeking such as the network-
based model of access to children’s mental health
services (Costello et al., 1998) and the gateway pro-
vider model (Stiffman, Pescosolido, & Cabassa, 2004).
The results do not demonstrate strong support for
linear progressions of help-seeking, which suggest that
parents first recognize a problem, then contact organi-
zations in a sequential manner for help with that
problem, and consequently receive help (Rogler &
Cortes, 1993).
Do parents identify one single problem or multiple
co-morbid problems? Parents did not seek services in
response to a particular problem but rather, they
sought services for multiple, co-morbid problems.
Other studies of families presenting at children’s
mental health centers have also found that parents
report multiple presenting problems (Yeh & Weisz,
2001). A linear help-seeking process would suggest that
parents often begin this process by first recognizing the
problem and then seeking help for the problem.
However, not all families need to recognize a problem
to enter the mental health care system (Pavuluri et al.,
1996). Consistent with the gateway provider model,
families could access services because they were told to
get help for their child by a professional such as the
school, or because they were mandated to receive
treatment by child protection agencies. The frequency
of parents who are told or mandated to seek help was
not examined in the present study; future studies
should examine this.
How do parents choose the agencies they contact?
Again, in support of the gateway provider model and
consistent with studies from the United States (Burns
et al., 1995; Farmer et al., 2003; Lavigne et al., 1998;
Stiffman et al., 2004), the majority of parents in the
present sample began to access help through physicians
or school personnel. It should be noted that for the
present study, first point of access was modelled after
Farmer et al. (2003) who reported parents’ recollection
of first contact based on lifetime use of services, rather
than use of services for the current episode of help-
seeking.
The high percentage of time parents utilized refer-
rals with professionals and non-professionals, along
with personal knowledge of agencies from friends or
family, is consistent with social network theories
suggesting that the process of help-seeking involves
consultation with numerous formal and informal
sources. Referrals may have been the primary choice
for how to select an agency because parents may not
have been aware of the various service options avail-
able to them or because parents thought they required
a referral to access services, which is not the case for
children’s mental health centers in Ontario. Parents
may have simply preferred to follow the advice of
professionals who have knowledge of the various
service options in their community. Given the number
of agency contacts prior to treatment (ranging from 1
to 11), these data suggest that agencies in the commu-
nity may not be as knowledgeable about service
options as parents would assume. Other studies have
found that service provider knowledge is related to
accessing mental health care [see (Stiffman et al.,
2001)].
Do parents simultaneously seek help from multiple
agencies, receive multiple treatments or receive no
treatment at all? These results support a previous study
that found parents to be simultaneously in contact with
multiple agencies within the same time period (Farmer
et al., 2003). Farmer et al. (2003) examined mental
health care utilization across sectors. The present study
included a further analysis of services received within
agencies and found that parents were not only typically
in contact with over two agencies in the month prior
to the interview, but they were also receiving up to
three different treatments at each agency. Examining
services received both across and within agencies
provides a clearer picture of the challenges and
complexities related to seeking and receiving mental
health care for children.
A linear help-seeking process implies that parents
progress from seeking help to receiving help. However,
it would appear that parents followed a more disorga-
nized and varied pathway, rather than a linear help-
seeking pathway. Almost all parents used multiple
services from multiple sectors within the same time
frame, and they often contacted a new agency before
concluding their involvement with a previous agency.
Parents did not necessarily stop seeking help once they
received treatment. Thus, families were simultaneously
at multiple stages of the linear help-seeking process
both across and within agencies.
Given the data from this study, one might question
whether the amount of effort parents expend looking
for help is reasonable. Parents contacted between one
and 11 different agencies before receiving help (with
an average of two agencies). To our knowledge, this is
first study to document the number of contacts parents
make prior to receiving treatment. We do not currently
have an understanding of the impact that the help-
seeking process has on families (e.g., parents’ stress) or
the systems that care for these children (e.g., costs of
multiple intake calls). Further, the number of agencies
contacted to receive treatment must be examined
against system resources (Costello, Burns, Angold, &
123
Adm Policy Ment Health (2008) 35:135–146 143

Leaf 1993; Costello et al., 1998). For families in rural
areas, contacting the school, physician and one agency
might represent contacting 100% of all resources,
whereas this might reflect only a fraction of potential
resources in urban areas. A related question is whether
receiving simultaneous treatments from an average of
nearly three different agencies during the previous
month is excessive. Depending on the nature and
complexity of the child/family’s problems, receiving
multiple treatments from multiple agencies may be
warranted. However if families are receiving treat-
ments from more than one agency for the same or a
similar problem, treatment effectiveness is likely
decreased, and family burden and costs increased.
Parents did not want just over one quarter of the
treatments offered to them due to reasons other than
logistical barriers. Neither a sub-group of parents, nor
a specific treatment, accounted for the high percentage
of parents who did not want the treatments offered.
Interestingly, the majority of parents who did not want
treatments still accepted the treatment that was
offered. Parents who accepted these treatments could
be demonstrating flexibility in that they were prepared
to try treatments they did not initially want, or they
could have been so frustrated that they were willing to
take whatever help was offered. Treatment engage-
ment and compliance are likely compromised for the
latter parents. Parents who accept a treatment regime
they do not want would be less likely to comply and
more likely to drop-out (Kazdin, Holland, & Crowley,
1997). They may also continue to seek alternative
treatments. This is not to suggest that agencies should
only offer what parents what. Parents often have their
own theory about what is needed to ‘fix’ their child’s
aggression, non-compliance, poor school achievement,
etc. However, professional assessment and subsequent
treatment planning should result in the most effective
treatment for child problems. Such treatment planning
needs to incorporate parental perceptions on what
might resolve their child’s problem. These data high-
light the challenge that many agencies face of helping
parents to develop a more comprehensive understand-
ing of the multiple influences on the development and
resolution of their child’s problems and to encourage
an active role in resolving these problems.
The basis of parents’ acceptance or rejection of
treatment needs further study. Parent attributions
about their child’s problems, and related expectations
that treatment should be child focused, have been
examined in relation to treatment engagement in a few
studies [see (Morrissey-Kane & Prinz, 1999) for a
review]. Our data suggest the need to examine the
broader notion of how parents conceptualize the cause,
development and maintenance of their child’s problem
(e.g., biological factors, parent, family, peer influences)
and its relation to their help-seeking strategies and
treatment acceptance.
Limitations
There are a number of limitations to this study. First,
parents were recruited from one intake service for
three children’s mental health centers that tend to
focus on externalizing behaviour problems. Therefore,
children with externalizing problems are likely over-
represented beyond the general tendency that these
children receive treatment more often than those with
internalizing problems.
Second, the sample was obtained from a mid-sized
city in Ontario that has multiple service options.
Results would vary for rural populations and areas
with fewer service options. They would also differ in
United States for families that have insurance that
covers both medical and psychological treatment. In
Canada, only families with private health insurance
benefits or high incomes tend to access private
psychologists, and extended health insurance often
covers only a fraction of the actual costs (Hunsley, Lee,
& Aubry, 1999).
Third, data were obtained only from parents. Studies
examining issues such as presenting problems have
compared child, parent and therapist ratings of pre-
senting problems (Yeh et al., 2001). Similar data cannot
be obtained in relation to help-seeking as many times
parents have only limited contact with a specific agency
or professional. For example, they call looking for help
only to be told that the agency contacted does not offer
the services that parents are looking for, the child/
family does not meet the agency criteria due to child
age, or because they live outside the agency’s catch-
ment area. Similarly, relying on parent report only does
not capture the added complexity of seeking help for
adolescents. Although the majority of time parents are
involved in seeking help for their teenage children,
adolescents may self-refer and they can have greater
input in accepting or rejecting the treatment options
that parents identify. The focus on parents is, however,
appropriate given that parental perceptions including
factors such as perceived burden are the strongest
predictions of help seeking (Angold et al., 1998).
Fourth, a minority of families who called the intake
service during the study period participated. We were
unable to compare our sample to entire sample of
potentially eligible participants as intake staff only
record descriptive information for parents who will be
receiving help from the centers. It is possible that the
123
144 Adm Policy Ment Health (2008) 35:135–146

demographics of non-respondents differed from the
demographics of this sample.
Fifth, a number of analyses comparing subgroups
within the sample would be informative (i.e., compar-
ing the data from parents who have accessed services
for more than 1 year with parents who have accessed
services for less than 1 year; comparing parents of
children with more severe problems with parents of
children with less severe problems). Given the sample
size of 60, the authors did not want to conduct analyses
on subsets of the data that were too small for
meaningful comparisons. It would be beneficial to
examine such issues in future research with larger
samples.
In conclusion, despite the limitations, the study
supports the need to understand help-seeking path-
ways as part of our knowledge of mental health care
utilization and ways to improve accessibility and
effectiveness of mental health care (Rogler & Cortes,
1993). A study utilizing community-sampling (Farmer
et al., 2003) would be better able to document service
paths in general and to confirm a particular help-
seeking model. However, our data suggests that linear
help-seeking processes involving problem recognition,
the decision to seek help, seeking help and then
receiving help, disregard the iterative referral process
that many parents face and do not fully describe how
parents interact with services that provide mental
health care to children. Accurately describing help-
seeking pathways for children’s mental health care is a
precursor to implementing and evaluating system
change (Morrissey, 1982).
The network-based model of access to children’s
mental health services (Costello et al., 1998) and the
gateway provider model (Stiffman et al., 2004) have
begun to capture the complexity of accessing mental
health care for children. These models can now be
extended to include not only how parents enter the
children’s mental health system, but also how parents
navigate between the various services. This would
begin to capture the iterative referral process that
many parents are experiencing.
Acknowledgments D.C. Shanley was supported by a Canadian
Institutes of Health Research Doctoral Research Award and
G.J. Reid was supported as the Bill and Anne Brock Professor in
Child Health. This manuscript is based on a thesis submitted in
partial fulfillment of a Masters in Clinical Psychology to the
University of Western Ontario. Portions of this manuscript have
been presented at the Trillium Primary Care Research Forum,
Toronto, Ontario, June, 2002, the Annual meeting of the
Canadian Psychological Association, Hamilton, Ontario, June,
2003, and the Annual meeting of the American Psychological
Association, Toronto, ON, August, 2003. We are much indebted
to the help of the intake staff at the participating children’s
mental health centers who identified participants for the project.
Thanks are also extended to Dr. Judith Belle Brown, Dr. David
Wolfe, and Dr. Rod A. Martin, who were members of the
Examining Board for the Masters thesis, to Dr. Charles
Cunningham for his assistance with the Brief Child and Family
Phone Interview (BCFPI) and to Kelly Quinnell who assisted
with the coding of parent interviews.
References
Andersen, R. & Newman, J. F. (1973). Societal and individual
determinants of medical care utilization in the United
States. The Milbank Memorial Fund quarterly. Health and
society, 51, 95–124.
Angold, A., Costello, E. J., Farmer, E. M., Burns, B. J., &
Erkanli, A. (1999). Impaired but undiagnosed. Journal of the
American Academy of Child and Adolescent Psychiatry, 38,
129–137.
Angold, A., Messer, S. C., Stangl, D., Farmer, E. M., Costello, E.
J., & Burns, B. J. (1998). Perceived parental burden and
service use for child and adolescent psychiatric disorders.
American Journal of Public Health, 88, 75–80.
Benway, C. B., Hamrin, V., & McMahon, T. J. (2003). Initial
appointment nonattendance in child and family mental
health clinics. American Journal of Orthopsychiatry, 73,
419–428.
Boyle, M. H., Offord, D. R., Racine, Y., Fleming, J. E., Szatmari,
P., & Sanford, M. (1993). Evaluation of the revised Ontario
Child Health Study scales. Journal of Child Psychology and
Psychiatry, and Allied Disciplines, 34, 189–213
Burns, B. J., Costello, E. J., Angold, A., Tweed, D., Stangl, D., &
Farmer, E. M. et al. (1995). Children’s mental health service
use across service sectors. Health Affairs (Millwood.), 14,
147–159
Costello, E. J., Angold, A., Burns, B. J., Erkanli, A., Stangl, D.
K., & Tweed, D. L. (1996). The great smoky mountains
study of youth: Functional impairment and serious emo-
tional disturbance. Archives of General Psychiatry, 53, 1137–
1143
Costello, E. J., Burns, B. J., Angold, A., & Leaf, P. J. (1993).
How can epidemiology improve mental health services for
children and adolescents? Journal of the American Academy
of Child and Adolescent Psychiatry, 32, 1106–1114
Costello, E. J., Pescosolido, B. A., Angold, A., & Burns, B. J.
(1998). A family network-based model of access to child
mental health services. Research in Community and Mental
Health, 9, 165–190
Cunningham, C. E., Pettingill, P., & Boyle, M. (2000). Brief child
and family phone interview: Interviewers manual. Hamilton,
ON: Canadian Centre for the Study of Children at Risk,
Hamilton Health Sciences Corporation, McMaster University
Farmer, E. M., Burns, B. J., Phillips, S. D., Angold, A., &
Costello, E. J. (2003). Pathways into and through mental
health services for children and adolescents. Psychiatric
Services, 54, 60–66
Farmer, E. M., Stangl, D. K., Burns, B. J., Costello, E. J., &
Angold, A. (1999). Use, persistence, and intensity: Patterns
of care for children’s mental health across one year.
Community Mental Health Journal, 35, 31–46
Fischer, E. H., Weiner, D., & Abramowitz, S. (1983). Seeking
professional help for psychological problems. In A. Nadler,
J. D. Fisher, & B. M. DePaulo (Eds.), New directions in
helping, Vol. 3: Applied perspectives in help-seeking and
receiving (pp. 163–212). New York: Academic Press.
123
Adm Policy Ment Health (2008) 35:135–146 145

Gurin, G., Veroff, J., & Feld, S. (1960). Americans view their
mental health. New York: Basic Books
Hunsley, J., Lee, C. M., & Aubry, T. (1999). Who uses
psychological services in Canada? Canadian Psychology,
40, 232–240
Kazdin, A. E., Holland, L., & Crowley, M. (1997). Family
experience of barriers to treatment and premature termi-
nation from child therapy. Journal of Consulting and
Clinical Psychology, 65, 453–463
Landgraf, J. M., Abetz, L., & Ware, J. E. (1996). Child health
questionnaire (CHQ): A user’s manual (1 ed.) Boston, MA:
The Health Institute, New England Medical Center
Lavigne, J. V., Arend, R., Rosenbaum, D., Binns, H. J.,
Christoffel, K. K., & Burns, A. et al. (1998). Mental health
service use among young children receiving pediatric
primary care. Journal of the American Academy of Child
and Adolescent Psychiatry, 37, 1175–1183
Leaf, P. J., Alegria, M., Cohen, P., Goodman, S. H., Horwitz, S.
M., & Hoven, C. W. et al. (1996). Mental health service use
in the community and schools: Results from the four-
community MECA study. Methods for the epidemiology of
child and adolescent mental disorders study. Journal of the
American Academy of Child and Adolescent Psychiatry, 35,
889–897
Logan, D. E. & King, C. A. (2001). Parental facilitation of
adolescent mental health service utilization: A conceptual
and empirical review. Clinical Psychology: Science and
Practice, 8, 319–333
Morrissey, J. P. (1982). Assessing interorganizational link-
ages—toward a systems analysis of community support
programs at the local level. In R. C.Tessler & H. H.
Goldman (Eds.), The chronically mentally ill: Assessing
community support programs (pp. 159–191). Cambridge,
MA: Ballinger Publishing Company
Morrissey-Kane, E. & Prinz, R. J. (1999). Engagement in child
and adolescent treatment: the role of parental cognitions
and attributions. Clinical Child and Family Psychology
Review, 2, 183–198
Offord, D. (1998). Charting the mental health status and service
needs of children: Report from the UNOCCAP oversight
board to the national advisory mental health council.
Rockville, MD: National Institute of Mental Health
Offord, D. R., Boyle, M. H., Fleming, J. E., Blum, H. M., &
Grant, N. I. (1989). Ontario child health study. Summary of
selected results. Canadian Journal of Psychiatry, 34, 483–491
Offord, D. R., Boyle, M. H., Szatmari, P., Rae-Grant, N. I.,
Links, P. S., Cadman, D. T. et al. (1987). Ontario child
health study. II. Six-month prevalence of disorder and rates
of service utilization. Archives of General Psychiatry, 44,
832–836
Pavuluri, M. N., Luk, S. L., & McGee, R. (1996). Help-seeking
for behavior problems by parents of preschool children: A
community study. Journal of the American Academy of
Child and Adolescent Psychiatry, 35, 215–222
Rawlinson, S. & Williams, R. (2000). The primary/secondary
care interface in child and adolescent mental health services:
The relevance of burden. Current Opinion in Psychiatry, 13,
389–395
Rogler, L. H. & Cortes, D. E. (1993). Help-seeking pathways: A
unifying concept in mental health care. American Journal of
Psychiatry, 150, 554–561
Sayal, K., Taylor, E., Beecham, J., & Byrne, P. (2002). Pathways
to care in children at risk of attention-deficit hyperactivity
disorder. The British Journal of Psychiatry, 181, 43–48
Srebnik, D., Cauce, A. M., & Baydar, N. (1996). Help-seeking
pathways for children and adolescents. Journal of Emotional
and Behavioral Disorders, 4, 210–220
Stiffman, A. R., Pescosolido, B., & Cabassa, L. J. (2004).
Building a model to understand youth service access: The
gateway provider model. Mental Health Services Research, 6,
189–198
Stiffman, A. R., Striley, C., Horvath, V. E., Hadley-Ives, E.,
Polgar M., & Elze, D. et al. (2001). Organizational context
and provider perception as determinants of mental health
service use. The Journal of Behavioral Health Services and
Research
28:188–204
Verhulst, F. C. & Van der, E. J. (1997). Factors associated with
child mental health service use in the community. Journal of
the American Academy of Child and Adolescent Psychiatry,
36, 901–909
Yeh, M. & Weisz, J. R. (2001). Why are we here at the clinic?
Parent-child (dis)agreement on referral problems at outpa-
tient treatment entry. Journal of Consulting and Clinical
Psychology, 69, 1018–1025
123
146 Adm Policy Ment Health (2008) 35:135–146

Reproducedwithpermissionofthecopyrightowner.Furtherreproductionprohibitedwithoutpermission.