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Parents identification and help-seeking behaviours around Child Mental Health difficulties

11 April 2019

Author: Sam Game, M.Sc. CAMH, B.Sc. (Hons) RGN, B.Sc. (Hons) SCPHN
 


Current appointment: Clinical Lead for Health Visiting, South Warwickshire Foundation Trust; Clinical Director, Standing in the Gap (An Early Intervention Mental Health charity) www.sitgap.org

This paper is drawn from my Dissertation completed as part of the MSc CAMH at the University of Northampton

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Key take home messages:

  • 78% of parents correctly identified that their child had a mental health difficulty, consistently around 50% of these parents asked for help. 
  • Parents with degree level education were five times more likely to correctly identify mental health problems in their children, than parents educated up to A level. 
  • Non-working parents were far more likely to have children with mental health difficulties (79% [59, 86]) than were working parents (27% [22, 34]). 
  • Parents with their own mental health diagnosis mis-identified 29% [15, 47] of these children as having mental health problems, whereas those without their own diagnosis mis-identified only 8% [5, 15] of healthy children.


Abstract


Overall purpose/aim: The aim of the study was to review a parent’s ability to identify and ask for help for their children’s mental health difficulties. The questions considered were: do demographic factors (gender, marital status, ethnicity, academic achievement, employment status and number of children) or a personal experience of mental health difficulties impacted on parent’s ability to identify mental health problems in their children and seek help.

Study design: A paper questionnaire was given to parents through three primary schools. This included a Strengths and Difficulties Parent Questionnaire for 4-17 year-olds and other sections on help seeking.

Results: 210 parents completed the questionnaire for 268 children. Parents were better at identifying problems in their children than if left to chance. Where such difficulties existed, parents correctly identified them in 78% [68, 86] of the cases. Parents were even better (90% [85, 94]) at correctly recognising cases where their child did not have diagnosable mental health difficulties. However, parents who have experienced a mental health problem were more likely to misdiagnose their children with difficulties (29%) than parents who didn’t have a mental health problem (8%). Consistently throughout the results 50% of parents asked services for help. Regarding demographic differences: Parents with degree level education were five times more likely to correctly identify mental health problems in their children, than parents educated up to A level.  Non-working parents were far more likely to have children with mental health difficulties (79% [59, 86]) than were working parents (27% [22, 34]).

Conclusions: An increasing number of parents with mental health difficulties were more likely to have children with mental health difficulties, however they were also more likely to misdiagnose concern.  It can be suggested that this makes these families more vulnerable requiring extra professional awareness and support. Although more research is required to analyse why, it is recommended that professional awareness is raised to the fact that only 50% of parents sought help during the study 



Introduction


Trends from national surveys reveal a slight increase over time in the prevalence of mental health disorders in 5 to 19-year-olds, rising from 9.7% in 1999 and 10.1% in 2004 to 12.8% in 2017 (NHS Digital, 2018). The 2017 National study (NHS Digital, 2018) showed about one in ten (9.5%) 5 to 10 year olds had at least one mental health disorder and about one in thirty (3.4%) met the criteria for two or more mental health disorders. Behavioural disorders (5.0%) and emotional disorders (4.1%) were the most common in this age group (NHS Digital, 2018).

Parents are key in identifying problems with, and seeking help for, their children. Sayal (2006) identified that parents have a central role in seeking help for early behavioural or emotional problems. However, Alexander, Brijnath & Mazza (2013) found that parents frequently lacked awareness of early child mental health problems and the importance of early intervention. Similarly, Oh & Bayer (2015) found that 66% of parents did not recognise when their child had a mental health difficulty. Ohan et al (2015) found that a small number of parents held the belief that no external help was needed for their child, instead viewing their child’s problem as a developmental stage or that their own efforts could resolve the problem. Schraeder and Reid (2015) found that parents familiar with the mental health services for themselves, made greater efforts in seeking help for their child. In considering the barriers to parents seeking help for child mental health difficulties Gulliver, Griffiths & Christensen (2010) showed the key barriers to be: stigma, confidentiality issues, lack of accessibility, self-reliance, low knowledge about mental health services and fear/stress about the act of help-seeking or the source of help itself.
This study, completed as part of a master’s dissertation in Child and Adolescent mental health, looks at parents’ identification of child mental health difficulties and whether they would seek help for their children. It was carried out with parents from three primary schools within a market town in the Midlands. 



Study aim / purpose


The full study contained six hypothesis areas. For the purpose of this paper two hypotheses around parents’ identification and help seeking behaviours will be considered. Firstly, the hypothesis that demographic factors will affect a parent’s ability to identify a problem and seek help for their child. The demographic factors considered were gender, marital status, ethnicity, academic achievement, employment status and number of children. Secondly the hypothesis that parents who have experienced a mental health problem are more likely to identify mental health problems in their children and seek help for them. 

 

Research Methods


A paper questionnaire was used to seek parent views. The advantages of using the questionnaire is that it is a standardised research tool capturing a wider data set and providing replication; the disadvantages include the possibility of it being time and mood sensitive as to how parents answer the question (Oppenheim 1992). No one available ‘score’ adequately covered the hypotheses, so a number of scores were used within the questionnaire, which was broken into four sections. Section one was ‘About the parent’ and included demographic information. The questions included were the same categories as used in the national census collection. Parents were then asked about their own mental health in a series of tick box questions with the option of ‘prefer not to say’. 


Section two was ‘Asking for help’ and asked parents a series of questions around how likely they were to seek help for their child? Who they would seek help from? If they felt they needed professional advice who they would approach? And what barriers they felt there were for parents asking for help around their child’s mental health? This was a series of tick boxes, taken from previous research and an open comments box of ‘other’. 


Section three contained the Strengths and Difficulties Parent Questionnaire for 4-17-year-olds (SDQP 4-17). The SDQ is well used within research as it has been shown to have good reliability and validity (r=0.74) (Goodman, 1997). Goodman, Renfrew and Mullick (2000) showed the agreement between SDQ prediction and an independent clinical diagnosis was substantial and highly significant (Kendall's tau b between 0.49 and 0.73; p<0.001). It identified individuals with a psychiatric diagnosis with a specificity of 94.6% (95% CI 94.1-95.1%) and a sensitivity of 63.3% (59.7-66.9%) (Goodman et al 2000) indicating it is a viable parent reporting measure.


Section four of the questionnaire asked about the parent’s views on the support available and is not relevant for the two hypotheses in this paper. 


The research was reviewed and approved by the University of Northampton Psychology Ethics Board. Prior to starting the main study, a pilot study with five parents was completed and amendments were made to the study design following this.


Participants 


Three primary schools agreed to participate in the study: a small rural school, a large school in an affluent area and a large school in a ward in the top 20% of deprivation in the country. Each parent (n=751) received a parent pack containing an introductory letter, the questionnaire and an information sheet. This explained that the questionnaire would take around 20 minutes to complete and should be returned in the envelope provided back to school, where it was placed in a sealed box. The parent information sheet contained more detailed information explaining how anonymity would be maintained and how parents could withdraw from the study. Consent was achieved by including a series of tick boxes on the front of the questionnaire. Once collected the questionnaires were stored in a locked filing cabinet to ensure confidentiality. Questionnaire responses were coded upon collection and inputted into a spreadsheet allowing statistical analysis. As it was a paper questionnaire a face to face debrief was unachievable, however given the sensitive and potentially emotive subject matter, a section of the information sheet included signposting options where parents could get support. 


Participants were advised that the research was being carried out in accordance with the British Psychological Society’s code of ethics and conduct (2009) and in compliance with the Data Protection Act (1998).


Results 


210 out of 751 parents completed and returned their paper questionnaires on a total of 268 children, giving a response rate of 28%. 

 

Child mental health incidence using the SDQ


Each of the SDQ parent scores submitted were analysed using the SDQ scoring system.  A total difficulties score was calculated along with an externalising, internalising and impact score. The scores were evaluated using the three-band categorisation of parent completed SDQs, giving a normal, borderline or abnormal categorisation of mental health difficulties. Analysis of the sample (n=268) showed a 30% rate of abnormal categorisation of mental health difficulties. 
Of the children with mental health difficulties:

  • 58% were boys and 42% were girls.
  • 55% (44 children) had one diagnosable difficulty. 
  • 29% (24 children) had two diagnosable difficulties.
  • 16% (13 children) had three diagnosable difficulties. 
  • 53% of children had internalising disorders (Emotional and Peer problems). 
  • 47% of children had externalising disorders (Conduct and Hyperactivity problems). 
  •  

Demographic factors impact on parent’s problem identification and help-seeking behaviours

The demographic factors considered in the study were: gender, marital status, ethnicity, academic achievement, employment status and number of children. The data is analysed in terms of the size of the observed effects and the margin of error (or confidence interval) associated with that effect.  Where confidence intervals are used, they are the 95% confidence interval, unless otherwise specified.  


Gender

 

Out of a total of 268 questionnaires returned, 245 were completed by mothers (95%) and 22 were completed by fathers (5%). How gender impacts on identifying a difficulty and asking for help is shown in Table 1. Mother’s feelings were consistent with the SDQ 79% of the time (4 out of 5 cases) for children with diagnosable mental health difficulties, but they missed 21% of these cases (1 out of 5). For children without diagnosable mental health difficulties, mothers were correct 85% of the time (about 6 in 7 cases) but perceived problems were not supported by the SDQ scores in 15% (or 1 in 7) of the cases. The data from the 22 fathers who responded is too sparse to draw conclusions about fathers’ perceptions more generally. However, it is worth noting that no fathers asked for help, although all 22 responded to that question. In response to the question “Do you think your child has a difficulty?” two fathers did not respond. 


Among the children with diagnosable mental health difficulties that were recognised by the mothers, just over half of these mothers (56%) asked for help. The same pattern held for cases where mothers perceived a problem that was not supported by the SDQ scores: 54% of these mothers asked for help.


Marital Status

For simplicity this was divided into two parents in the home (n= 173, 84%) and one parent in the home (n= 32, 16%). Table 2 shows this in relation to asking for help and identifying a mental health difficulty. For children with diagnosable mental health difficulties, single parents recognised that there was a difficulty 88% [64, 97] of the time, whereas two-parent household recognised the situation 75% [64, 84] of the time.  The substantial overlap of the confidence intervals with the percentage observed in the other group provides evidence that any difference based on the number of parents is likely to be negligible.  

For children without diagnosable mental health disorders, single parents were correct in 85% [64, 95] of the cases, whereas two-parent households were correct in 88% [81, 92] of the cases.  Again, the data provides evidence that any difference between one- and two-parent households is negligible. 

Again overall, about half of the parents who perceived a problem asked for help.

 

Ethnicity

 

The sample showed 93% respondents were white British or white other, 4% were black African, 1% were Indian and 2% were Pakistani. For simplicity this was divided into two categories ‘white’ and ‘other ethnic groups’ as shown in Table 3. In this study the ‘other ethnic group’ is small (7%), so it is difficult to draw conclusions. However, patterns between ‘white’ and ‘other ethnic’ parents are similar: For children with diagnosable mental health difficulties, 77% of white parents and 67% of other ethnic parents had feelings that were supported by the SDQ diagnosis. For children without mental health difficulties, the percentage correct was 86% for white parents and 87% for other ethnic group parents. 


Roughly half of the parents who perceived a problem asked for help, regardless of ethnicity.

 

Academic achievement

 

To aid analysis educational capacity was compressed into two categories: Up to A levels, and Higher education. 202 parents responded to the question “What is your highest educational qualification?” 140 parents (70%) were educated up to A levels, while 62 parents (30%) had received a higher education. Table 4 shows how parental education achievement collates with identifying difficulties and asking for help. The effect of education level is quite clear in terms of perceiving mental health difficulties for children deemed as diagnosable based on the SDQ. For parents with degree level education, only one missed the signs, producing a hit rate of 16:1, whereas for parents with the highest qualification at A-levels, the hit rate was only roughly 3:1.  

Parents with degrees were thus more than five times as likely to correctly identify mental health problems in their children. Parents at all educational levels were equally likely to perceive a mental health difficulty in cases that were not identified by the SDQ, with a false alarm rate of roughly 1 in 7. 

Again, across all groups, roughly half of the parents who perceived a problem had asked for help.

 

Employment Status


When asked about their employment status 205 parents responded, for simplicity this was analysed as any parent in the house working or not working as seen in Table 5. Employment status was clearly not related to recognising mental health difficulties where they exist, with both groups recognizing the problem roughly 3 times out of 4 or 75% of the time. Where the SDQ does not identify mental health difficulties, non-working parents were slightly more likely to feel that their child had a mental health difficulty than were working parents. Roughly 1 in 7 (13% [9, 19]) working parents felt that their child had a mental health difficulty whereas 1.5 in 7 (18% [6, 41]) non-working parents did so. No conclusions can be drawn about whether or not this small observed difference would persist in the wider population because of the very small numbers in the non-working category, leading to a very wide margin of error for that observation.


It is worth noting that non-working parents were far more likely to have children with mental health difficulties (79% [59, 86]) than were working parents (27% [22, 34]). As for non-working parents the odds of a child having mental health difficulties in this sample were 4:1, or four of every five children, whereas for working parents the odds were only 1:4 or one of every five children.  As the sample of non-working parents (n=38) is small it would indicate that more research is needed in this area.
Number of children in the household


The results showed 95% of the respondents’ children came from families with between one and three children. For parents of children with diagnosable mental health difficulties, the number of children in the household has, at most, only a negligible effect on the likelihood that they will perceive the problem. For smaller families the problems were noticed by 81% [61,89] of parents whereas for larger families the problems were noticed 72% [54, 85] of the time, well within the margin of error for the smaller families. 


For parents of children not identified by the SDQ, in smaller families problems were nevertheless perceived by 15% [10, 22] of the parents, whereas in larger families only 8% [3, 20] felt that there was a problem.  This small difference may not be reliable: The margin of error for the larger families includes the 15% observed for the smaller families. Once again, across all groups, roughly half of the parents who perceive a problem seek help. 

 

Parents with a Mental Health diagnosis


When asked if they had their own mental health diagnosis, 22% of parents said they had. This ranged from: depression (54%, n= 31); anxiety (36%, n=21); postnatal depression (14%, n=8) to the less common OCD (0.4%, n=1) and an eating disorder (0.4%, n=1). Table 7 shows how parental diagnosis relates to identifying a problem with their child and asking for help. Interestingly, whether or not parents had a mental health diagnosis made no difference in terms of whether or not they recognised diagnosable mental health problems in their children; they successfully did so 80-81% of the time.

Being diagnosed with a mental health problem was, however, related to a greater likelihood of perceiving mental health problems in children without diagnosable mental health difficulties. Parents with their own mental health diagnosis mis-identified 29% [15, 47] of these children as having mental health problems, whereas those without their own diagnosis mis-identified only 8% [5, 15] of healthy children.


Once again, across all groups, roughly half of the parents who perceived problems asked for help. Therefore, the results do not support the hypothesis that parents who have experienced a mental health problem are more likely to identify mental health problems in their children and seek help for them. It would indicate that parents who have experienced a mental health problem were more likely to misdiagnose their children with difficulties than parents who didn’t have a mental health problem: 


Conclusion


In looking at parents’ ability to identify problems in their children it can be seen that parents were far better than chance at correctly identifying signs of mental health difficulties in their children.  Where such difficulties exist, based on the SDQ, they correctly identified them in 78% [68, 86] of the cases, missing 22% [14, 32] of these cases. Parents were even better (90% [85, 94]) at correctly recognizing cases where their child did not have diagnosable mental health difficulties.

However, parents who have experienced a mental health problem were more likely to misdiagnose their children with difficulties (29%) than parents who didn’t have a mental health problem (8%). This would indicate that while these parents had more children with mental health difficulties, they also made more misdiagnoses and therefore were a more vulnerable group requiring extra professional awareness and support.

What could be seen was that children with diagnosable mental health difficulties were more likely to come from homes where the parent has less education, is a single parent and is not in work. The impact of education showed that parents with a higher education qualification were more accurate at identifying mental health difficulties in their children (hit rate 16:1) compared to lower educated parents (hit rate 3:1). This pattern would suggest that it is more important for professionals to be aware of children in lower educated families as parents are less likely to raise concerns as frequently as higher educated parents.
What has been seen consistently throughout the results is that around 50% of parents did ask for help. This ratio appears not to be influenced by any of the factors examined here, except perhaps the parent’s gender. There were too few fathers’ responding to enable any conclusions about the role of parent’s gender. This would certainly indicate that further research is needed to identify what prevents parents asking for help would be useful.

 

Implications and recommendations


Compared to the national 2017 study (NHS Digital, 2018), this study showed a higher rate of mental health difficulties 30% compared to 12.8%. However, as the school volunteered to participate and the parents self-selected by whether they responded it may be that school with more children experiencing difficulties wanted to take part and parents with children with child mental health difficulties were more motivated to answer a questionnaire around child mental health difficulties. Therefore, the results of incidence of difficulties should be reviewed in this manner.


That 78% of parents could accurately identify if their child had a mental health difficulty is a much better picture than seen in the Oh & Bayer (2015) research that found that 66% of parents did not recognise when their child had a mental health difficulty. While identification has improved, which is positive, only around 50% of parents who have a child with difficulties then asked for help. Action to address the reluctance to ask for help would put a strain on the underfunded systems that we have, but it could make a substantial difference to obtaining appropriate treatment and support for families and children with mental health difficulties, provided we could understand the reasons for the reluctance and overcome it. Kataoka, Stein, Nadeem & Wong (2007) found that a third of parents did not follow through after receiving a referral to child mental health service and Bussing, Zima, Gary & Garvin (2003) found 66% of parents believed no services were needed despite having recognised a problem. At the end of the questionnaire parents were given an open text box to tell us anything else they felt was relevant. One parent made an astute comment:


‘If your child broke a limb, everyone knows where to get it fixed. If your child’s head or mind started to break, it’s not clear where to go to get it fixed.’ 


This mum identified she did not know who to ask for support, therefore practitioners and education professionals need to be proactive in offering support. However, a lack of available service provision can inhibit both the referrals and offers of support to parents. A more joined up provision of adequate and robust Tier 1 and 2 provision for child mental health is required nationally with suitably trained and funded professionals to allow issues to be dealt with effectively at an early intervention stage instead of waiting for the entrenchment of conditions before a referral is made into an overburdened service with lengthy waiting lists. 

Tables:

Table 1: Gender of parents and whether they felt their child had a mental health difficulty and asked for help. The cells highlighted in yellow are where parents' feeling match SDQ dianosis criteria

 

Children without diagnosable mental health difficulties (n=186)

 

Children with diagnosable mental health difficulties (n=81)

Parent completed questionnaire

Mother

Father

 

Mother

Father

Parent felt child had a difficulty

24

0

 

62

1

Parent felt child had no difficulty

140

17

 

16

2

Parent asked for help

13

0

 

35

0

Parent did not ask for help

146

19

 

43

3

 

Table 2: Number of parents in the home and whether they felt their child had a mental health difficulty and asked for help. The cells highlighted in yellow are where the parents' feeling match SDQ diagnosis criteria.

 

Children without diagnosable mental health difficulties (n=186)

 

Children with diagnosable mental health difficulties (n=81)

Number of parents in the home

One

Two

 

One

Two

Parent felt child had a difficulty

3

20

 

14

49

Parent felt child had no difficulty

17

140

 

2

16

Parent asked for help

3

10

 

7

28

Parent did not ask for help

18

146

 

9

37

 

 

 

Table 3: Ethnicity and whether they felt their child had a mental health difficulty and asked for help. The cells highlighted in yellow are where parents' feeling match SDQ diagnosis criteria.

 

Children without diagnosable mental health difficulties (n=186)

 

Children with diagnosable mental health difficulties

(n=81)

Ethnic group

White

Other

 

White

Other

Parent felt child had a difficulty

22

2

 

58

2

Parent felt child had no difficulty

138

13

 

17

1

Parent asked for help

12

1

 

32

1

Parent did not ask for help

145

14

 

42

3

 

Table 4: Education level and whether parents felt their child had a mental health difficulty and asked for help. The cells highlighted in yellow are where parents' feelings match SDQ diagnosis criteria.

 

Children without diagnosable mental health difficulties (n=186)

 

Children with diagnosable mental health difficulties

(n=81)

Education level:

Up to A levels

Higher Education

 

Up to A levels

Higher Education

Parent felt child had a difficulty

16

8

 

47

16

Parent felt child had no difficulty

105

52

 

17

1

Parent asked for help

9

4

 

29

6

Parent did not ask for help

112

53

 

35

11

 

 

Table 5: Employment status and whether parents’ felt their child had a mental health difficulty and asked for help. The cells highlighted in yellow are where parents' feeling match SDQ diagnosis criteria.

 

Children without diagnosable mental health difficulties

(n=186)

 

Children with diagnosable mental health difficulties

(n=81)

Employment status:

Working

Not working

 

Working

Not working

Parent felt child had a difficulty

21

3

 

46

17

Parent felt child had no difficulty

143

14

 

14

4

Parent asked for help

10

3

 

27

9

Parent did not ask for help

151

14

 

33

13

 

Table 7: parents' own diagnosis of mental health problems and whether they felt their child had a mental health difficulty and asked for help. The cells highlighted in yellow are where parents' feeling match the SDQ diagnosis criteria.

 

Children without diagnosable mental health difficulties (n=186)

 

Children with diagnosable mental health difficulties (n=81)

Parents’ own mental health diagnosis:

No

Yes

 

No

Yes

Parent felt child had a difficulty

9

8

 

32

22

Parent felt child had no difficulty

97

20

 

8

5

Parent asked for help

4

4

 

17

14

Parent did not ask for help

102

24

 

24

12

 

 

References

Alexander K, Brijnath B, & Mazza D. (2013). “Can they really identify mental health problems at the age of three?” Parent and practitioner views about screening young children’s social and emotional development. The Australian & New Zealand Journal of Psychiatry 47 (6): 538-545.  See https://www.ncbi.nlm.nih.gov/pubmed/23399856 (accessed 21 March 2019).

Bussing R, Zima B, Gary F, & Garvan C. (2003). Barriers to detection, help-seeking, and service use for children with ADHD symptoms. Journal of Behavioural Services & Research, 30: 176-189. See https://www.ncbi.nlm.nih.gov/pubmed/12710371 (accessed 21 March 2019).

Goodman R. (1997) The strength and Difficulties Questionnaire: A research note. Journal of Child Psychology and Psychiatry, 38: 581-586. See https://www.ncbi.nlm.nih.gov/pubmed/9255702 (accessed 21 March 2019).

Goodman R, Renfrew D, Mullick M. (2000). Predicting type of psychiatric disorder from Strengths and Difficulties Questionnaire (SDQ) scores in child mental health clinics in London and Dhaka. European Child and Adolescent Psychiatry, 9: 129-134. See https://www.ncbi.nlm.nih.gov/pubmed/10926063 (accessed 21 March 2019).

Gulliver A, Griffiths KM, & Christensen H. (2010). Perceived barriers and facilitators to mental health help seeking in young people: a systematic review. BMC Psychiatry, 10: 113. See https://bmcpsychiatry.biomedcentral.com/articles/10.1186/1471-244X-10-113 (accessed 21 March 2019).

Kataoka S, Stein B, Nadeem E, & Wong M. (2007). Who gets care? Mental Health Services use following a school-based suicide program. Journal of the American Academy of Child and Adolescent Psychiatry, 46: 1341-1348. See https://www.ncbi.nlm.nih.gov/pubmed/17885576 (accessed 21 March 2019).

NHS Digital. (2018). Mental health of Children and Young People in England, 2018, Summary of key findings. See https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2017/2017 (accessed 21 March 2019)

Ohan JL, Seward RJ, Stallman HM, Bayliss DM & Sanders MR. (2015). Parents’ barriers to using school psychology services for their child’s mental health problems. School Mental Health, 7(4): 287-297. See https://link.springer.com/article/10.1007/s12310-015-9152-1 (accessed 21 March 2019).

Oh E. & Bayer J (2015). Parents health seeking processes for early childhood mental health problems. Child and Adolescent Mental Health 20 (3): 149-154. See https://onlinelibrary.wiley.com/doi/abs/10.1111/camh.12081 (accessed 21 March 2019).

Oppenheim AN. (1992). Questionnaire design, interviewing and attitude Measurement. New York. Continuum.

Sayal K. (2006). Annotation: pathways to care for children with mental health problems. Journal of Child psychology and Psychiatry, 47: 649-659. See https://www.ncbi.nlm.nih.gov/pubmed/16790000 (accessed 21 March 2019).

Schraeder KE & Reid GJ. (2015). Why wait? The effect of wait-times on subsequent help-seeking among families looking for children’s mental health services. Journal of abnormal child psychology, 43(3): 553-565. See https://www.ncbi.nlm.nih.gov/pubmed/25178864 (accessed 21 March 2019).

 

Acknowledgements

To the primary schools and parents who participated and to Dr Catherine Fritz as my Dissertation supervisor.

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