Social and economic determinants of disparities in professional help-seeking for child mental health problems: evidence from a national sample

Health Services Research, Oct, 2005 by Frederick J. Zimmerman

Considerable evidence exists that children's mental health problems are undertreated, with fewer than half and as few as 11 percent of children who screen positive for some disorder actually receiving treatment (Zahner et al. 1992; Cohen and Hesselbart 1993; Leaf et al. 1996; Costello et al. 1997; Verhulst and van der Ende 1997; Farmer et al. 1999; Haines et al. 2002). Undertreatment for mental health problems is especially tragic, given that depression, attention-deficit, hyperactivity, and other mental health problems have been shown to interfere not only with children's current well-being, but also with educational attainment and future job performance, and therefore with future psychosocial and economic well-being (Mannuzza et al. 1997; Velting and Whitehurst 1997, Caspi et al. 1998; Fergusson and Horwood 1998). The importance of these problems is heightened by the fact that over the last 50 years, the trend has been for ever earlier onset of mental health problems, now reaching well into childhood (Burvill 1995).

The decisions to seek treatment for children's mental health issues occur in a peculiar environment, substantively unlike other health care decisions for children and even unlike adult mental health treatment decisions. For this reason, the study of the social and economic determinants of children's mental health services use is particularly important. Children's mental health problems may develop slowly, subtly, or be difficult to distinguish from normal--although at times difficult--child and adolescent development. Depression in children (as for some adults) can manifest as physical symptoms, sometimes without report of psychological symptoms (Stewart 2003). Moreover, children rarely seek treatment on their own, instead parents make decisions about whether and how to seek treatment. However, they do so in a social context that can be confusing. Parental perceptions or concern about stigma surrounding mental health problems continue to exist, and this stigma is strengthened by a belief on the part of many parents that effective treatments are not available, or that their child will not be well served by mental health providers (Richardson 2001; Starr, Campbell, and Herrick 2002). Finally, for most health issues the child's primary care provider can provide some clarity and insight for parents as to the best care for their child. For mental health issues, however, many primary care providers are unsure of appropriate treatments and not comfortable dealing with mental health (Geller 1999). School teachers and counselors exhibit some influence on the process (Farmer et al. 2003), and this influence may or may not align well with the parents' own perceptions of the child's need for treatment. At the same time, dedicated school mental health programs, which are becoming increasingly common, are potentially very important mechanisms for the identification and referral of needful students (Rones and Hoagwood 2000; Haynes 2002).

It is only a slight exaggeration to say that from the perspective of many parents, they must decide whether to seek a stigmatized solution that might not work for a problem that they are not sure exists, often with little help from their trusted health advisors. In this environment, the social context in which care decisions occur can become especially salient. Existing research has indeed identified important socioeconomic determinants of the decision to seek help, and in particular to seek help from a mental health professional.

Income has been shown in several studies to have an effect on seeking treatment, either independently (Cohen and Hesselbart 1993; Haines et al. 2002) or as an interaction with symptom severity (Cunningham and Freiman 1996), although the effect of income is considerably less or nonexistent in Europe (Gasquet et al. 1997; Verhulst and van der Ende 1997). Insurance effects in the U.S. have been shown to be modest: one study finds an effect for Medicaid as opposed to no insurance, but no effect for private insurance versus no insurance (Cunningham and Freiman 1996). Another study found that almost all of 98 insurance plans queried covered depression care for adolescents (Fox, McManus, and Reichman 2003). Interestingly, several studies have failed to find an effect for parental education, when income and insurance are controlled (Cunningham and Freiman 1996; Verhulst and van der Ende 1997).

Other demographic factors have been shown to have meaningful effects. Girls in Britain are less likely than boys to get treatment, conditional on morbidity (Haines et al. 2002), but girls in France and Quebec are more likely to get treatment (Gasquet et al. 1997; Salomon and Strobel 1997). In the U.S. and the Netherlands, no effect of child gender was found in several studies (Cohen and Hesselbart 1993; Cunningham and Freiman 1996; Verhulst and van der Ende 1997; Witt, Kasper, and Riley 2003), while significant effects were found in other studies (Bussing, Zima, and Belin 1998; Bussing et al. 2003), particularly for treatment of Attention Deficit Hyperactivity Disorder (ADHD).