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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.
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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).
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.