Rapid and Deferred Help Seeking Among African American Parents of Children With Emotional and Behavioral Difficulties
Abstract
Objective:
Little is known about the factors African American parents consider when seeking care for their child after emotional and behavioral difficulties emerge. This study aimed to examine factors associated with seeking professional care within 30 days after identifying a child’s need (i.e., rapid care seeking) and with deferring care for ≥1 year.
Methods:
This cross-sectional study surveyed African American parents raising a child with emotional or developmental challenges (N=289). Logistic regression was used to examine associations of parent activation, medical mistrust, and care-seeking barriers with two outcomes: rapidly seeking care and deferring care seeking.
Results:
About 22% of parents rapidly sought care, and 49% deferred care for 1 year or longer. Parents were more likely to rapidly seek care if they had higher parent activation scores; lived with other adults with mental health challenges; or, contrary to the authors’ hypothesis, mistrusted doctors. Parents were less likely to rapidly seek care if the challenge did not initially bother them much or if their health insurance would not cover the service. Parents were more likely to defer care if they feared involuntary hospitalization for their child or if their health insurance would not cover the service. Parents were less likely to defer care if they had at least some college education or lived with other adults with mental health challenges.
Conclusions:
Community-based pediatric and child welfare professionals should be informed about facilitators and barriers to mental health care seeking as part of efforts to develop interventions that support African American families.
HIGHLIGHTS
•
Among 289 African American parents raising a child with emotional or developmental challenges, 22% rapidly sought care (i.e., within 30 days) after identifying a need for help, whereas 49% deferred care for ≥1 year.
•
Parents were more likely to rapidly seek care if they had higher activation scores, lived with other adults with mental health challenges, or mistrusted doctors.
•
Parents were more likely to defer care if they feared involuntary hospitalization for their child.
•
Child welfare professionals should be informed about factors associated with mental health care seeking to support African American families.
Children with mental health challenges, such as extreme mood swings, anxiety, and difficulty learning or talking, face complex obstacles when engaging with the health care system (1). About one in six U.S. children have been diagnosed with a mental, behavioral, or developmental disorder, and many of these children experience an unmet need for care (2–4). Research investigating these unmet needs must consider factors that influence help seeking among parents and caregivers, the key gatekeepers to care for children (5).
Barriers to mental health care are greater for African American parents, who are more likely than White parents to experience structural obstacles that hinder timely diagnosis (e.g., cost issues) (6–10). African American children are also exposed to systemic racism and other harmful structures in the health care system (e.g., disproportionate contact with juvenile legal systems and diagnostic biases) (9, 11–14). As a result, African American children with emotional and behavioral challenges are more often misdiagnosed and less likely to receive early intervention than are White children (7, 14–17). Few studies examine the factors that African American parents consider when deciding to seek care for their child after emotional and behavioral difficulties emerge—a time when clinical intervention can be critical for childhood development.
Furthermore, scholars often explore delayed or deferred health care utilization, frequently defined as waiting ≥1 year to seek care for a medical need (18, 19). However, it is also important to address the opposite phenomenon—rapid care seeking. Understanding both help-seeking pathways—rapid and deferred care seeking—may inform interventions that respond to the distinct pathways to proactive and deferred care.
The Andersen behavioral model of health services use is one framework that can inform research focused on rapid and deferred care seeking. This model posits that use of health services is determined by predisposing factors (e.g., sociodemographic characteristics), enabling factors (e.g., health insurance status), and need factors (e.g., symptom severity) (20). Godoy and Carter (21) drew on the Andersen model and other health-related theories to present a comprehensive model of parental help seeking for children. In Godoy and Carter’s model, parental help seeking is determined by several factors, such as parent appraisal processes (e.g., parent activation and the degree to which parents possess the capacity, knowledge, and willingness to manage their child’s needs), predisposing and contributing influences on parent appraisal processes (e.g., sociodemographic characteristics), and core pediatric contextual influences (e.g., access barriers). The model also highlights parents’ trust in medical doctors as a key factor influencing help seeking. Godoy and Carter’s model has been applied to assess parental appraisals of child behavioral problems in racially diverse samples, but findings were not disaggregated by race (22–24). Thus, additional research is needed to explore how parental concerns about child mental health needs may uniquely influence help seeking for African American families.
This study aimed to address these gaps in the literature by examining factors related to rapidly seeking care (i.e., seeking care within 30 days of personally identifying their child’s need) and deferring care (i.e., waiting 1 year or longer to seek care) among African American parents and caregivers (hereafter referred to as “parents”) of children with emotional and behavioral health needs. Informed by the two aforementioned theoretical models, we developed four hypotheses. First, we hypothesized that African American families with higher parent appraisal scores (i.e., higher parent activation) would have higher odds of rapid care seeking and lower odds of deferred care seeking. Second, we hypothesized that parents who reported negative appraisal processes (e.g., worry about their child being involuntarily hospitalized) would have lower odds of rapid care seeking and higher odds of deferred care seeking. Third, we hypothesized that parents who cited pediatric contextual barriers to care, such as health insurance challenges, would have lower odds of rapid care seeking and higher odds of deferred care seeking. Fourth, we hypothesized that parents who mistrusted doctors would have lower odds of rapid care seeking and higher odds of deferred care seeking.
Methods
Study Population and Recruitment
We used data from the Teaching Advocacy Skills for Kids study, a cross-sectional study conducted in 2010–2011 that enrolled African American parents living in North Carolina who were raising a child with emotional or developmental challenges. This study aimed to recruit parents who recognized that their child was having mental health or developmental challenges (e.g., extreme anger, mood swings, or difficulty talking), regardless of whether the child had received a formal diagnosis. We identified mental health needs as “challenges” to capture the broad ways parents may characterize their child’s behavior. Participants were eligible if they were ages ≥18 years, identified as African American, were a parent of a child (ages ≤25 years) with emotional or developmental challenges, and spoke English. Parents of children ages ≤25 were eligible to capture the full age range of children enrolled in school.
Study staff distributed recruitment fliers to early intervention and social service agencies, school special education directors, advocacy organizations, and mental health agencies. After providing informed consent, eligible parents completed a 45-minute computer-assisted telephone interview and received a $40 incentive. This study was approved by the institutional review board at the University of North Carolina at Chapel Hill. Additional study details are published elsewhere (25).
Measures
Outcome variables.
Parents answered the question, “How long had you been thinking that [the child] needed to see a professional before you made the first appointment?” Consistent with previous literature, we created two binary outcome measures to assess factors associated with rapidly seeking care (i.e., making an appointment in ≤30 days after identifying the need) and deferring care (i.e., waiting ≥1 year to make an appointment) (18, 19). All parents in the sample eventually sought care for their child.
Independent and control variables.
Mistrust of doctors was assessed with the question, “Are there any people you would not trust to talk to about your child’s emotional or developmental challenges?” Participants were characterized as mistrusting doctors if they did not trust their child’s doctor or their own doctor. Parent activation was measured with the 13-item parent-focused Patient Activation Measure (Cronbach’s alpha in current study=0.88) (26). As an example, one item from the Patient Activation Measure asks, “When all is said and done, I am the person who is responsible for managing my child’s health and well-being and service use.” Total scores ranged from 38.7 to 100.0, with higher scores indicating greater activation.
Parents were also given a list of reasons why people sometimes put off getting help for their children and indicated whether each reason applied to them. We used this question to assess negative appraisal processes and pediatric contextual barriers. For example, one listed reason related to negative appraisal was, “I was scared about my child being put in a hospital against my will.” An example reason related to pediatric contextual barriers was, “My health insurance would not cover the service.” We also assessed sociodemographic variables, including the child’s sex, child’s age at diagnosis, parent education level, household income, whether the child had a serious mental disorder (defined as a serious mood or anxiety disorder, psychosis, autism, traumatic brain injury, or other unspecified serious mental health issue) and whether there were other adults or children in the household with mental health challenges.
Analytic Approach
We used descriptive statistics to characterize the study sample. In unadjusted analyses, we used t tests and chi-square tests to examine whether there were significant differences between parents who did and those who did not rapidly seek care (the first outcome) and between parents who did and those who did not defer care (the second outcome). We used logistic regression to examine adjusted associations of parent activation, negative appraisal processes, pediatric contextual barriers, and mistrust of doctors with our two outcomes. We controlled for parent and child sociodemographic characteristics, presence of a serious mental disorder, and whether the household had other adults or children with mental health challenges. We examined model fit by using the c-statistic and Cox-Snell version of R2 (27). We used the Hosmer-Lemeshow test to assess model goodness of fit. Analyses were conducted with SAS, version 9.4.
Results
Participant Characteristics
In total, 289 parents provided information about the outcome variables, and their data were included in analyses. Table 1 presents the demographic and other characteristics of the study participants. Most children were male (69%), and the mean age at diagnosis was 6 years. About 43% of participants selected high school or less as the highest level of education in the household, and approximately 80% had an annual household income below $35,000.
| Characteristic | N | % |
|---|---|---|
| Demographic | ||
| Child’s sex | ||
| Female | 91 | 32 |
| Male | 198 | 69 |
| Child’s age at diagnosis (M±SD years) (N=287)a | 6.0±4.1 | |
| Highest education level of adults in household (N=275) | ||
| Less than high school | 32 | 12 |
| High school diploma | 84 | 31 |
| Some college | 101 | 37 |
| College diploma or higher | 58 | 21 |
| Annual household income, in $ (N=285) | ||
| <35,000 | 229 | 80 |
| 35,000–50,000 | 37 | 13 |
| >50,000 | 19 | 7 |
| Child has serious mental disorder | 121 | 42 |
| Other adults in household have mental health challenges | 39 | 14 |
| Other children in household have mental health challenges | 73 | 25 |
| Parent activation and mistrust | ||
| Parent activation score (M±SD)b | 65.1±14.1 | |
| Parent mistrusted doctors (N=286) | 46 | 16 |
| Negative appraisal processesc | ||
| Parent did not think help would make any difference | 65 | 23 |
| Child received help before, and it did not work | 61 | 21 |
| Parent was concerned about what people would think if they found out the child was getting help | 72 | 25 |
| Parent was scared about their child being put in a hospital against the parent’s will | 47 | 16 |
| Parent was scared about Department of Social Services involvement | 48 | 17 |
| Parent thought the issue would get better by itself | 148 | 51 |
| The challenge did not bother the parent very much at first | 134 | 46 |
| Parent wanted to handle the challenge on their own | 150 | 52 |
| Pediatric contextual barriersc | ||
| Parent’s health insurance would not cover the service | 61 | 21 |
| Parent was concerned about cost | 83 | 29 |
| Parent had problems such as transportation or scheduling challenges that made it hard to get to the help | 115 | 40 |
| Parent was unsure about where to go or who to see | 164 | 57 |
| Parent thought it thought it would take too much time or be inconvenient | 35 | 12 |
| Parent could not get an appointment | 39 | 14 |
| Parent was not satisfied with available services | 57 | 20 |
a
Range 0–23 years.
b
Scores on the 13-item parent-focused Patient Activation Measure ranged from 38.7 to 100.0, with higher scores indicating greater activation.
c
Participants could endorse more than one process.
Unadjusted Associations Between Sample Characteristics and Help Seeking
Table 2 presents the unadjusted associations between sample characteristics and both rapid and deferred help seeking. About 22% (N=62) of parents rapidly sought care. These parents had significantly higher mean±SD activation scores (68.7±16.2) than those who did not rapidly seek care (64.1±13.3) (p=0.02). Additionally, a smaller percentage of parents who rapidly sought care reported that they thought the issue would get better by itself or that they wanted to handle the challenge on their own compared with parents who did not rapidly seek care (p<0.05). Similarly, a smaller percentage of parents who rapidly sought care reported that they had problems with transportation or were unsure about where to go (p<0.05). A smaller percentage of parents who rapidly sought care reported that the challenge did not initially bother them compared with parents who did not rapidly seek care (p=0.002).
| Rapid care | Deferred care | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Yes | No | Yes | No | |||||||
| Characteristic | N | % | N | % | pa | N | % | N | % | pa |
| Total (N=289) | 62 | 22 | 227 | 79 | 141 | 49 | 148 | 51 | ||
| Parent activation and mistrust | ||||||||||
| Parent activation score (M±SD)b | 68.7±16.2 | 64.1±13.3 | .022* | 63.4±13.1 | 66.7±14.8 | .043* | ||||
| Parent mistrusted doctors (N=286) | 13 | 21 | 33 | 15 | .210 | 20 | 14 | 26 | 18 | .418 |
| Negative appraisal processes | ||||||||||
| Parent did not think help would make any difference | 12 | 19 | 53 | 23 | .505 | 33 | 23 | 32 | 22 | .717 |
| Child received help before, and it did not work | 12 | 19 | 49 | 22 | .703 | 34 | 24 | 27 | 18 | .222 |
| Parent was concerned about what people would think if they found out the child was getting help | 12 | 19 | 60 | 26 | .254 | 36 | 26 | 36 | 24 | .813 |
| Parent was scared about their child being put in a hospital against the parent’s will | 8 | 13 | 39 | 17 | .419 | 27 | 19 | 20 | 14 | .194 |
| Parent was scared about Department of Social Services involvement | 7 | 11 | 41 | 18 | .204 | 28 | 20 | 20 | 14 | .147 |
| Parent thought the issue would get better by itself | 21 | 34 | 127 | 56 | .002** | 79 | 56 | 69 | 47 | .110 |
| The challenge did not bother the parent very much at first | 18 | 29 | 116 | 51 | .002** | 70 | 50 | 64 | 43 | .275 |
| Parent wanted to handle the challenge on their own | 22 | 36 | 128 | 56 | .004** | 76 | 54 | 74 | 50 | .507 |
| Pediatric contextual barriers | ||||||||||
| Parent's health insurance would not cover the service | 8 | 13 | 53 | 23 | .074 | 35 | 25 | 26 | 18 | .131 |
| Parent was concerned about cost | 12 | 19 | 71 | 31 | .066 | 42 | 30 | 41 | 28 | .695 |
| Parent had transportation or scheduling challenges to getting the help | 15 | 24 | 100 | 44 | .005** | 66 | 47 | 49 | 33 | .017* |
| Parent was unsure about where to go or whom to see | 24 | 39 | 140 | 62 | .001*** | 89 | 63 | 75 | 51 | .033* |
| Parent thought service would take too much time or be inconvenient | 7 | 11 | 28 | 12 | .823 | 17 | 12 | 18 | 12 | .978 |
| Parent could not get an appointment | 7 | 11 | 32 | 14 | .567 | 12 | 9 | 27 | 18 | .016* |
| Parent was not satisfied with available services | 8 | 13 | 49 | 22 | .128 | 32 | 23 | 25 | 17 | .215 |
| Demographic characteristics | ||||||||||
| Sex of child, male | 41 | 66 | 157 | 69 | .649 | 91 | 65 | 107 | 72 | .156 |
| Age of child at time of diagnosis (M±SD years) (N=287) | 5.8±4.9 | 6.1±3.9 | .596 | 6.5±3.8 | 5.5±4.3 | .043* | ||||
| Some college or more education (N=275) | 35 | 59 | 124 | 57 | .792 | 67 | 49 | 92 | 67 | .003** |
| Annual income >$50,000 (N=285) | 6 | 10 | 13 | 6 | .263 | 5 | 3 | 14 | 10 | .043* |
| Child has serious mental disorder | 23 | 37 | 98 | 43 | .390 | 62 | 44 | 59 | 40 | .479 |
| Other adults in household have mental health challenges | 13 | 21 | 26 | 12 | .052 | 13 | 9 | 26 | 18 | .038* |
| Other children in household have mental health challenges | 13 | 21 | 60 | 26 | .380 | 42 | 30 | 31 | 21 | .084 |
a
p values are based on chi-square tests for categorical variables and independent-samples t tests for continuous variables.
b
Scores on the 13-item parent-focused Patient Activation Measure ranged from 38.7 to 100.0, with higher scores indicating greater activation.
*p<0.05, **p<0.01, ***p<0.001.
Nearly half of the parents (N=141, 49%) deferred care for ≥1 year. Mean activation scores were lower for parents who deferred care (63.4±13.1) than for those who did not defer care (66.7±14.8) (p=0.04). Additionally, parents who deferred care reported higher mean ages at child diagnosis than those who did not defer care (mean=6.5 years vs. mean=5.5 years, p=0.04). A greater percentage of parents who deferred care reported that they had problems with transportation or were unsure about where to go compared with those who did not defer care (p<0.05). A smaller percentage of parents who deferred care reported that they could not get an appointment or that there were other adults in the household with mental health challenges compared with parents who did not defer care. Parents who deferred care had lower education and income levels than parents who did not defer care (p<0.05).
Adjusted Associations Between Sample Characteristics and Help Seeking
In the adjusted model for rapid care seeking (left side of Table 3), parents were more likely to rapidly seek care if they had higher activation scores (odds ratio [OR]=1.03, 95% confidence interval [CI]=1.00–1.05), mistrusted doctors (OR=4.13, 95% CI=1.56–10.95), or lived with other adults with challenges (OR=5.42, 95% CI=1.90–15.49). Parents who thought seeking help would take too much time or be inconvenient also had higher odds of rapidly seeking care (OR=7.42, 95% CI=1.99–27.71). Parents were less likely to rapidly seek care if their child’s emotional or developmental challenges did not bother them much at first (OR=0.28, 95% CI=0.12–0.65) or if their health insurance would not cover the service (OR=0.28, 95% CI=0.09–0.88).
| Characteristic | Rapid carea | Deferred careb | ||||
|---|---|---|---|---|---|---|
| OR | 95% CI | p | OR | 95% CI | p | |
| Parent activation and mistrust | ||||||
| Parent activation score | 1.03 | 1.00–1.05 | .024* | .99 | .97–1.01 | .212 |
| Parent mistrusted doctors | 4.13 | 1.56–10.95 | .004** | .63 | .29–1.38 | .250 |
| Negative appraisal processes | ||||||
| Parent did not think help would make any difference | 2.07 | .76–5.64 | .153 | .69 | .34–1.43 | .321 |
| Child received help before and it did not work | 2.63 | .96–7.20 | .059 | .87 | .41–1.84 | .713 |
| Parent was concerned about what people would think if they found out the child was getting help | 1.24 | .47–3.31 | .663 | .63 | .29–1.37 | .248 |
| Parent was scared about their child being put in a hospital against the parent’s will | .69 | .21–2.28 | .546 | 2.72 | 1.13–6.53 | .025* |
| Parent was scared about Department of Social Services involvement | .44 | .11–1.71 | .233 | 1.30 | .53–3.19 | .568 |
| Parent thought the issue would get better by itself | .86 | .36–2.02 | .727 | 1.39 | .73–2.63 | .317 |
| The challenge did not bother the parent very much at first | .28 | .12–.65 | .003** | 1.14 | .63–2.08 | .670 |
| Parent wanted to handle the challenge on their own | .47 | .19–1.12 | .088 | 1.11 | .58–2.11 | .759 |
| Pediatric contextual barriers | ||||||
| Parent's health insurance would not cover the service | .28 | .09–.88 | .029* | 2.45 | 1.07–5.63 | .035* |
| Parent was concerned about cost | .98 | .36–2.63 | .960 | .83 | .40–1.74 | .626 |
| Parent had transportation or scheduling challenges to getting to the help | .45 | .19–1.05 | .066 | 1.60 | .85–2.99 | .144 |
| Parent was unsure about where to go or whom to see | .81 | .36–1.84 | .616 | 1.35 | .72–2.51 | .354 |
| Parent thought it would take too much time or be inconvenient | 7.42 | 1.99–27.71 | .003** | .60 | .22–1.60 | .306 |
| Parent could not get an appointment | 1.57 | .50–4.93 | .437 | .19 | .07–.51 | .001*** |
| Parent was not satisfied with available services | .28 | .07–1.04 | .057 | 1.74 | .72–4.21 | .221 |
| Demographic characteristics | ||||||
| Sex of child, male | .78 | .36–1.70 | .537 | .71 | .39–1.29 | .256 |
| Age of child at diagnosis | 1.01 | .92–1.10 | .918 | 1.03 | .96–1.11 | .394 |
| Some college or more education | .96 | .46–2.01 | .918 | .52 | .29–.94 | .031* |
| Annual income >$50,000 | 3.23 | .88–11.84 | .077 | .45 | .13–1.52 | .198 |
| Child has serious mental disorder | .45 | .20–1.02 | .055 | 1.58 | .85–2.93 | .151 |
| Other adults in household have mental health challenges | 5.42 | 1.90–15.49 | .002** | .32 | .14–.77 | .011* |
| Other children in household have mental health challenges | .90 | 0.37–2.19 | .814 | 1.00 | .52–1.92 | .993 |
a
Model fit statistics for the rapid care model: c=0.811, pseudo R2=0.199, Hosmer-Lemeshow p=0.746.
b
Model fit statistics for the deferred care model: c=0.741, pseudo R2=0.175, Hosmer-Lemeshow p=0.978.
*p<0.05, **p<0.01, ***p<0.001.
In the adjusted model for deferred care seeking (right side of Table 3), parents were more likely to defer care if they were scared about their child being involuntarily hospitalized (OR=2.72, 95% CI=1.13–6.53) or if their health insurance would not cover service (OR=2.45, 95% CI=1.07–5.63). Parents were less likely to defer care if they could not get an appointment (OR=0.19, 95% CI=0.07–0.51), had some college or more education (OR=0.52, 95% CI=0.29–0.94), or lived with other adults with challenges (OR=0.32, 95% CI=0.14–0.77).
Discussion
This study is among the first to examine factors among African American parents that are associated with rapidly (i.e., within 30 days) seeking care and with deferring care for ≥1 year after a mental health need was identified for a child with emotional and behavioral difficulties. Only 22% of parents rapidly sought care, whereas 49% deferred care. This finding is in line with previous literature citing widespread unmet treatment needs among children with mental health challenges (3, 4).
Consistent with previous studies and our first hypothesis, parents with higher activation scores were more likely to rapidly seek care. Indeed, findings from several studies suggest that people with higher patient activation have better health outcomes and care experiences (28–31). However, parent activation was not associated with deferred care (i.e., the second outcome). Most research on patient activation has focused on receipt of health care services but not on timeliness of service initiation. Future research is needed to understand the mechanisms by which parent activation may be differentially associated with rapid versus deferred care seeking.
Consistent with our second hypothesis, we found associations between negative parental appraisals of care processes and help seeking. Specifically, parents who feared that their child may be involuntary hospitalized were more likely to defer care. Previous studies have highlighted that involuntary commitment for mental health needs is highly racialized (32–34). For example, African Americans, including youths, are overrepresented among those receiving involuntary psychiatric hospitalization (32–34). Accordingly, concerns regarding involuntary hospitalization may uniquely influence help seeking among African American parents.
Our third hypothesis assessed whether pediatric contextual barriers, such as access issues, were associated with help seeking. We found that parents whose health insurance would not cover care had lower odds of rapid care seeking and higher odds of deferred care seeking. This result was consistent with previous literature citing cost as a barrier to mental health care (35, 36). Contrary to our hypothesis, parents who endorsed that they could not get an appointment had lower odds of deferred care. Parents who endorsed this statement may have been actively attempting to get an appointment, and this determination resulted in lower odds of deferred care. One possible interpretation is that enhancing patient and family navigation services for mental health care may support help seeking (e.g., by helping parents make appointments with providers who accept their insurance) (37, 38). Future research is needed to assess interaction effects and subgroup differences regarding how pediatric contextual barriers may differ depending on child characteristics, such as age and gender. For example, parents may face different barriers when seeking care for younger versus older children.
Also in contrast to our third hypothesis, endorsing that seeking help would take too much time or be inconvenient was associated with higher odds of rapidly seeking care. This endorsement may be precipitated by past negative experiences with the health care system and difficulty scheduling appointments, which may motivate parents to seek care for their child soon after identifying a need, given challenges they expect to face during the process. If so, it is possible that previous negative health care experiences may be a frustrating yet motivating factor for parents when seeking care for their child. Future research is needed to assess how negative experiences with and attitudes about the health care system may affect help seeking. Additionally, future work is needed to promote positive health care experiences for African American families.
In contrast to our fourth hypothesis, mistrust of doctors was associated with higher odds of rapid care seeking and showed no association with deferred care seeking. Previous research suggests that mistrust of medical professionals is associated with delays in help seeking (39–42). However, most research on medical mistrust has focused on adults seeking care for themselves and not on parents making decisions for their children (43). It is possible that parents who mistrust doctors make different choices for their children than for themselves. For example, parents who mistrust doctors, perhaps because of previous negative health care experiences, may be more motivated to advocate for their child to receive rapid, high-quality care so that their family can avoid further negative experiences. Future work is needed to understand how medical mistrust may affect parental help seeking and to improve the trustworthiness of the mental health care system.
Our results also suggest that mental health knowledge and awareness play important roles in help seeking. Parents were more likely to rapidly seek care and less likely to defer care if there were other adults in the household with mental health challenges. Parents were also less likely to defer care if they had at least some college education. When other adults in the household have mental health challenges, parents may have increased awareness of the importance of seeking help and may already be connected to the mental health care system. Similarly, higher education levels may promote mental health awareness. Future interventions are needed to promote awareness about mental health. School districts can also promote mental health awareness by offering tests for emotional and developmental challenges, sponsoring information sessions, and following up with parents whose children may have an unmet need.
Our study had several limitations. First, we recruited a convenience sample of African American parents in North Carolina who were raising a child with emotional or developmental challenges. Educational attainment in our sample was close to the state average (21% with a college diploma or higher vs. 26% among all state residents in 2010–2014) (44). This robust distribution of education underscores the appropriateness of our sample for examining help seeking. However, our sample was more likely than the general public in the state to have low income (80% below $35,000 vs. 50% below $43,300 among all residents in 2010) (45). Additionally, the results may not generalize to other populations, and the cross-sectional study design limited our ability to establish causal relationships. Parents also self-reported data about barriers to help seeking and how long they waited before seeking care. Therefore, recall and other self-report biases may have affected results. We also did not have access to information about provider availability, which may influence help seeking (46).
Despite these limitations, our findings advance the literature beyond documentation of racial differences in help seeking. African American children are rarely prioritized in psychiatric research, and our study was among the first to assess factors associated with help seeking among African American parents—a population disproportionately exposed to structural barriers to receiving care. To our knowledge, this study was the first to use a theory-driven approach to test specific hypotheses about factors associated with help seeking and to jointly assess factors associated with rapid and deferred care seeking. Our findings indicate that a broad array of factors is associated with rapid and deferred care seeking and suggest that a range of strategies are needed to address unmet mental health needs. Additional research is necessary to prioritize the mental health needs of African American children and to test novel hypotheses with clear public health implications (e.g., regarding the effect of new interventions).
Conclusions
About one-fifth of African American parents raising a child with emotional or developmental challenges sought help for their child’s difficulties within 30 days, whereas almost one-half deferred care for ≥1 year. Given the low percentage of parents who rapidly sought care and the high percentage who deferred care, it is vital that child welfare professionals be informed about facilitators and barriers to mental health care seeking among African American families. Broader awareness of these factors could lead to interventions that facilitate rapid access to care and prevent deferred care (e.g., by removing cost-related obstacles).
References
1.
Perou R, Bitsko RH, Blumberg SJ, et al: Mental health surveillance among children—United States, 2005–2011. MMWR Suppl 2013; 62:1–35
2.
Cree RA, Bitsko RH, Robinson LR, et al: Health care, family, and community factors associated with mental, behavioral, and developmental disorders and poverty among children aged 2–8 years—United States, 2016. MMWR Morb Mortal Wkly Rep 2018; 67:1377–1383
3.
Whitney DG, Peterson MD: US national and state-level prevalence of mental health disorders and disparities of mental health care use in children. JAMA Pediatr 2019; 173:389–391
4.
Ghandour RM, Sherman LJ, Vladutiu CJ, et al: Prevalence and treatment of depression, anxiety, and conduct problems in US children. J Pediatr 2019; 206:256–267.e3
5.
Costello EJ, Pescosolido BA, Angold A, et al: A family network-based model of access to child mental health services. Res Community Ment Health 1998; 9:165–190
6.
Burkett K, Morris E, Manning-Courtney P, et al: African American families on autism diagnosis and treatment: the influence of culture. J Autism Dev Disord 2015; 45:3244–3254
7.
Dababnah S, Shaia WE, Campion K, et al: “We had to keep pushing”: caregivers’ perspectives on autism screening and referral practices of black children in primary care. Intellect Dev Disabil 2018; 56:321–336
8.
Jang J, Matson JL, Cervantes PE, et al: The relationship between ethnicity and age of first concern in toddlers with autism spectrum disorder. Res Autism Spectr Disord 2014; 8:925–932
9.
Alegria M, Vallas M, Pumariega AJ: Racial and ethnic disparities in pediatric mental health. Child Adolesc Psychiatr Clin N Am 2010; 19:759–774
10.
Planey AM, Smith SM, Moore S, et al: Barriers and facilitators to mental health help-seeking among African American youth and their families: a systematic review study. Child Youth Serv Rev 2019; 101:190–200
11.
Wells R, Hillemeier MM, Bai Y, et al: Health service access across racial/ethnic groups of children in the child welfare system. Child Abuse Negl 2009; 33:282–292
12.
Aarons GA, Brown SA, Hough RL, et al: Prevalence of adolescent substance use disorders across five sectors of care. J Am Acad Child Adolesc Psychiatry 2001; 40:419–426
13.
Farmer EMZ, Burns BJ, Chapman MV, et al: Use of mental health services by youth in contact with social services. Soc Serv Rev 2001; 75:605–624
14.
Mandell DS, Listerud J, Levy SE, et al: Race differences in the age at diagnosis among Medicaid-eligible children with autism. J Am Acad Child Adolesc Psychiatry 2002; 41:1447–1453
15.
Feinberg E, Silverstein M, Donahue S, et al: The impact of race on participation in Part C early intervention services. J Dev Behav Pediatr 2011; 32:284–291
16.
Mandell DS, Ittenbach RF, Levy SE, et al: Disparities in diagnoses received prior to a diagnosis of autism spectrum disorder. J Autism Dev Disord 2007; 37:1795–1802
17.
Mandell DS, Wiggins LD, Carpenter LA, et al: Racial/ethnic disparities in the identification of children with autism spectrum disorders. Am J Public Health 2009; 99:493–498
18.
Wang PS, Angermeyer M, Borges G, et al: Delay and failure in treatment seeking after first onset of mental disorders in the World Health Organization’s World Mental Health Survey Initiative. World Psychiatry 2007; 6:177–185
19.
Nguyen T, Tran T, Green S, et al: Delays to diagnosis among people with severe mental illness in rural Vietnam, a population-based cross-sectional survey. BMC Psychiatry 2019; 19:385
20.
Andersen RM: Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav 1995; 36:1–10
21.
Godoy L, Carter AS: Identifying and addressing mental health risks and problems in primary care pediatric settings: a model to promote developmental and cultural competence. Am J Orthopsychiatry 2013; 83:73–88
22.
Godoy L, Mian ND, Eisenhower AS, et al: Pathways to service receipt: modeling parent help-seeking for childhood mental health problems. Adm Policy Ment Health 2014; 41:469–479
23.
Mian ND, Eisenhower AS, Carter AS: Targeted prevention of childhood anxiety: engaging parents in an underserved community. Am J Community Psychol 2015; 55:58–69
24.
Acri MC, Bornheimer LA, O’Brien K, et al: A model of integrated health care in a poverty-impacted community in New York City: importance of early detection and addressing potential barriers to intervention implementation. Soc Work Health Care 2016; 55:314–327
25.
Thomas KC, Annis I, Ellis AR, et al: Parent activation and child mental health service use in African American families in a large cross-sectional study. Perm J 2020; 25:1
26.
Green AL, Lambert MC, Hurley KD: Measuring activation in parents of youth with emotional and behavioral disorders. J Behav Health Serv Res 2019; 46:306–318
27.
Cox DR, Snell EJ: Analysis of Binary Data. London, Chapman and Hall, CRC Press, 1989
28.
Hibbard JH, Greene J: What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health Aff 2013; 32:207–214
29.
Greene J, Hibbard JH: Why does patient activation matter? An examination of the relationships between patient activation and health-related outcomes. J Gen Intern Med 2012; 27:520–526
30.
Kimerling R, Pavao J, Wong A: Patient activation and mental health care experiences among women veterans. Adm Policy Ment Health 2016; 43:506–513
31.
Greene J, Hibbard JH, Sacks R, et al: When patient activation levels change, health outcomes and costs change, too. Health Aff 2015; 34:431–437
32.
Rosenfield S: Race differences in involuntary hospitalization: psychiatric vs. labeling perspectives. J Health Soc Behav 1984; 25:14–23
33.
Breland-Noble AM: Mental healthcare disparities affect treatment of Black adolescents. Psychiatr Ann 2004; 34:534–538
34.
Lindsey KP, Paul GL: Involuntary commitments to public mental institutions: issues involving the overrepresentation of Blacks and assessment of relevant functioning. Psychol Bull 1989; 106:171–183
35.
Rowan K, McAlpine DD, Blewett LA: Access and cost barriers to mental health care, by insurance status, 1999–2010. Health Aff 2013; 32:1723–1730
36.
Gulliver A, Griffiths KM, Christensen H: Perceived barriers and facilitators to mental health help-seeking in young people: a systematic review. BMC Psychiatry 2010; 10:113
37.
Godoy L, Hodgkinson S, Robertson HA, et al: Increasing mental health engagement from primary care: the potential role of family navigation. Pediatrics 2019; 143:e20182418
38.
Pearson JN, Meadan H: African American parents’ perceptions of diagnosis and services for children with autism. Educ Train Autism Dev Disabil 2018; 53:17–32
39.
Adams LB, Richmond J, Corbie-Smith G, et al: Medical mistrust and colorectal cancer screening among African Americans. J Community Health 2017; 42:1044–1061
40.
Hammond WP, Matthews D, Mohottige D, et al: Masculinity, medical mistrust, and preventive health services delays among community-dwelling African-American men. J Gen Intern Med 2010; 25:1300–1308
41.
Powell W, Richmond J, Mohottige D, et al: Medical mistrust, racism, and delays in preventive health screening among African-American men. Behav Med 2019; 45:102–117
42.
LaVeist TA, Isaac LA, Williams KP: Mistrust of health care organizations is associated with underutilization of health services. Health Serv Res 2009; 44:2093–2105
43.
Benkert R, Cuevas A, Thompson HS, et al: Ubiquitous yet unclear: a systematic review of medical mistrust. Behav Med 2019; 45:86–101
44.
Tippett R: NC in Focus: Increasing Educational Attainment. Chapel Hill, University of North Carolina, Carolina Demography, 2015
45.
Median Household Income, by State: Selected Years, 1990 Through 2010. Washington, DC, National Center for Education Statistics, 2011
46.
Thomas KC, Ellis AR, Konrad TR, et al: North Carolina’s mental health workforce: unmet need, maldistribution, and no quick fixes. N C Med J 2012; 73:161–168
Information & Authors
Information
Published In
History
Received: 10 September 2021
Revision received: 4 March 2022
Accepted: 1 April 2022
Published online: 9 June 2022
Published in print: December 01, 2022
Keywords
Authors
Competing Interests
The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.
Competing Interests
Dr. Sikich has received research funding from F. Hoffmann La Roche, serves on the communications and publications committee for its balovaptan program, is a member of the Healthy Weight Research Network, and serves on a study advisory board for Impel Neuroscience. The other authors report no financial relationships with commercial interests.
Funding Information
This work was supported by the National Institute on Minority Health and Health Disparities (P60 MD-000244). Dr. Richmond was supported by the Agency for Healthcare Research and Quality (grant T32 HS-026122) and a Loan Repayment Award from the National Cancer Institute (L60 CA-264691).
Metrics & Citations
Metrics
Citations
Export Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.
For more information or tips please see 'Downloading to a citation manager' in the Help menu.
View Options
View options
PDF/EPUB
View PDF/EPUBLogin options
Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.
Personal login Institutional Login Open Athens loginNot a subscriber?
PsychiatryOnline subscription options offer access to the DSM-5-TR® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.
Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).