Childhood and early adolescence is a critical period for mental health. One in eight children and young people (5 to 19 year olds) are now thought to have a least one mental health disorder (MHDs; NHS Digital, 2018), and half of all lifetime MHDs have their first onset before the age of 14 (Kessler et al., 2005). Left untreated, they can be related to a host of difficulties that can persist across the lifespan, including poorer health, academic, and social outcomes (Green et al., 2005). This means that early detection of difficulties and prompt provision of professional help is crucial, to prevent these disorders from developing.
However, while effective, evidence-based treatments for MHDs in young people do exist, less than two-thirds of those experiencing difficulties access any professional help (Reynolds et al., 2012; Sadler et al., 2018). Demographic factors (e.g., age, gender and race) that predict service utilisation and barriers to accessing professional help from parents’ and practitioners’ perspectives have been identified (Radez et al., 2020). However, there has been no clear understanding of young people’s reasons for not seeking help, from their own perspective. This knowledge is key if we are to successfully address these barriers, and reduce the discrepancy between the high rates of MHDs and low access to treatment.
Radez et al. (2020) aimed to address this evidence gap by conducting a systematic review of all the studies focusing on barriers and facilitators to help-seeking from children and adolescents’ perspectives.
This systematic review was conducted following PRISMA guidelines. Searches were conducted in several databases including Medline, PsycINFO, Embase, and Web of Science Core Collection.
Search terms covered four major concepts: 1) barriers/facilitators, 2) help-seeking, 3) mental health and 4) children/adolescents and parents.
Eligibility criteria included: a) studies that focused on child and/or adolescents’ reports (mean sample age up to 18) and b) participants’ reported barriers and/or facilitators to seeking and accessing professional help for mental health problems.
3,682 studies that have been published since October 2014 were identified. Following screening, only 53 studies were included in the review; of them 30 were qualitative, 22 were quantitative, and one was mixed-methods.
A narrative synthesis was used (Popay et al., 2006) instead of a statistical meta-analysis, due to the high methodological variability across studies and the predominantly descriptive nature of the results.
Four themes were identified that influenced help-seeking.
Theme 1: Young people’s individual factors
- Knowledge about mental health and services – knowing when and where to seek help
- Perceptions of help-seeking (i.e. attitudes and stigma)
- A desire to cope with problems alone
- Commitment to the process – reluctance to attend appointments and adhere to recommended treatments, and doubts about the effectiveness of professional help
- Perceived autonomy – whether it was their own choice to seek help
- Preference for informal support (i.e. family and friends)
- Ability to verbalise the need for help and to talk about difficulties
- Emotional and motivational factors (i.e. anxiety/depression symptoms, lack of motivation)
- Past experiences with help-seeking – positive or negative past experiences predicted likelihood of seeking help again
Theme 2: Social factors
- Views and attitudes towards mental health and help-seeking in the wider environment – perceived stigma in the community and public embarrassment
- Views and attitudes towards mental health and help-seeking in their support network (e.g., family, teachers) – more common in ethnically-diverse samples
- Anticipated impact of help-seeking on social network – fear of being taken away from parents, losing status with peers, or making family angry or upset
Theme 3: Relationship factors with professionals
- Perceived confidentiality
- Perception of professional – e.g. respect, non-judgmental attitude
- Ability to trust a stranger and concerns about disclosing personal information
- Similarity between young person and professional – e.g. gender, ethnicity/race, and age
Theme 4: Systemic and structural factors
- Logistical factors – lack of time, interference with other activities, and transportation difficulties (particularly in rural areas)
- Costs – associated with mental health services (typically in America)
- Availability of professional help – limited availability and excessive waiting times
- Accessibility of professional help – difficulty making an appointment, or staffs’ attitudes towards them
- Use of technology – desire to communicate distress and attend treatment via digital tools
The authors concluded that:
The main reasons for (not) seeking and accessing professional help given by young people are those related to mental health stigma and embarrassment, a lack of mental health knowledge, and negative perceptions of help-seeking. Young people also reported a preference for relying on themselves when facing difficulties, and issues with committing fully to the process of help-seeking.
Strengths and limitations
I see the main strength of this research as the focus on young people’s perspectives, which was very pleasing given that literature often focuses on parents and practitioners’ views. The inclusion of qualitative studies was also particularly beneficial; this helped provide additional contextual information and a more detailed insight into young people’s experiences. Additionally, it was great to see the inclusion of all types of mental health disorders. Research often concentrates on anxiety and depression, and so help-seeking factors for other disorders may be missed. In order to be able to promote help-seeking effectively, we have to understand all the barriers, identified by young people themselves.
The review also benefited from the inclusion of international studies. I believe this is particularly important given that there are some demographic predictors of help-seeking and differences in cultural attitudes to mental health. This aspect of the study will allow for the promotion of help-seeking behaviours worldwide.
However, given the differences across cultures and disorders, I felt there could have been more detailed comparisons, including those between participants (e.g., ethnicities), disorders, or sources of help-seeking. There was also no clear distinction between help-seeking intentions and actual behaviours, so differences in perceived barriers couldn’t be explored. Finally, due to the scale of the study, some level of nuance and detail was missing. Whilst I understand that this may have been unfeasible, I still feel it was a shame, particularly given the inclusion of qualitative studies.
Implications for practice
The results of this study provide valuable insight into the barriers that need to be addressed to ensure young people are accessing the help they need.
Rates of mental health disorders in this age group are increasing, and suicide is now the second leading cause of death for 14-25 year olds. One way to reduce the prevalence and prevent these devastating long-term outcomes is to intervene early. However, this is dependent on young people flagging their symptoms and seeking help. If young people can recognise symptoms, know where to go for help, and are not deterred by stigma or logistical factors, then the likelihood of this happening increases.
Based on my own research, I think that school-based initiatives and mental health literacy interventions that promote knowledge and awareness may be useful for tackling stigma and normalising mental health difficulties among this population. Of course more research is always needed into interventions and their core components to establish their effectiveness, which will ensure that the most suitable interventions are widely disseminated.
We also need to make access to mental health services and appropriate support easier. We could have clearer signposting in schools, professional services available within the school environment, or school partnerships with external services.
Regarding concerns about disclosures, professionals should be mindful about seeking family involvement, balancing the need for this against young people’s desire to make their own decisions. It is important that mental health professionals promise privacy explicitly, and make it clear that they are promoting young people’s agency and control. Accessing professional services should be a positive experience, so young people are not deterred from using them when needed.
Finally, practitioners may want to look at increasing the availability of digital services to ease logistical issues, as this may help young people self-refer or feel more comfortable accessing support (e.g., text message services or computerised treatment).
Statement of interests
Radez, J., Reardon, T., Creswell, C., Lawrence, P. J., Evdoka-Burton, G., & Waite, P. (2020). Why do children and adolescents (not) seek and access professional help for their mental health problems? A systematic review of quantitative and qualitative studies. European Child & Adolescent Psychiatry, 1-29.
Green H, McGinnity A, Meltzer H et al (2005) Mental health of children and young people in Great Britain, 2004. Palgrave Macmillan, Basingstoke
Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. (2005). Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62 (6) pp. 593-602.
Kmet LM, Lee RC, Cook LS (2004) Standard quality assessment criteria for evaluating primary research papers from a variety of fields. Alberta Heritage Foundation for Medical Research (AHFMR), Edmonton
NHS Digital (2018). Mental health of children and young people in England, 2017. NHS Digital.
Popay J, Roberts H, Sowden A et al (2006) Narrative synthesis in systematic reviews: a product from the ESRC methods programme. ESRC Methods Program.
Reynolds S, Wilson C, Austin J, Hooper L (2012) Effects of psychotherapy for anxiety in children and adolescents: a metaanalytic review. Clin Psychol Rev 32:251–262.
Sadler K, Ti Vizard, Ford T et al (2018) Mental health of children and young people in England, 2017. Health and Social Care Information Centre, Leeds