• Service use;
  • child and adolescent mental health;
  • epidemiology


  1. Top of page
  2. Abstract
  3. Key Practitioner Message:
  4. Introduction
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. References

Background:  Most previous studies of service use in relation to mental health have examined services in the USA. We wanted to provide up-to-date findings from a general population sample of British schoolchildren.

Method:  A total of 2461 children aged 5–15 from the 1999 British Child and Adolescent Mental Health Survey were followed up for 3 years. We examine the relationship between a wide variety of potential predictors gathered in 1999 and the use of services over the following 3 years.

Results:  Contact with most services was predicted by three factors: the impact of psychopathology; contact with teachers or primary health care; and parents’ and teachers’ perceptions that the child had significant difficulties. Other predictors were specific to each service.

Conclusions:  Education of parents, teachers and other important adults might increase the proportion of children with impairing psychiatric disorders reaching services.


Development and Well-Being Assessment

Key Practitioner Message:

  1. Top of page
  2. Abstract
  3. Key Practitioner Message:
  4. Introduction
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. References
  • The impact of psychopathology on the child or on others predicted contact with most public sector services.
  • The recognition of psychopathology by key adults, particularly parents and teachers predicted contact with teachers, educational specialists and paediatrics in relation to mental health.
  • Regional differences in contact with public sector services for mental health services suggest that the organisation of services can influence who is and is not seen


  1. Top of page
  2. Abstract
  3. Key Practitioner Message:
  4. Introduction
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. References

In an ideal world, all children with an impairing psychiatric disorder would receive evidence-based interventions, administered by professionals with an appropriate level of expertise and/or supervision, from a service appropriate to their needs. One way of examining how close we have come to this goal is by studying the characteristics of children who are in contact with services. This proves complex since differences in sample selection, diagnostic criteria, case and service definition, age range and analysis mean that comparisons across studies should be interpreted cautiously (Roberts, Atkinson, & Rosenblatt, 1998). Some investigators have compared service users with non-service users without controlling for psychopathology and so interpretation of findings is difficult (Anderson et al., 1987; Feehan et al., 1990; Fergusson, Horwood, & Lynskey, 1993; Velez, Johnson, & Cohen, 1989).

However, psychopathology and impairment is associated with service contact in most, but not all studies (Angold et al., 2002; Laitinen-Krispijin et al., 1999; Pihlakoski et al., 2004; Sayal, 2004; Staghezza-Jaramillo et al., 1995; Sourander et al., 2005; Verhulst & Van de Ende, 1997; Zahner & Daskalakis, 1997; Zwaanswijk et al., 2003). Comorbidity, chronicity and parental, teacher or child's perception that there are problems are also associated with mental health service use (Koot & Verhulst, 1992; Sourander et al., 2001, 2005; Staghezza-Jaramillo et al., 1995; Wu et al., 1999; Zahner & Daskalakis, 1997). Three studies have reported on the importance of the impact of child psychopathology on the parent in determining service use (Angold et al., 1998; Brannan, Heflinger, & Foster, 2003; Sayal, 2004).

Most studies reported no gender effect on service contact after adjusting for gender differences in the prevalence of disorders; but those authors reporting a significant gender difference found a preponderance of boys (Angold et al., 2002; Katoaka, Zthang, & Wells, 2002; Zahner & Daskalakis, 1997; Zimmerman, 2005). Interactions have been reported between gender with age, psychopathology, neighbourhood and service setting (Cuffe et al., 1995; Gomez-Beneyeto et al., 1994; Gasquet et al., 1999; Laitinen-Krispijin et al., 1999). Few studies examining age detected an effect, although where it occurred older children were more likely to be seen (Katoaka et al., 2002; Wu et al., 1999; Zahner & Daskalakis, 1997). Several investigators have reported a positive association between physical illness and contact with mental health services (Gasquet et al., 1999; Wu et al., 1999; Zahner & Daskalakis 1997). Experiencing stressful life events and academic difficulties are also correlates in most studies (Briggs-Gowan et al., 2000; Zahner & Daskalakis, 1997; Zwaanswijk et al., 2003).

Authors are divided between non-significant findings and the over- or under-representation of children from ethnic minorities in services (Angold et al., 2002; Briggs-Gowan et al., 2000; Kataoka et al., 2002; Zahner & Daskalakis, 1997; Zwaanswijk et al., 2003; Zimmerman, 2005). The relationship between socio-economic status and service use for childhood psychopathology is unclear, with most papers reporting no statistical association and contradictory significant findings (Burns et al., 1995; Gasquet et al., 1999; Koot & Verhulst, 1992; Laitinen-Krispijin et al., 1999; Staghezza-Jaramillo et al., 1995; Zahner & Daskalakis, 1997). Some studies suggest that non-traditional family structure and parental psychopathology may be associated with mental health service use, while maternal age, employment and level of education seem not to be (Pihlakoski et al., 2004; Staghezza-Jaramillo et al., 1995; Verhulst & Van de Ende., 1997; Zwaaswijk et al., 2003; Zimmerman, 2005).

The region in which the child lives may influence service contacts (Leaf et al., 1996). Contact with non-mental health services may increase contacts with mental health services, while the evidence for heavier use in urban rather than rural settings is conflicting and may be related to the type of service (Burns et al., 1995; Gasquet et al., 1999; Offord et al., 1987; Zahner & Daskalakis, 1997).

Few studies have examined the correlates of contact with non-mental health services for mental health issues, despite the fact that Sourander and colleagues (2004) reported that parents preferred to seek help for children's emotional and behavioural problems from teachers, school nurses and school psychologists. Most studies suggest that the presence of psychopathology is related to use of these services, especially school-based services (Angold et al., 2002; Koot & Verhulst, 1992; Kumpulainen & Rasanen, 2002; Wu et al., 1999; Zahner et al., 1992). Three studies reported that younger children were more likely to access paediatrics, while older children were more likely to use school-based services, but an earlier study found more paediatric contacts among older children (Feehan et al., 1990; Angold et al., 2002; Zahner et al., 1992). While Feehan and colleagues (1990) documented increasing numbers of contacts with teachers for older girls, others have reported more access to school services for boys (Kumpulainen & Rasanen, 2002; Zahner & Daskalakis, 1997). Findings about socioeconomic status are similarly conflicting, with two studies suggesting that deprived families are more likely to access school services, in contrast to one suggesting that middle class families have higher rates (Koot & Verhulst, 1992; Kumpulainen & Rasanen, 2002; Zahner & Daskalakis, 1997). Finally, teacher perception of difficulties may aid access to school based services, as may parent and self-perceptions (Wu et al., 1999; Zahner & Daskalakis, 1997).

Much of the research discussed above was carried out in the USA, where public sector services are organised and financed differently. In Britain most of the studies were completed prior to the 1990s and since this time there have been changes in the organisation of services (Garralda & Bailey, 1988; Shepherd, Oppenheim, & Mitchell, 1966; Wolff, 1967). The aim of this study is to follow up a general population sample of British school children to investigate the characteristics of children and their families associated with contact with public sector services in relation to mental health. It is hypothesized that the impact of psychopathology on others would be stronger predictors of service contact than the impact of psychopathology on the child, and that there would be few differences in predictors between services at a national level.


  1. Top of page
  2. Abstract
  3. Key Practitioner Message:
  4. Introduction
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. References

Subjects and design

The British Child and Adolescent Mental Health Survey 1999 (Time 1) was a large (10,438) survey of children aged 5–15 years, selected from the child benefit register (Ford, Goodman, & Meltzer, 2003). All the children identified as having a psychiatric disorder (n = 911) and a random third (n = 3081) of those without from Time 1 were selected for follow-up at 2 years by a postal questionnaire (Time 2; 74% participated). At 3 years, all those who had returned the postal questionnaire (n = 2942) were invited to participate in a repeat of the baseline interview (Meltzer et al., 2003). Nine percent of children selected for the Time 3 follow-up were found to be ineligible, as they had died, moved out of the country, or were living in foster or institutional care. The response rate among those remaining was 88%, with 2461 children having data available at all three time points. This group forms the sample under study.

After both follow-ups, some parents were selected for telephone interviews about service use, either because of reported service contact (462 at Time 2, 411 at Time 3) or because the parents reported persistent concerns about their child's mental health but no service use (37 and 63 respectively). The telephone surveys obtained response rates of 88% at Time 2 and 85% at Time 3.


Psychopathology and characteristics of children and families in the baseline survey.

Psychiatric disorder was assessed using the Development and Well-Being Assessment (DAWBA); a structured interview was administered by lay interviewers to the parents or carers of all children, and also to the children themselves when they were aged 11 years or more. Besides administering the fully structured questions, the interviewers recorded detailed verbatim descriptions of any problem areas. An abbreviated version was mailed to the child's teacher. A small team of experienced clinicians used the information provided by all the informants, combining information as they would in the clinic, to make diagnoses according to ICD 10 criteria (World Health Organisation, 1993). Pilot studies of the DAWBA indicated excellent discrimination between community and clinical samples (Goodman et al., 2000). Within a community sample, children with DAWBA diagnoses differed markedly from those without a disorder in external characteristics and prognosis, while there were high levels of agreement between the DAWBA and case notes among the clinical sample (Kendall's tau b = 0.47–0.70). Children with disorder were divided into those with moderate or severe impairment based on the level of impairment described in the DAWBA interview.

Parents and teachers also completed the Strengths and Difficulties Questionnaire (SDQ), a well-validated and commonly used measure of childhood psychopathology (Goodman, 1999). The SDQ question on burden correlates highly (0.74, n = 506, p = .001) with one of the best known measures of the impact of childhood psychiatric disorder on parents, the Child and Adolescent Assessment of Impact (CAIA) (Goodman, 1999; Messer et al., 1996). In the interests of providing a teacher measure of burden and minimising missing data we used the SDQ burden question as a measure of impact. The SDQ impact scale also has a question about whether the parent considers their child to have mental health difficulties, which was used to estimate parental recognition of psychopathology.

Children were assessed using the British Picture Vocabulary Scale and the British Ability Scales Reading tests (Dunn, Whetton, & Burley, 1997; Elliott, Smith, & McCullock, 1996). Demographic details were collected during the parents’ interview, and included the child's general health and whether the child suffered from a list of conditions. A child was classified as having a ‘neurodevelopmental disorder’ if parents reported cerebral palsy, epilepsy, muscle disease or weakness, or co-ordination problems. The General Health Questionnaire assessed parental anxiety and depression on a dimensional scale (Goldberg et al., 1997), while the McMaster Family Assessment Device measured family functioning (Miller et al., 1985). Parents were asked whether 10 stressful life events had happened during their child's lifetime (Goodyer, Wright, & Altham, 1990). All three measures have been validated for use in population samples and performed well during the piloting procedure (Meltzer et al., 2000). We could not differentiate between families living in urban or rural areas, but we were able to examine differences between the south (Southeast, Southwest and eastern England) and the north (rest of England, Wales and Scotland) of Britain.

Service use in the follow-ups

The postal questionnaire at Time 2 and main survey at Time 3 presented parents with a list of services, asking if there had been contact for mental health issues since the original interview (at Time 2) or over the previous year (at Time 3). The telephone interviews used the Children's Service Interview, which combines a semi-structured approach with a structured screen, and shows moderate reliability and concordance with clinical records (Ford et al., 2007). As the telephone interviews provided the most detailed and accurate data, we have used these responses where present, defaulting to the main survey responses when no telephone interview was available. The Children's Services Interview was completed with over 70% of parents reporting service contact at each time point. We have combined information from both follow-ups to examine the predictors of service contact over the entire 3-year follow-up period. We classified services with universal access and a long-term relationship with children and their families as front line (primary health care and teachers), while services requiring a degree of impairment and/or a referral to access them as specialist (mental health services, paediatrics, social services and specialist educational resources).


Adjusting for the complex survey design.

With the exception of contact with front line services the analysis was restricted to measures of psychopathology and predictors gathered at baseline. The participants in both follow-ups were a socio-economically advantaged group with more traditional families and fewer children from the ethnic minority groups as compared to the original participants (analysis available on request). The parents of children with disorder were also less likely to participate, particularly if their child had a conduct disorder. The analysis was weighted to adjust for the differential selection and attrition according to psychiatric diagnosis, and the complex design of the baseline survey, so that our findings are representative of British school children. We used the Statistics/Data Analysis (STATA 8.0) survey package to adjust for the complex design (Stata Corporation, 2003).

Combining multiple measures into a single scale.

The generalised linear latent and mixed modelling (gllamm) program in STATA allowed us to combine the data for each individual about the impact of psychopathology on the child from the multiple available measures (parental and teacher SDQ total difficulty and impact scores, impairment related to psychiatric disorder and the number of disorders diagnosed) into a single scale (Rabe-Hesketh, Pickles, & Skrondal, 2001). A similar scale was devised to describe the impact of psychopathology on others based on teacher and parent SDQ burden score and contact with the police. This process reduced measurement error and provided estimates for individuals with at least one relevant item of data, thus minimising missing data; it also minimises problems that can arise when several variables are very closely related (collinearity).

Analysing the association between baseline characteristics and service use.

Each variable was examined in relation to every service. Characteristics that were associated with service use were entered into the multivariate analysis, which was performed in two stages. Variables were classified into four groups; factors relating to 1) psychopathology; 2) the child; 3) their family and 4) services. Each group of variables was examined in relation to each service using logistic regression analysis to establish the variables that continued to predict contact with that particular service after adjusting for all the other variables (independent predictors). Variables were entered all together, with the least statistically significant removed, until all those remaining were statistically significant at a probability of 0.05. The results of this interim analysis are not shown but are available from the corresponding author on request. All independent predictors from each of the four groups were entered in the final stage of multivariate analysis, which used the same strategy and was repeated for each service.


  1. Top of page
  2. Abstract
  3. Key Practitioner Message:
  4. Introduction
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. References

Bivariate analysis

Tables 1 and 2 present the bivariate analysis for categorical predictors and dimensional variables for all specialist services combined. The odds ratios in the table measure the strength of an association, so that an odds ratio of one indicates equal service use among children with or without a characteristic, or the lack of a statistical relationship between them. If the 95% confidence interval around the odds ratio does not cross one, there is a statistically significant association between that variable and contact with that service, and the bigger or smaller the odds ratio, the stronger the association. Thus, an odds ratio of 2.00, like that for reconstituted or single parent families in Table 1, indicates that these groups have double the specialist service use compared to the reference group, which in this case is children living in traditional families. Similarly, an odds ratio of 0.5, such as that for Asian children in Table 1, indicates that this group has half as many specialist service contacts as the comparison group (white children), although in this case the confidence interval spans unity, suggesting that this could just be a chance finding.

Table 1.   Bivariate analysis of categorical predictors of contact with any specialist services
Variable and number of cases (n)Contacts with any specialist service (%)Odds ratio (95% confidence) interval
Hyperkinetic disorder (n = 2461)63.516.90 (10.12–28.22)
Conduct disorder (n = 2461)49.411.00 (8.09–14.95)
Anxiety disorder (n = 2461)33.44.98 (3.55–6.98)
Depressive disorder (n = 2461)45.17.61 (4.35–13.32)
Male gender (n = 2461)11.81.48 (1.15–1.92)
Older age group (11–15 years) (n = 2461)10.81.16 (0.91–1.48)
Ethnic group (n = 2460)
 Black8.40.82 (0.32–2.12)
 Asian5.00.47 (0.15–1.47)
Poor general health (n = 2460)31.04.86 (3.53–4.70)
Neurodevelopmental disorder (n = 2461)37.05.86 (3.79–9.08)
Three or more stressful life events (n = 2461)18.72.39 (1.78–3.22)
Family type (n = 2450)
 Single-parent15.12.07 (1.54–2.79)
 Reconstituted16.32.27 (1.59–2.26)
Parental unemployment (n = 2461)19.42.52 (1.89–3.35)
Renting versus home owner (n = 2461)16.62.25 (1.73–2.94)
Three or more siblings versus two or less (n = 2461)19.52.20 (1.03–4.68)
Weekly income <£200 (n = 2352)15.91.97 (1.47–2.63)
No maternal qualifications (n = 2461)14.51.70 (1.26–2.29)
Parental occupation manual (n = 2422)11.01.18 (0.91–1.53)
Living in the south of Britain (n = 2461)10.61.11 (0.86–1.41)
Contact with primary health care (n = 2461)66.137.16 (26.80–51.53)
Contact with teachers (n = 2461)40.913.21 9.92–17.59
Table 2.   Dimensional predictors of contact with any specialist services
Variable and number of cases (n)MeanStandard errorOdds ratio (95% confidence interval)
  1. 1Odds ratio shows change per standard deviation as Z transformed; that is the mean is 0 and the standard deviation is 1).

Impact of psychopathology on the child (n = 2461)
 No contact− (2.38–3.93)
Impact of psychopathology on others (n = 2458)
 No contact− (2.59–3.28)
Parental recognition of child's difficulties (SDQ) (n = 2459)
 No contact0.40.013.65 (3.08–4.31)
Teacher recognition of child's difficulties (SDQ) (n = 2001)
 No contact0.30.013.06 (2.61–3.58)
Lower verbal intelligence quotient (n = 2371)
 No contact104.00.41.391 (1.17–1.65)
Lower reading ability (n = 2240)
 No contact106.50.41.641 (1.41–1.90)
Age of mother at birth of the child (years) (n = 2376)
 Contact28.40.11.02 (0.99–1.05)
 No contact27.90.4
Higher parental score for symptoms of anxiety and depression (n = 2453)
 No contact1.60.11.611 (1.45–1.78)
Poorer family function score (n = 2448)
 No contact24.50.031.381 (1.26–1.52)

The factors predicting service contact were also associated with psychiatric disorder in this sample. Ethnicity was not significantly associated with either service contact or psychiatric disorder, and was omitted from further analysis. The results for each service followed a similar pattern to those for all specialist services combined with the following exceptions. Mental health services were more likely to see boys than girls (66% versus 34%F = 14.0, p = .0002). Social services were more likely to be in contact with the children of younger mothers (mean age 26.1 versus 28.4 years, F = 11.9, p = .0006) and fathers who had a manual occupation (61% versus 44%, F = 8.1, p = .005); they were also marginally more likely to be in contact with children living in the south of Britain (55% versus 45%, F = 3.5, p = .06). Predictors of paediatric service use included coming from a large family (7.0% versus 1.4%, F = 14.7, p = .0001) and living in the north (68% versus 55%, F = 6.6, p = .01).

Independent predictors of service use

Table 3 shows the final model for contact with front line and specialist services which shows the association of predictors at baseline with service use over three years after taking account of all the other predictors. For ease of presentation, any variables that were not statistically associated with contact with any of the services after adjusting for other variables are omitted from this table, and only the odds ratios for the independent predictors are shown.

Table 3.   Odds ratios (95% confidence intervals) for the characteristics that predicted front line and specialist services in the multivariate analysis after adjusting for all the other variables (variables with no significant relationship with any service have been omitted from the table, and blank fields denote no significant relationship with that service)
PredictorContact with primary health care*Contact with teachersContact with mental health servicesContact with special educational resourcesContact with social servicesContact with paediatrics
  1. 1Odds ratio's represent the change per standard deviation * Interaction of age with contact with primary health care: figures in the table relate to older children, while those relating to younger children are described in the text.

Impact of psychopathology on the child1 1.26 (1.12–1.42)1.40 (1.07–1.84) 1.45 (1.13–1.86) 
Impact of psychopathology on others11.89 (1.51–2.50)1.94 (1.66–2.27)1.44 (1.07–1.92)1.59 (1.18–2.13)  
Parent recognition of child's difficulties (SDQ) 1.65 (1.06–2.58)   1.81 (1.28–2.57)
Teacher recognition of child's difficulties (SDQ)   1.53 (1.03–2.28)  
Older age*     
Male gender0.53 (0.33–0.86)0.51 (0.39–0.67)    
Poor physical health2.99 (1.57–5.69)     
Neurodevelopmental disorder  3.14 (1.10–8.93)  2.49 (1.07–5.79)
Three or more stressful life events  2.23 (1.19–4.20)   
Low reading quotient1    1.71 (1.23–2.39) 
Single parent family    3.17 (1.32–7.58) 
Rented housing    2.24 (1.00–5.02) 
Three or more siblings     6.07 (1.29–28.59)
Parental symptoms of anxiety and depression11.35 (1.11–1.62)1.26 (1.12–1.42) 1.37 (1.10–1.71)  
Contact with primary care  24.24 (13.54–43.40)6.17 (3.40–11.22)6.85 (3.06–15.36)11.18 (5.50–22.70)
Contact with teachers  2.11 (1.15–3.85)6.93 (3.91–12.26) 2.41 (1.24–4.66)
Living in the north of Britain    0.49 (0.24–0.96)1.87 (1.03–3.38)

Age modified the predictors of contact with primary health care, so the figures in the table relate to older children, while among younger children only the impact of psychopathology on the child (odds ratio 1.33, 1.06–1.68) and impact on others (odds ratio 1.98, 1.59–2.47) predicted contact with primary health care. There were more contacts relating to mental health with teachers among younger children, despite psychiatric disorder being commoner among older children. Children at primary school (5–11 years) tend to be taken to school and have a single class teacher, while secondary school pupils (11–16/18) arrive unaccompanied and have many teachers, which may impede contacts between parents and teachers.

Predictors remaining in the final model still acted in the same direction as their relationship with the presence of a psychiatric disorder, with the exception of the region of Britain in which the child lived. The strongest association in the final model for each specialist service was contact with front line services, with contact with primary health care most strongly related to specialist health service use, and with contact with teachers most strongly related to specialist educational resources. Taken together, the two impact scales predicted contact with all services except paediatrics, suggesting that most services are being accessed by children with the severest difficulties. Parental psychopathology and the perceptions of teachers and parents predicted contact with half of the services. Other predictors were fairly specific to the service. The predictors of contact with CAMHS (neurodevelopmental disorder and experiencing three or more life events) are well know risk factors for childhood psychiatric disorder, while it is not surprising that educationally and socio-economically disadvantaged children were most likely to have used social services, although living in the South was a less obvious predictor of contact with social services. Coming from a large family, living in the North and having a neurodevelopmental disorder was related to use of paediatric services.


  1. Top of page
  2. Abstract
  3. Key Practitioner Message:
  4. Introduction
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. References

Substantive findings

Our findings accord with the bulk of the literature in suggesting that the presence and severity of psychopathology was related to contact for mental health problems with all services except paediatrics (Briggs-Gowan et al., 2000; Farmer et al., 1997; Koot & Verhulst, 1992; Staghezza-Jaramillo et al., 1995; Zwaanswijk et al., 2003). There have been few previous studies of paediatric services but these have reported an association with the presence or impact of psychopathology and it is unclear why our findings should contradict them (Angold et al., 2002; North, 2001; Zahner & Daskalakis, 1997). It may be that the presence of universal primary care in Britain has influenced this study. The bulk of studies on predictors of service use have been carried out in the USA, where many paediatricians provide primary rather than secondary level care, and it is frequently unclear what type of paediatricians are being studied.

The relative importance of impact on others and impact on the child varied according to type of service. Impact on others seemed more important in relation to contact with educational specialists, teachers and primary health care in older children. Impact on others and on the child was roughly equally important in relation to mental health services. Impact on others did not predict contact with paediatrics or social services.

Contact with front line services was strongly associated with contact with specialist care, replicating the findings of earlier work, in line with the role of frontline services as gatekeepers to specialist services. Apart from contact with front line services and the impact of psychopathology, different baseline characteristics predicted contact with the different types of services.

Most of the predictors we detected had some support from the literature. In the case of mental health services, these predictors are known risk factors for psychiatric disorders. It seems intuitively plausible that teacher recognition of the child's difficulties is a prerequisite for contact with specialist educational services, and that the predictors of contact with social services are indicators of economic and educational disadvantage. The increased number of contacts with social services among children living in the south of Britain may relate to greater training opportunities for psychotherapeutic techniques available in London and the South East. Alternatively, great population mobility in the south of England might disrupt social networks, increasing the number of families approaching social services in crisis. Finally, parents may seize the chance to discuss mental health issues with the paediatric staff that they are already in contact with because of a neurodevelopmental disorder. Perhaps the same applies to parents of large families, who may be more likely to know paediatric staff via one of their children. The association between paediatric contact and living in the north of Britain may relate to a shortage of child psychiatrists and a higher percentage of children waiting more than 6 months to be seen by mental health services in the north of England revealed by administrative data collected at the same time as data for this study (

Methodological issues

This study used a nationally representative population sample, prospective collection of service use in relation to baseline predictors, and clearly defined services that were analysed separately. A few service contacts may have been missed as a result of the decision to interview only parents, although investigators have reported high levels of agreement about service contact between parents and children (Ascher et al., 1996; Stiffman et al., 2000). Data on contact with front line services were gathered at the same time as that on specialist services. Given that general practitioners and teachers are key referrers to CAMHS, the strength of association is not surprising; however, referral criteria are extremely varied across and within CAMHS, and some front line contacts will be related to ongoing difficulties and management, rather than merely seeking referral (Ford, Hamilton, & Goodman, 2005).

We combined data from different measures of service use because the restriction of the data to the telephone sample would have reduced the sample size by a factor of four and made it difficult to weight the sample back to the British population without introducing considerable bias. Analyses (available on request) revealed that while the telephone interview provided more accurate data on service contacts, the other measures provided good measures of ‘no service contact’. Importantly, the service contacts reported by parents who were not interviewed over the telephone were fairly evenly distributed across services.

The original survey took place in 1999, so the paper refers to service use between 1999 and 2002. Services are not static and the past few years have seen concerted attempts to expand child and adolescent mental health services and to rethink services for children in general (Chief Secretary to the Treasury, 2003; Department of Health, 2004). However, change occurs slowly in large organisations, and we think it unlikely that the predictors of service use will have changed greatly during the intervening years, even if the number of children supported by CAMHS may have increased a little.

Clinical and policy implications

Each service should be aware of the characteristics associated with the children it sees in order to consider which children may currently be underserved and how this situation might be redressed. Contact with front line services was associated with the use of specialist services and the perception that the child has significant difficulties by an important adult was associated with consultation with teachers, education specialists and paediatrics. Education to improve the recognition and management of child mental health problems should be part of the training programmes and the continued professional development of people working with children, particularly in primary health care and schools. Information for parents about child mental health can be effectively provided through the mass media, as indicated by the Triple P program in Australia (Sanders, Montgomery, & Brechman-Toussaint, 2000). However, the network of services involved in supporting child mental health is highly complex, and deficits or changes in one area may have unforeseen knock on effects on other services (Jenkins, 2001).


  1. Top of page
  2. Abstract
  3. Key Practitioner Message:
  4. Introduction
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. References

Services do seem to be accessed by those most in need in Britain. Nevertheless, teaching parents, teachers and general practitioners more about the nature and impact of child mental health problems might lead to more appropriate specialist referrals. On the whole, social and demographic variables did not predict contact with services, unless they were correlates of psychiatric disorder, suggesting that access was reasonably equitable in terms of the characteristics of the child and their family. In contrast, there were north-south variations in the likelihood of accessing paediatrics and social services, which might relate to geographical variation in the organisation or availability of services and training opportunities.


  1. Top of page
  2. Abstract
  3. Key Practitioner Message:
  4. Introduction
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. References
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