This review synthesised findings from 44 studies addressing parental perceptions of barriers/facilitators to seeking and accessing help for mental health problems in children and adolescents. Perceived barriers/facilitators related to four key themes emerged across studies (displayed in Fig. 2).

In relation to systemic-structural issues surrounding the mental health system, the demand on services emerged as a perceived barrier internationally, reported in studies conducted in the UK, USA, Australia, and Canada. Importantly, waiting times and difficulty getting a referral were most commonly reported as barriers among samples of service users, suggesting that it is after some experience of waiting to access services (or experiencing difficulty accessing services) that these issues often become most pertinent to families. In contrast, the barrier posed by the cost of services (or associated insurance issues) was most frequently reported among community samples in USA, suggesting the ‘threat’ of paying fees to access services can actually deter families from attempting to seek help at all. Other indirect costs associated with service use, such as loss of wages and travel costs, were less commonly reported as barriers within and across studies, but, nevertheless, highlight how certain family circumstances (e.g., living in a rural area) may increase the likelihood that aspects of the mental health system present a barrier to access. Equally, findings indicated that some parents perceive logistical aspects of mental health systems (such as the appointment/administrative system and the location of services) as both barriers and facilitators to seeking and accessing help—but the wide variation in the frequency with which these issues were reported across studies highlights how both variations in mental health systems (e.g., presence/absence of flexible appointment systems/convenient services) and variation in family circumstances (e.g., access to transport and time available to attend appointments) may influence the likelihood that parents perceive such issues as barriers.

A range of views and attitudes towards services and treatment emerged as perceived barriers/facilitators, and notably, these views and attitudes often appeared to be shaped by the previous experience with the mental health system (or contact with services/professionals more generally). In particular, feeling not listened to or dismissed/blamed by professionals was frequently reported as a barrier to seeking and accessing help across qualitative studies; and equally, the perceived benefit of ‘supportive’ professionals was also evident. Similarly, trust and confidence in professionals, views surrounding the quality of services, and views relating to specific professionals (e.g., teachers, GPs) were all identified as presenting barriers/facilitators to both seeking and accessing help across diverse samples. Other attitudinal barriers/facilitators related to the consequences of treatment also emerged, including beliefs surrounding the effectiveness or relevance of treatment, fears surrounding the negative consequences of treatment, and fears associated with treatment itself. However, more notable was the frequency with which parents across studies reported the detrimental impact of perceived negative attitudes of others (as well as personal discomfort surrounding mental health) on help seeking.

Knowledge surrounding both mental health problems and the help seeking process emerged as perceived barriers and facilitators across a wide range studies. The large number of studies—and the large number of participants within some studies—that reported barriers related to not knowing where or how to seek help was particularly salient. Interestingly, among studies that addressed recognition of a child’s mental health problem, relatively large numbers of parents reported perceived difficulties identifying a problem (or a child’s lack of recognition) as a barrier to seeking help, and similarly, parents’ perception of the importance of recognition of the severity and impact of a problem was also clear in some studies.

Perceived barriers/facilitators relating specifically to family circumstances, such as other commitments or responsibilities and a family’s support network, were less commonly directly addressed in studies than other types of barriers/facilitators. Nevertheless, these issues were raised in qualitative studies, and reported by a sizeable minority of participants in several quantitative studies, thus highlighting the role family circumstances can play. Moreover, the potential impact of other aspects of a family’s circumstances (e.g., prior contact with mental health services, living in a rural area, access to transport, language spoken) on the experience of other types of barriers was also clearly illustrated.

Implications

This review highlights several key areas of potential intervention to minimise barriers to help seeking to improve rates of treatment access for mental health problems in children. In relation to mental health systems, it is evident that ensuring service provision is sufficient, and available free of charge would remove key barriers to seeking and accessing professional help. Minimising the ‘cumbersome’ nature of mental health systems and offering flexible services would also make seeking help easier for many families (e.g., providing drop-in services in local community settings, such as schools and primary care facilities). Moreover, the potential benefit of ensuring professionals working within the mental health system (primary care, schools and specialist services) have the opportunity and skills to develop trusting relationships with families, adopt a supportive approach, and communicate well with other professionals was equally evident.

In addition to improvements to mental health systems, the potential benefit of targeted approaches to improving public knowledge and understanding of childhood mental health difficulties and the help-seeking process was also illustrated. Equipping parents with knowledge and tools to help them identify mental health problems in children, as well as specifically targeting stigmatising attitudes towards parents and the culture of parental ‘blame’ would help to overcome key barriers to help seeking. Moreover, raising awareness and understanding of the professional help that is available and the process involved in seeking help for childhood mental health problems could help provide families with the necessary knowledge about where and how to seek help, as well as foster positive attitudes towards the potential benefits of psychological treatment.

Strengths and limitations

By focusing on parents’ own perspective surrounding the help-seeking process, this review importantly extends what is known from research specifically addressing the predictors of service use. Notably, the wide range of perceived barriers/facilitators identified here illustrates the plethora of factors at play in determining the likelihood that a family will access services. Findings from quantitative studies shed light on the number of parents who perceive particular barriers at different stages of the help–seeking process; and qualitative studies provided further detail on the specific nature of barriers and corresponding facilitators, as well as identifying additional issues that were not addressed in questionnaire studies. Variation in findings across studies helped illustrate who may and may not experience particular barriers/facilitators and the relationship between barriers/facilitators across the key themes.

Studies included in the review varied widely in terms of design and primary purpose, the amount of data relevant to the review, participant populations, and measures of barriers/facilitators. While similarities and differences across study characteristics were explored, due to the wide variability in sample characteristics, it was not possible to carry out more detailed sub-group analyses examining factors associated with perceived barriers/facilitators, e.g., the age of the child/adolescent, study setting, child/adolescent mental health status, or the type of mental health problem. Although removing the poorest quality studies from the analysis did not impact on the overall findings, it is also important to acknowledge the wide variation in quality of studies included in the synthesis. The lack of well-evaluated measures of perceived parental barriers/facilitators specifically in relation to help seeking for childhood mental health problems presented a limitation across quantitative studies. Indeed, the fact that barriers/facilitators were reported in qualitative studies that were not addressed in the questionnaires illustrates limitations with existing questionnaire measures. Moreover, a large number of both qualitative and quantitative studies focused on parents of children who had accessed services, and therefore, the review was limited in the extent that it was able to address barriers among families who have not reached services. It is also important to note that the systematic search used to identify studies for inclusion in this review was conducted in October 2014, and therefore, any relevant studies published since this data were not included in the review.

The available literature highlights the need for improvements to child mental health services and interventions to raise public awareness and understanding of childhood mental health difficulties and how to access available services. However, further investigation into parents’ perceptions of barriers and facilitators to seeking and accessing treatment for mental health problems in children and adolescents is needed. Specifically, findings from qualitative studies should inform the development of questionnaire measures to ensure all relevant barriers/facilitators which are captured and can be quantified. For example, qualitative studies have highlighted the need to address parents’ perceptions of the dismissiveness/supportiveness of professionals in barrier/facilitator measures—an area frequently neglected in quantitative studies to date. Studies also need to focus on community populations to develop a fuller understanding of varying factors that help and hinder parents at all stages of the help-seeking process. Closer examination of variation in the perceived barriers/facilitators among parents of children of different ages and across different mental health disorders is also necessary to inform more tailored approaches to improve access to treatment.