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

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). Mothers who themselves have used mental health services are more likely to seek mental health care for their children, controlling for the child's symptomology in some studies (Dulcan et al. 1990; Cunningham and Freiman 1996), but not in others (Riley et al. 1993). It is not clear whether this effect, where it exists, is because of the mother's experience of mental health treatment, or to her experience of the mental health problem itself. African Americans, and to a less pronounced extent, Hispanics, are less likely to obtain mental health services, controlling for symptomology (Cunningham and Freiman 1996; Kataoka, Zhang, and Wells 2002; Leslie et al. 2003; Richardson et al. 2003; Sturm, Ringel, and Andreyeva 2003; Slade 2004), as are Native Americans (Riley et al. 1993; Costello et al. 1997). Some potentially important social variables have not been explored. For example, it has been shown in some studies (e.g., Mott, Kowaleski Jones, and Mehaghan 1997) that the presence of the father in the household is protective against behavioral problems in children—although other studies fail to find such an effect (e.g., Crockett, Eggebeen, and Hawkins 1993). Mother-only families have been found to be 70 percent more likely to treat mental health problems, controlling for the child's symptoms and functional status (Cunningham and Freiman 1996), but this may be because mother-only families are more likely to have experienced a recent divorce or separation, which sensitizes the mother to the need for psychological counseling for her children. Accordingly, it remains unclear whether the father's presence increases the likelihood of the child receiving mental health treatment when there is a need. Similarly, the number of adults in the household might be expected to influence the probability of treatment, especially if there are important time constraints in seeking out specialty treatment. This issue, too, has never been examined. Finally, birth order has been shown to have an impact on other forms of investment in children, such as education (Datcher Loury 1988; Hanushek 1992), but birth order, too, has not been examined in the context of children's mental health services use. Much of the work that has been done on the determinants of children's mental health services use has not differentiated among types of disorders. Yet, the few studies that have made such distinctions have found differences. For example, in the Great Smoky Mountains study, girls were shown to be less likely than boys to have treatment for ADHD, conditional on need (Angold et al. 2000). Such results suggest that it would be useful to further the previous analyses by breaking out at least the two most common disorders in childhood, depression and ADHD. The existing research can be profitably extended in several other dimensions, as well, most notably by contributing to greater understanding of outstanding questions such as the role of income, the child's gender and the mother's own mental health services use. Many of the previous studies have used small clinic-based samples, or samples of children from a single community or geographical area. This paper uses the National Longitudinal Survey of Youth and the Child/Young Adult supplement (NLSY-C/YA), a nationally representative sample of 7–14-year-old children to assess the social and economic determinants of the probability of seeking mental health specialty treatment for any mental health problems, and for depression and attention problems separately.