Design
The study was a cross-sectional study, where parents of all children aged 2–17 years referred to outpatient CAMHS were invited to participate. Information about barriers to help-seeking was collected using the Children’s services interview[16].
Setting
The study was conducted at the only specialized CAMHS center in the North Denmark Region. The catchment area of the center covers both rural and urban areas with a total population of around 600.000. The center assesses and treats all psychiatric disorders for children aged 0–18 years of age. Denmark has a tax-funded public sector meaning that all public mental health services are free of charge. Access to CAMHS requires a formal referral from either a general practitioner or another medical doctor, an educational psychologist, or a caseworker in social services.
Eligibility criteria and recruitment
All parents or foster parents (henceforth just referred to as parents) who had a child referred between 1st and July and 31st of December 2018 were invited to participate.
Participants were excluded from the study, if the child was not a Danish resident; contact information on the parents was unknown, or the parents did not understand Danish.
When the CAMHS center received a referral letter for the child, an invitation to participate in the study was sent electronically to the parent along with a consent form. Two reminders were sent with three weeks interval to every eligible participant who had not responded before they were accepted as non-responders.
Procedures
After accepting to participate in the study, parents completed an electronic questionnaire comprising background information and the extended version of the Strength and difficulties questionnaire (SDQ). In addition, a research psychologist (CMJ) or medical doctor (ASH) conducted a telephone interview on barriers encountered in accessing services for their child’s mental health problem using the Children’s services interview.
Study participants were contacted up to three times to remind them to fill out the electronic questionnaire, and likewise three attempts were made to schedule the telephone interview before the data was accepted as missing.
Measures
The Children’s service interview is a service use measure, developed to be administered by telephone[16]. The first section uses a semi-structured approach to inquire about interventions received for the child’s mental health problems and the satisfaction with these within a set period. The second section examines reluctance to seek help and perceived barriers to accessing services. If a parent endorses a barrier, they are asked to specify how they experienced the specific barrier[17]. The length of the interview was between 30–60 minutes.
The extended version of the Strenght and difficulties questionnaire (SDQ)[18] is a short behavioral screening questionnaire about mental health symptoms and their impact [18]. Danish norms for SDQ scores exist[19].
Referral source and referral diagnosis was collected from the referral letters. Previous contacts with the regional CAMHS center and current referral decision were documented from the medical records.
Referral diagnoses were divided into I) Neurodevelopmental disorders (Attention deficit disorders (ADHD/ADD), autism spectrum disorders (ASD), and tic disorders), II) Emotional disorders (anxiety disorders, affective disorders, and eating disorders) and III) Others (psychosis, conduct disorders, attachment disorders, personality disorders, and unspecified mental health problems). The referral diagnoses used were the referral reason stated on the referral letter to CAMHS, and therefore not verified CAMHS diagnoses.
Analyses
Continuous variables are presented with medians and interquartile ranges (IQR), and categorical variables with frequencies and percentages. T-test were conducted for continuous variables and Fischer’s exact test for categorical variables.
Logistic regression was used to test for specific barriers’ association with age, referral diagnosis, symptom duration prior to referral, and impairment score above the norm on the SDQ. All logistic regression analyses were tested with bootstrap using 200 repetitions. Adjusted logistic regression analyses were controlled for sex, placement outside the home, previous psychiatric assessment, age, referral diagnosis, symptom duration, and impairment above the norm on SDQ.
The level of statistical significance was set at 5% for all analyses. All statistical analyses were executed using Stata Statistical Software: Release 15. College Station, TX: StataCorp LLC.
To examine reasons for perceived barriers, the specification of why a barrier was endorsed was systematically examined by ASH using semantic thematic analysis [20]. This qualitative method for analyzing the responses was selected, despite the data not fulfilling the criteria for qualitative data, as it is not verbatim transcriptions, to better understand the different reasons as to why parents perceived different barriers to exist.