health "need" in children and what is known about their service utilization patterns are provided. Then, a model for the study of children's help-seeking pathways ...
Help-Seeking Pathways for Children and Adolescents
DEBRA SREBNIK, ANA MARI CAUCE, AND NAZLI BAYDAR
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society's views of children's mental health needs have changed: Instead of being seen as a subset of adult needs, they are now considered a topic of concern in their own right (see Note). For example, the Diagnostic and Statistical Manual for Mental Disorders has evolved from the initial version that described disorders of adults only (and assuming that children's disorders were manifested similarly) to the most current one, which incorporates disorders specific to children. In a similar vein, health-care and mental healthcare delivery systems traditionally served children by using the same modalities as for adults, with slight modifications. More recently, treatment methods and specialized agencies have developed that are tailored to mental health services for children. Underlying such trends have been several movements that have begun to make clear the need to study children, including (a) the emerging field of developmental psychopathology, which has demonstrated that illness manifestations are influenced by a variety of factors interacting over time and age (Cicchetti, 1990); (b) the Child and Adolescent Service System Program (CASSP; Stroul & Friedman, 1986), which has prompted the development of individualized mental health services JOURNAL
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The processes by which children with emotional and behavioral disorders seek and obtain help have received little study; yet, they are critical for determining mental health policy and practice. In this article, help-seeking pathways for children are defined and a pathway model is presented. Influences on help-seeking pathways are then reviewed, including illness profile variables, predisposing factors, and barriers to and facilitators of care. Research targets such as the role of informal supports, collateral services, and cultural influences on help-seeking are recommended. Methodological considerations are presented that include assessment of clinically defined mental health need as well as subjective assessment of need, use of complementary qualitative and quantitative methods, and use of crosssystem data. The implications for practice and policy of research on help-seeking pathways are described.
coordinated with existing child-serving systems (e.g., child protective services, child welfare, schools, developmental disabilities); (c) research suggesting that children may enter the service system through a variety of pathways (Barker & Adelman, 1994; Saunders, Resnick, Hoberman, & Blum, 1994); and (d) preliminary studies of childhood psychiatric epidemiology (Brandenburg, Friedman, & Silver, 1990; Koot & Verhulst, 1992; Offord et al., 1987). These efforts have culminated in the initiation of the first large-scale studies of the epidemiology of child psychiatric disorders and service needs, funded by the National Institute of Mental Health. Given the growing awareness of the importance of studying the mental health problems of children and subsequent service and support responses, it is a particularly good moment to provide a summary of the research on BEHAVIORAL
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children's help-seeking activities. For children, help-seeking can be defined as seeking assistance from mental health services, other formal services, or informal support sources for the purpose of resolving emotional or behavioral problems. Help-seeking efforts can be made by children themselves or by their parents. Research on help-seeking has traditionally focused on estimation of mental health-service use exclusively. From a policy perspective, however, it is important to develop an understanding of the process by which children seek and obtain mental health services, as well as other services and supports to address emotional and behavioral problems. Studying help-seeking pathways begins to address this issue. What do we know about help-seeking for children with emotional and behavioral problems? And, what do we need to know? In answering these questions, we VOL.
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will note gaps in the research and suggest new questions worthy of exploration. In this article, estimates of emotional and behavioral problems or mental health "need" in children and what is known about their service utilization patterns are provided. Then, a model for the study of children's help-seeking pathways is presented. This model is based on extant adult help-seeking models; however, it is adapted to incorporate the family context within which children's help-seeking occurs. Within the model's framework we review the empirical support for variables associated with help-seeking, primarily helpseeking to formal mental health services. Finally, areas for further research are suggested and relevant methodological, practice, and policy considerations are noted.
MENTAL HEALTH NEED AND SERVICE USE FOR CHILDREN Estimates of Need Researchers have defined the presence of a mental health need in various ways, including receipt of services, meeting criteria for psychiatric diagnosis, psychiatric diagnosis plus functional impairment, and exposure to risk factors for psychiatric disturbance (Costello, Burns, Angold, & Leaf, 1993). Receipt of service is only appropriate as an indicator of need if one assumes that all children in need receive mental health services, a prospect that is highly unlikely. In contrast, using exposure to risk factors for illness as a definition of mental health need is likely to be overly inclusive. Most commonly, mental health need is defined as clinically assessed psychiatric diagnosis and/or functional impairment. Unmet need can then be defined as the difference between assessed need and service utilization. Estimates based on cross-sectional community samples of children suggest that between 14% and 20% experience some emotional or behavioral disorder as indicated by meeting criteria for a JOURNAL
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psychiatric diagnosis (Bird et al., 1988; Brandenburg et al., 1990; P. Cohen & Hesselbart, 1993; Costello, 1989; Zahner, Pawelkiewicz, DeFrancesco, & Adnopoz, 1992), and 4% to 16% show some functional impairment or are considered to be more seriously emotionally disturbed (SED; Bird et al., 1988; Knitzer, 1982; Trupin, Low, ForsythStephens, Tarico, & Cox, 1988). The rate of serious emotional disturbance has been shown to vary widely by ethnicity, from less than 2% to 18% (Trupin et al., 1988). There is a critical distinction between clinically assessed mental health need and subjective perception of need (Costello et al., 1993; Goldsmith, Jackson, & Hough, 1988; A. Horwitz, 1987). The construct of subjective perception of need has had little study. However, discomfort, as perceived by the individual, is often different from more "objectively" assessed need and may also be a stronger predictor of mental health problem recognition and help-seeking than the nature of the symptoms themselves (Costello & Janiszewski, 1990; Goldsmith et al., 1988; A. Horwitz, 1987; Kellam, Branch, Brown, & Russell, 1981). Furthermore, children and their families may have their own understanding about diagnoses, level of impairment, and the extent of behavior problems. These perceptions may differ from those of clinicians or other observers. Nonetheless, there is no commonly accepted estimate of subjective mental health need for children, and little is known about the relation between clinically assessed need and subjective perception of need, and their individual and conjunctive impact on help-seeking. Service Utilization and "Unmet" Need Similar to defining mental health need, service utilization definitions vary in breadth, based on whether or not they include services provided in settings other than mental health centers. Of those children in need of mental health services as defined by the presence of psychiatric diagnosis, approximately 6%
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to 10% receive services in mental health settings (Burns, 1991; Knitzer, 1982; Koot & Verhulst, 1992; Offord et al., 1987). If we assume that unmet need is the difference between assessed need and utilization of formal mental health services, the small proportion of children receiving such services represents considerable unmet need. However, two to five times as many children are considered to be service recipients when mental health services provided in other service sectors, such as primary care and schools, are considered (Costello, 1989; S. Horwitz, Leaf, Leventhal, Forsyth, & Speechley, 1992; Morissey & Schott, 1990). Some researchers have suggested that the highest rate of service contact for children's emotional and behavioral problems is within the school setting (Koot & Verhulst, 1992; Zahner et al., 1992). Child welfare agencies have also been shown to play a significant role in the provision of mental health service (Kellam et al., 1981; Knitzer, 1982). Primary health care, education, and child welfare systems may all be critical path points into mental health services for children, and they may also provide such services. Examination of services across the range of social service sectors is therefore needed to obtain reasonable estimates of utilization (Costello et al., 1993) and to truly capture the nature of help-seeking pathways. Service utilization varies by ethnicity. For example, compared to White children, African American children are more likely (P. Cohen & Hesselbart, 1993; Costello & Janiszewski, 1990), and Latino, Asian American, and Native American children are less likely (Bui & Takeuchi, 1992) to receive mental health treatment. Some evidence also suggests that ethnic minority children with serious emotional disturbance (SED) are more apt to end up in the juvenile justice or child welfare systems than in a mental health setting (Comer & Hill, 1985; Hawkins & Salisbury, 1983; Shore, 1978). Still, there is no database to draw upon that would help us understand if these differential usage patterns are due to differential need, greater reliance on informal supports, problems with accesOCTOBER
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sibility, or differential referral patterns. Furthermore, most studies examining ethnic patterns of service utilization limit their estimates of utilization to the public mental health system and report these based on parity of the ethnic group in proportion to the demographic characteristics of the broader community. This ignores the use of other service systems (e.g., private mental health, school services) and ignores potential differences in actual prevalence of emotional and behavioral disorders (Meinhardt&Vega, 1987). Children seen by various service sectors (e.g., juvenile justice, substance abuse, child welfare) demonstrate comparable mental health needs (R. Cohen et al., 1990; Trupin, Tarico, Low, Jemelka, & McClellan, 1993). Clinical comorbidity of psychiatric symptoms, delinquency, substance abuse, school problems, and child abuse and neglect history can provide a partial explanation for the cross-system service utilization of many children. However, because unduplicated counts of service utilization across sectors (e.g., mental health, juvenile justice, the school system) are seldom available, little is known about the links between comorbidity and single or multiple service usage. In fact, there is little detailed information available about such straightforward issues as what services are provided across service sectors and what the characteristics of these services and the populations they serve are (Costello et al., 1993). In sum, there appears to be a substantial gap between the number of children estimated to have mental health needs and the number who actually receive services across the range of service sectors. More information is needed about the nature of this gap and what can be done to bridge it. Further, the extent to which informal supports supplement or serve in place of formal services has not been examined. INFLUENCES ON HELP-SEEKING PATHWAYS A useful framework for understanding and organizing information about factors affecting help-seeking for mental health concerns is Goldsmith et al.'s (1988) JOURNAL
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reformulation of Anderson and Newman's (1973) help-seeking model. This model describes stages along a helpseeking pathway and factors associated with movement through the stages. The stages include problem recognition, decision to seek help, and support and service utilization. Movement along these stages is associated with illness profile variables, predisposing factors, and barriers and facilitators to care. A model adapted for children that shows the hypothesized directions of effect of these influences on stages in the helpseeking pathway is presented in Figure 1. Pescosolido (1992) commented that help-seeking has often been defined as an individual's rational decision about whether or not to seek out the assistance of a mental health professional. As an alternative, she proposed that action toward help-seeking is embedded in the social network and that network interactions influence identification of a problem as well as what should be done about the problem. Further, help-seeking is a process, involving a series of decisions, rather than a single, planned choice. People tend to continue to seek advice regarding a problem from a range of informal sources of support (e.g., family, friends, coworkers); ethnic/traditional healers (e.g., clergy, curanderos [folkhealers]); collateral service providers (e.g., physicians, teachers); and mental health professionals until a resolution is found or all options are exhausted. A help-seeking episode for children can thus be defined as the pattern of interactions with network members over time intended to resolve an emotional or behavioral problem (Rogler & Cortes, 1993). Although individuals are likely to have unique help-seeking episodes, some episode patterns may be discernible. It is these patterns that are the subject of study; the elements can be predicted by variables included in the illness profile, predisposing factors, and barriers or facilitators of care. Although possible directions of effect are suggested by the model, each set of help-seeking influences are likely to be concurrently interrelated and temporally related. BEHAVIORAL
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To adapt a help-seeking model for children, it must be recognized that (a) children rarely seek help on their own, and (b) less than 20% of those who do seek help go to mental health service providers. However, many more children contact members of their social network for assistance (Cheung, 1984; Offer, Howard, Schonert, & Ostrov, 1991; Rickwood & Braithwaite, 1994), particularly parents and family members. Use of informal sources of support may be even more pronounced for some ethnic/cultural groups (Narikiyo & Kameoka, 1992; Suan & Tyler, 1990). When adolescents seek formal services for mental health problems, schoolbased services or medical personnel are seen most often (Barker & Adelman, 1994). Physician contact may in fact increase the probability that adolescents will obtain professional mental health care (Saunders et al., 1994). Parents also generally make some network contacts after attempting to resolve their child's problem on their own and prior to seeking formal treatment. Frequently, these contacts are with teachers (P. Cohen, Kasen, Brook, & Struening, 1991; Pottick, Lerman, & Micchelli, 1992). Clearly, the range of informal sources of support, mental health professionals, and collateral formal services must be included in a help-seeking model for children. Illness Profile The illness profile includes clinically assessed need and subjectively assessed need (e.g., Costello et al., 1993; A. Horwitz, 1987). Understanding the relationship of these two perspectives will improve our understanding of the reasons underlying the extent of unmet need as well as of the early stages of help-seeking pathways (Goldsmith et al., 1988). Clinical Assessment of Need. Aspects of a clinical assessment of need such as symptoms, diagnosis, and functional impairment are likely to be related directly to problem recognition (i.e., the first stage of the help-seeking pathway). Clinical symptoms have been VOL.
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STAGES IN THE HELP-SEEKING PATHWAY
ILLNESS PROFILE Clinical assessment of need (child & parent/family) - disability/role functioning, symptoms/behaviors, diagnoses Perceived (subjective) need (child and parent/family) - well being, disability/role functioning, symptoms/behaviors - definition of behavior as a mental health concern Family characteristics - Structural - family size - parental education - Relational - warmth, cohesion, dis/organization, family/marital conflict - abuse/neglect, parental psychopathology, criminality
Problem recognition
PREDISPOSING CHARACTERISTICS Demographic characteristics - age, gender, ethnicity Sociocultural values/beliefs (child and parent/family) - values/attitudes/knowledge concerning health and illness - ethnic identity, acculturation - help-seeking desirability (e.g., scientific orientation) - coping strategies - religion
Decision to seek help
BARRIERS/FACILITATORS Community and social networks - residential mobility - network strength, helpfulness, openness to outsiders, knowledge about and use of services - congruence of network attitudes toward use of services Support network and service utilization patterns - Informal support network - Ethnic/traditional service providers - Collateral service providers - Mental health service providers
Economic factors - income, health insurance Service characteristics - availability per population base - access (hours, physical access, daycare, location) - organization (e.g., staffing, programming available) - attitudes of providers Policy - federal, state, and local health-care policy - eligibility requirements - financing methods and incentives
FIGURE 1. Youth help-seeking and service utilization model. (Adapted from Aday et al., 1993; Anderson & Newman, 1973; and Goldsmith et al, 1988.) JOURNAL
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shown to be a powerful predictor of help-seeking for adults and children, and symptom severity discriminates children who obtain formal mental health services from those who obtain it from informal support network sources alone (e.g., Freeman et al., 1992; Rickwood & Braithwaite, 1994). One study showed that restrictions in functioning predicts obtaining formal mental health services over and above clinical severity alone (Robbins & Greenley, 1983). It may be that impairment of role functioning increases the likelihood that a problem will be recognized (e.g., Leaf et al., 1985). Because children seldom initiate their own treatment, recognition of problems by others is critical to helpseeking. Subjective Assessment of Need. Researchers suggest that subjectively perceived need may be related to problem recognition and, ultimately, to helpseeking behavior (Costello & Janiszewski, 1990). To obtain services from a mental health provider, the individual must perceive the problem as a mental health concern. To the extent that the problem is defined as something other than a mental health concern, individuals may seek and obtain services from other providers (e.g., physician, clergy, etc.; Goldsmith et al., 1988; A. Horwitz, 1987). For example, poor school performance may be interpreted as a lack of interest in the subject matter or a symptom of depression. Problem identification and interpretation by parents, particularly mothers, is critical to determining help-seeking and service selection (Burns, Angold, & Costello, 1992; Combs-Orne, Kager, & Chernoff, 1991). Although clinicians often readily interpret behavior problems in terms of mental health symptoms, parents are only likely to do so when such problems have an impact on functioning (e.g., truancy, school problems) or overall well-being (Pottick et al., 1992). Family Characteristics* To adapt extant models to be more appropriate for the unique circumstances of children, one needs to include family characteristics related to family structure and JOURNAL
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the help-seeking literature is the consistency with which gender differences are reported. The finding that women show more positive attitudes toward help-seeking for psychological problems has been demonstrated for adults (Fisher & Cohen, 1972; Kessler, Brown, & Broman, 1981), adolescents (Garland & Zigler, 1994), and children (Barnett et al., 1990). This finding persists even after controlling for symptom severity (Rickwood & Braithwaite, 1994). Adolescent girls are also more likely than boys to report the need for professional help with problems; however, gender differences may disappear with respect to actually obtaining such help once identification of need for help is controlled (Saunders et al., 1994). As such, it is hypothesized that gender differences in help-seeking are related to willingness to identify internal states and problems as mental health concerns necessitating help (A. Horwitz, 1977; Kessler et al., 1981; Saunders et al., 1994). Recognition of behaviors as symptoms of a mental disorder in children can be strongly related to age and development (e.g., Clark, Smith, Neighbors, & Skerlec, 1994). The same behaviors can be viewed as problematic or not, depending on age. For example, bedwetting in a 2-year-old generally would not be considered problematic; thus, assistance in altering the behavior would not be sought by a parent. However, the same behavior in an 8-year-old would probably prompt a parent to seek more likely to self-identify having a problem help. In addition, older adolescents have warranting professional help, although attained the social and cognitive dethese variables did not predict help- velopment necessary to self-identify seeking behavior (Saunders et al., 1994). problems and make help-seeking decisions, whereas young children must act out emotional problems behaviorally Predisposing Factors and have others identify problems and Predisposing characteristics are stable initiate help-seeking. conditions of an individual that influDetermining the effect of ethnicity ence one's readiness to seek help. Demo- on help-seeking is a complex endeavor. graphic characteristics and sociocultural As discussed, the research findings on values and beliefs are incorporated into rates of mental health service utilizathis model as predisposing characteris- tion vary by ethnicity (Bui & Takeuchi, tics. 1992; P. Cohen & Hesselbart, 1993; Costello & Janiszewski, 1990). This may Demographic Characteristics* be due in part to differences in assessed One of the most prominent findings in need among various ethnic groups
relations in the illness profile. These characteristics can affect both clinical interpretation of children's symptoms and a caregiver's recognition and reporting of symptoms and functioning. A variety of structural and relational factors (e.g., marital or family conflict, family disorganization, large family size) may affect the extent to which a particular child's problem is visible and identified by caregivers. For example, if parents are preoccupied with marital conflict, they may not attend to the behaviors of their children. Low parental education, parental psychopathology or criminality, and abuse or neglect may also influence the degree to which caregivers interpret behaviors as deviant or problematic. It is also possible that parents whose problem-solving strategies for their children's misbehavior involve physical punishment may be less concerned if their children act out aggressively. Similarly, parents who have not valued education for themselves may not view poor academic achievement in their children as a problem in need of intervention, much less as a potential mental health intervention. Along these lines, in one study it was reported that low parental education lessens the probability that adolescents will ultimately receive professional mental health care when in need (Saunders et al., 1994). However, the same study showed that adolescents who had a family member attempt or complete suicide, who perceived little parental caring, or who were abused were
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(Meinhardt & Vega, 1987; Trupin et al., 1988). It is also possible that ethnicity directly influences problem recognition or points further on in the help-seeking pathway. However, ethnicity is a biopsychosocial construct, and, as such, the effect of ethnicity per se on help-seeking pathways is difficult to isolate relative to sociocultural values, beliefs, and coping styles, as well as community and social network characteristics. A discussion of these interrelated influences follows. Sociocultural Values and Beliefs. It is recognized that sociocultural values of children and their families affect the experience of illness, perception and definition of the problem, beliefs about the desirability of mental health symptoms, the manifestation of symptoms, and methods of coping—including whether or not to obtain help and from whom (Rogler & Cortes, 1993). For example, help-seeking behavior is thought to occur only if symptoms are seen as highly culturally undesirable, thus making such help-seeking more desirable (Rogler & Cortes, 1993). Also, to the extent an individual identifies with ethnic/cultural attitudes and values inconsistent with help-seeking (e.g., exposing problems will shame the family, stigma of having personal problems or seeking help), they may be reluctant to seek help (Narikiyo & Kameoka, 1992). Having a scientific orientation (i.e., believing in the effectiveness of science and health practitioners) rather than fatalism or belief in a cure through magic or religion is also thought to be related to help-seeking behavior (Goldsmith et al., 1988). In addition, the importance of the cultural context for immigrants and refugees—such as their country of origin, ethnic diversity of settlement community, acculturation, and ethnic identity (Portes, Kyle, & Eaton, 1992; Ying & Miller, 1992)— have been suggested as influences on help-seeking attitudes and behavior. It may be hypothesized, for example, that increased acculturation would be associated with greater help-seeking from formal mental health providers. Similarly, the extent to which immigrants JOURNAL
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remain isolated from mainstream U.S. culture may decrease their probability of formal mental health service utilization. There is little information linking this developing knowledge base to the known differential rates by ethnicity of help-seeking of formal mental health services. Coping strategies represent methods used to solve problems. As such, coping styles and strategies should be related to problem recognition and help-seeking (Goldsmith et al., 1988). If caregivers used primarily denial or emotion-focused coping strategies, we would expect them to be less likely to seek help than if they employed problem-focused strategies. For example, one study found that attributing problems to stable, internal dispositional causes predicted formal mental health service utilization (Robbins, 1981). Also, individuals who closely monitor their internal feeling states (Rickwood & Braithwaite, 1994) and who are open to confiding in others about their mental health problems (Freeman et al., 1992; Rickwood & Braithwaite, 1994; Tijhuis, Peters, & Foets, 1990) may be more likely to seek help more generally. Although religion could be construed as a subtopic of coping strategies, there may be a separate relationship between religion and help-seeking. For example, some religions have proscriptions against seeking external help for problems, whereas others may actively encourage members to obtain such help. In one study, for example, it was found that Jewish people were more likely than either Catholics or Protestants to seek help for psychological problems (Yeung & Greenwald, 1992).
Barriers and Facilitators Barriers to and facilitators of helpseeking are social and environmental pressures that can occur at the individual, community, or broader political level. The model suggests inclusion of community and social network characteristics, economic factors, service characteristics, and policy issues as potential external influences on help-seeking.
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Community and Social Network Characteristics. When children and families experience mental health problems, mental health-care providers are seldom the first to hear about it (P. Cohen et al., 1991; Pottick et al., 1992). Pathways to help-seeking and service utilization occur within the context of the child and family's community and social networks, which include a range of informal consultants, extended family members, native/religious healers and friends, mental health professionals, and collateral service providers (Cauce & Srebnik, 1990). Network contacts are part of the help-seeking pathway itself— affecting recognition of the problem, the decision to seek help, and the type of help sought (Goldsmith et al., 1988). For example, a parent's neighbor or friend may identify a child's behavior problem and point it out to the parent. Such an individual could also recommend that the parent seek more formal mental health services for the child. Network members themselves may also play a role in providing help, particularly in the provision of informal advice and guidance. However, residential mobility of families and their networks can limit the extent to which strong network ties can be developed, potentially lessening their impact on the helpseeking process. Community and social networks can facilitate or inhibit help-seeking, depending on their characteristics. For example, network member attitudes toward services and their knowledge and use of services can affect help-seeking. For example, adolescents who seek assistance from family members and who know someone who has received mental health services increase their likelihood of obtaining professional help (Rickwood & Braithwaite, 1994; Saunders et al., 1994; Tijhuis et al., 1990). On the other hand, when symptoms are culturally acceptable, they may not prompt network members to make referrals to more formal treatment (Alegria et al., 1991). When networks are very closeknit and insular, such norms regarding help-seeking and service utilization are stronger. To the extent network contacts themselves prove helpful in solvOCTOBER
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ing the identified problems, children and their families may not seek further assistance from formal services. Particularly strong and interlocking social/ familial network ties can delay or deter individuals from seeking formal mental health services because their needs are being met within the network (A. Horwitz, 1987; McKinlay, 1973). Some research suggests, for example, that ethnic minorities have a higher attrition rate from formal services, which could in part be related to a greater reliance on informal sources of support (Lin, Inui, Kleinman, & Womack, 1982; Sue & Zane, 1987). Economic Factors. Researchers have suggested that a curvilinear model best describes the relationship between socioeconomic status (SES) and formal mental health service utilization (P. Cohen & Hesselbart, 1993; Koot & Verhulst, 1992). Children from very low or very high SES backgrounds are more likely than others to utilize mental health services. This pattern has been attributed, in part, to greater access to health insurance (i.e., Medicaid or private insurance). Indeed, investigators have shown that when insurance copayments are increased and/or coverage reduced, utilization decreases (Patrick, Padgett, Burns, Schlesinger, & Cohen, 1993).
Service Characteristics. Poor availability of services is a clear systemslevel barrier to formal mental health care, just as an inadequate social network is a barrier to informal support. Additional barriers to formal services can include lack of transportation, long waiting lists, inflexible hours, lack of childcare, and distance to services (Combs-Orme et al., 1991; Goldsmith et al., 1988). The types of programming available at service centers may also serve as barriers to or facilitators of care. For example, a poor match between services and a family's language and/or culture can inhibit service use (Meinhardt & Vega, 1987; Sue, 1988). Although some noteworthy attempts to JOURNAL
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improve the cultural sensitivity of services have been made (O'Sullivan, Peterson, Cox, & Kirkeby, 1989; Sue, Fujino, Hu, Takeuchi, & Zane, 1991), there is still a long way to go toward the creation of a culturally competent system of care. Attitudes of professionals can also become a barrier to service use, particularly when these attitudes are at odds with family beliefs. For example, professionals often attribute family's nonattendance at services or underutilization of the services to family resistance, but the families perceive the problem in terms of systems barriers (Trupin et al., 1993). These different perspectives can create a situation in which there is little motivation for either professionals or family advocates to address barriers to care. Policy. Local, state, and federal health-care policy issues that alter eligibility for and access to services (e.g., mandates for care, integration of care) can affect formal mental health service utilization (Combs-Orme et al., 1991). Health-care reform efforts and managed care initiatives also influence the ease with which individuals can enter the service system as well as the amount and types of services (e.g., home-based) they may seek and receive. Financing of services, often directed by policy decisions, can similarly affect eligibility and amount and type of available services. Capitation plans, for example, pay providers based on the population size they will "cover" (i.e., commit to providing a minimum level of service). As such, incentives exist to cover a large population. Such plans may lead to increased access to care while at the same time decreasing services for certain groups (Ehreth, personal communication, January 16, 1996).
FUTURE DIRECTIONS The research presented in this article indicates that the rate of childhood mental disorder and need for service in the general population of children is considerably greater than the rate of BEHAVIORAL
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service utilization, particularly for some ethnic minority populations. We also can glean from the literature that helpseeking and entry into services is influenced by illness profile, predisposing factors, and a variety of variables that can facilitate or pose a barrier to receipt of services. This review clearly suggests that the weaknesses and gaps in the literature are many. There is little systematic data about the factors that influence children and families in need to seek mental health services, why some people demonstrating clinically defined need do not obtain service, and why some individuals without diagnoses seek out and receive service. In addition, the relationship of clinically defined need and subjectively perceived need to each other and to support and service utilization is unclear. Patterns and pathways of support and service use over the course of childhood and adolescence also remain largely unexplored. In particular, more information is needed on child and family perceptions of services and the use of alternatives to formal mental health and social services (Goldsmith et al., 1988). More information is also needed to map the strength and directions of social, cultural, financial, service, and policy influences on seeking out and obtaining care (Costello et al., 1993; A. Horwitz, 1987). In sum, there is very limited information on the pathways of support and service for children, and what is available is further limited by weak methodology. In the next section, we first enumerate some areas for research that will foster greater understanding of these issues and then highlight a number of methodological issues.
Research Targets 1. How help-seeking patterns and pathways differ over the course of childhood and adolescence. The emerging literature on developmental psychopathology suggests that illness profile variables change over the course of development, implying that the nature of helpseeking pathways may also vary with age. More research is needed to better VOL.
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understand these pathway variations. Questions might include the following: At what ages do various social network members have their greatest impact on help-seeking? Once in formal services, what is the cross-sector service course for children with mental disorders at different ages? When in the course of development are mental health problems likely to be identified by various service sectors? 2. The relationships among the illness profile, predisposing factors, and barriers to/facilitators of care in terms of their influences on help-seeking and service utiliza-
tion. Most often, researchers seek to study the impact of one or a few variables on help-seeking and utilization of services. Although these studies may be intriguing, it is clear that the helpseeking process is determined by a wide range of factors whose relationships to each other are still unclear. Furthermore, the relative predictive strength of specific help-seeking influences in the context of multiple predictors is unknown. 3 . The role of culture in help-seeking and service utilization. Very little litera-
ture exists that discusses the role of culture for children as part of the helpseeking pathway, even though this information is critical to understanding apparent differences in service utilization rates across ethnic/cultural groups. Among other topics, researchers need to address how culture affects presentation of symptoms, identification of a mental health problem by family and network members, and receptivity and effectiveness of service providers. 4. How the service system can augment family and informal sources of help.
Children and families do not often seek formal mental health services immediately upon recognizing a mental health concern. A series of coping strategies, informal support sources, and service providers may be called upon first in the help-seeking pathway. These sources can be viewed as resources contributing valuable support both prior to and during the course of formal mental health services. Indeed, the CASSP model (Stroul & Friedman, 1986) calls for identification and incorporation of JOURNAL
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such resources into the treatment planning process. Research Methods The methods for how research is conducted in the area of help-seeking and service utilization are also critical. The following guidelines for such studies are offered:
difficult to meet. Ideally, records would also contain unduplicated individuals across service sectors so that all formal services would be captured. Such seamless data systems are currently rare (Burns et al., 1992). 4 . Focus on the prediction of patterns of network contacts, including informal and formal sources of support and service, rather than on formal mental health service entry
alone. A broader conceptualization of help-seeking pathways to include the range of formal services and commuimpairment. Researchers need to exam- nity and social network contacts is ine the nature of subjective definitions needed (Pescosolido, 1992). To this end, of emotional and behavioral problems— a standardized taxonomy of service charfrom the perspectives of children and acteristics across mental health and of their families. In addition, the factors collateral service sectors, as well as the that contribute to identification of a social network, is recommended (Burns problem as a mental health concern et al., 1992; Costello et al., 1993). For must be examined. Further research to each help-seeking episode, the sector clarify these constructs and relationships in which it took place can be described will be valuable for designing service (e.g., schools, mental health provider, systems to provide service equitably self-help/social network); as well as the based on need. unit of "service" (i.e., visits, days, net2. Use quantitative methods augmented work contacts), service type (e.g., psyby qualitative methods to obtain a richer chotherapy, therapeutic foster care), and understanding of sociocultural and network setting (e.g., community mental health variables. Many of the sociocultural center, school, home; Burns et al., 1992). variables that may influence the help- Using this taxonomy, the relationships seeking process have undergone scant of the illness profile, predisposing facformal study. As such, qualitative meth- tors, and barriers to and facilitators of ods are necessary to refine definitions care on specific patterns of service and of these variables and to develop appro- support can be examined. priate instrumentation. Further, tailorThe methods we just suggested deviing instruments to increase their rele- ate only slightly from strong, traditional vance for specific communities requires research methods. However, there is an spending time in a community and gath- increasing tension in the mental health ering qualitative information about its field regarding the optimum scope for community-specific definitions and net- such research. Some researchers support work interactions. the use of large, national representa3 . Corroborate self-reported service tive samples; others advocate examinutilization via use of service databases across ing one or a few communities in detail, service sectors. Although it is critical to then testing the generalizability of findobtain self-reported information regard- ings. In reality, the research infrastrucing service utilization, self-reports have ture (e.g., project funding, acceptable certain limitations. First, parents may methods, researcher training) is curnot know about some school-based ser- rently designed to support data collecvices their child receives. Also, memory tion on large, national representative may be inaccurate beyond 3 to 4 months, samples. Although this method may be and parents may define services in ways less expensive in the short run, what is that differ from those of service provid- derived may be a rather superficial ers. Obtaining service records can thus understanding of the phenomena under be an important adjunct data source. study. Factors related to help-seeking and However, service records must be accu- service use are truly local in nature and rate and timely, conditions generally need to be examined also at that level. 1. Assess subjective as well as clinically defined mental health need, including diagnosis, symptoms, and functional/role
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cover the junctures at which mental health outreach can best be targeted, and the most accessible target service sectors for early intervention.
IMPLICATIONS For Practice Developing a greater understanding of predictors of help-seeking can assist in disentangling reasons why certain communities appear to be underserved or overserved by mental health services or other service sectors. In particular, describing the effect of sociocultural variables on help-seeking can help clarify service utilization issues for ethnic and minority communities. For example, sociocultural proscriptions against seeking mental health services may emerge. Alternatively, social network strengths that mitigate the need for seeking mental health service may be uncovered. For some communities, access to culturally relevant services may be at issue. Findings may lead to the development of alternative services; however, they may also point to areas for education or community-building activities. Detailing the interplay of informal support and formal services will also be important for service planning. Informal social network members can play a role in provision of help and referrals to formal services. Understanding who informal support providers are and what role they play will increase our understanding of how children do or do not gain access to formal services. Services should strive to become as accessible as possible without at the same time undermining the strengths and support of family and informal network members. Services should work toward methods for supporting family and network efforts to solve problems on their own. Predictors and pathways to different kinds of services and support are likely to be different. For example, access to child protective services occurs through reports of abuse or neglect and referrals for service. In contrast, services provided in schools may be accessible to all students. Uncovering barriers to and facilitators of specific service sectors, as well as those that operate more generally, will clarify targets for service changes. Further, examination of pathways through informal supports and the range of formal services will help un7"|Q
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For P o l i c y In our changing political and healthcare environment, the utility of research on help-seeking and service utilization cannot be underestimated. T h e switch to block grants and the devolving role of federal leadership in supporting social services suggests that social service administrators will need to work efficiently and effectively together to address gaps between service need and receipt. Finding solutions to service gaps is truly a cross-system issue that requires crosssystem solutions. It may be that certain communities underutilize mental health services while fully utilizing services from a different service sector. Sharing service utilization data and employing cross-system administration will inform both service sectors. Also, such mechanisms for collaboration can provide the structure from which barriers to specific services can be addressed. Without collaboration at the administrative level, services are likely to compete with each other or be duplicative, leading to system inefficiency. T h e advent of health-care reforms and managed care has brought about new restrictions on and barriers to care for children and adolescents. Often, managed care firms limit the amount and type of services available. Research on help-seeking pathways can shed light on the impact such barriers will have on care. A more comprehensive and standardized definition of emotional and behavioral problems could also lead to a policy that would prevent managed care firms from limiting services to youth based on specific diagnoses. Given our knowledge about the limited resources available for m e n t a l health services, it is likely that rates of disorder will outstrip receipt of service for the forseeable future. Currently, service resources available are provided in a somewhat haphazard manner. For example, a child suffering from mild depression may receive services at the BEHAVIORAL
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same level of intensity as a child with psychotic symptoms due to such issues as demographic characteristics or family knowledge of the service system. Service delivery for children at present depends at least as much on family, community, service characteristics, and the political environment as on assessed and perceived need for service and whether or not effective treatment has been developed. Although service decisions will always be determined in part by factors other than need and ability to meet that need with effective service, we hope that, as the research on help-seeking pathways grows, it will provide a more informed and rational context for how to best set policy to "triage" cases and deliver service. About the Authors DEBRA SREBNIK, PhD, is an assistant professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington. She has primary interests in mental health services research and has published regarding supported housing approaches and mental health outcomes. In particular, she is interested in the impact of health and mental health policy changes on client access to and utilization of services. ANA MARI CAUCE, PhD, is a professor in the Department of Psychology at the University of Washington. She has particular interests in child development with ethnic and minority populations. She has conducted extensive research on ecological models of development in African American and Asian American families. She also has examined the effectiveness of intensive case management for homeless youth. NAZLI BAYDAR, PhD, is a senior research scientist in the Battelle Seattle Center for Public Health Research and Evaluation. She has conducted research on child and adolescent socioemotional and cognitive development. Specifically, she has examined individual and familial processes that influence child and adolescent mental health and problem behavior. Dr. Baydar has also studied cognitive and socioemotional development in infants and children. Address: Debra Srebnik, Department of Psychiatry, CH-13/ 359300, University of Washington, Seattle, WA 98195. Note The term children is used throughout this article to indicate both children and adoVOL.
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