Abstract
Half of all lifetime mental health disorders emerge in childhood, so intervening in the childhood years is critical to prevent chronic trajectories of mental health disorders. The prevalence of child mental health disorders is not decreasing despite the increased availability of evidence-based interventions. One key reason for the high prevalence and low treatment uptake may be low levels of child mental health literacy in the general community. Mental health literacy refers to knowledge and beliefs about mental health disorders that aid in their recognition, prevention and management. There is emerging evidence of poor recognition of child mental health problems in the community and low levels of parental knowledge about how to seek help, along with high levels of stigmatising attitudes. Although Australia has been a world leader in research and practice in improving mental health literacy for adolescent and adult mental health disorders, particularly depression and anxiety, mental health literacy for childhood disorders has been largely overlooked. In order to improve knowledge of child mental health disorders, reduce stigma, improve appropriate help-seeking and impact on the prevalence of child mental health disorders, we argue that a national initiative focussing on increasing mental health literacy for childhood disorders is urgently needed.
Half of all lifetime mental health disorders emerge in childhood (Kessler et al., 2005). One in seven Australian children experience a mental health disorder in any given year (Lawrence et al., 2015) with the major diagnoses for children aged 4–12 years being Disruptive Behaviour Disorders (DBD), Anxiety Disorders (AD), Attention-Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD). These disorders typically have early onset and are associated with chronically poor adjustment as well as a range of later psychological and physical disorders (Copeland et al., 2009). Although effective evidence-based interventions exist for many of these disorders and produce lasting effects when delivered early in life (Weisz and Kazdin, 2010), many children with mental health disorders do not receive professional help. For those who do receive help, it is often delayed, insufficient in duration or frequency or more commonly received only by those with severe disorders (Lawrence et al., 2015; Sawyer et al., 2018a). It is therefore not surprising that the prevalence of these disorders is not decreasing (Sawyer et al., 2018b). While there are many reasons for the high prevalence rates and low or delayed uptake of treatment, we believe that one critical factor is low levels of knowledge in the community about childhood mental health disorders. In this article, we argue that there is an urgent need for a national initiative to improve community levels of mental health literacy (knowledge and beliefs about mental disorders which aid their recognition, management or prevention; Jorm et al., 1997) regarding common mental health disorders for children under 12 years of age. Such an initiative, we argue, has the potential to improve appropriate and early help-seeking and treatment uptake and, in turn, reduce the prevalence of childhood mental health disorders.
Mental health literacy includes the ability to recognise mental illness, knowledge and beliefs about risk factors and causes, knowledge about self-help interventions, knowledge and beliefs about available professional help, attitudes that facilitate recognition and appropriate help-seeking, and knowledge about how to seek appropriate mental health information (Jorm et al., 1997). Over the past two decades, Australia has emerged as a world leader in implementing and evaluating community campaigns to increase media health literacy (MHL) in adolescent and adult mental health disorders, particularly depression and AD. For example,
Child mental health literacy is under-researched
Despite the burgeoning research on MHL initiatives for adolescents and adults, MHL research focussing on childhood mental health problems has been largely overlooked. To the best of our knowledge, no psychometrically sound measures to assess adults’ knowledge and beliefs around child mental health disorders have been developed, and no interventions have been systematically evaluated. A child mental health literacy (CMHL) initiative could target all adults in the general population, as well as parents, teachers, health professionals and/or children themselves, yet there is a paucity of research spanning all of these target groups. We argue that while all of these groups are important targets in efforts to increase CMHL, the general population of adults in the community should be the primary target group, in order to improve knowledge and beliefs regarding child mental health disorders and their treatment at the population level.
The reasons for the lack of research on CMHL to date are unclear. However, we believe that they may include four main concerns: (1) concern about stigmatising children and/or parents; (2) the challenge of differentiating mental health disorders from developmentally normal and transient challenging behaviours, especially in young children; (3) concerns about creating anxiety in parents resulting in unwarranted help-seeking; and (4) concerns about the availability of sufficient treatment services in the community to deal with increased demand that may occur if CMHL is improved. It is important to note that some of these concerns are legitimate and should be addressed explicitly in future research. Regardless of the reasons, however, we believe that the lack of focus on CMHL has resulted in widespread community ignorance regarding child mental health disorders, which has resulted in the absence of a common language to describe child mental health disorders, unnecessary stigma towards children and parents, and low levels of appropriate help-seeking by parents.
Evidence of low levels of CMHL
Research to date is sparse but suggests that childhood mental disorders are poorly recognised and understood in the general population. For example, the US National Stigma Study–Children (NSS-C) found that the US public lacked knowledge about ADHD and depression and their respective treatments (Pescosolido et al., 2008). Only 42% of a community sample recognised ADHD (58% for depression) and 46% labelled it as a mental illness (69% for depression) (Pescosolido et al., 2008). We were unable to identify any published studies describing the general population’s level of knowledge of the nature and treatment of childhood mental disorders in Australia. However, a recent survey conducted by The Royal Children’s Hospital (2017) with over 2000 Australian parents found that only 35% were confident that they could recognise the signs of a mental health problem in their child. This survey found low levels of knowledge about some aspects of child mental health. For example, 41% of parents did not know that persistent difficulties with anger and aggression were not normal in primary-school-age children. Similarly, the second Australian Child and Adolescent Survey of Mental Health and Well-being found that not knowing whether children needed help and/or whether problems would get better by themselves posed barriers to help-seeking by parents of children with mental health problems (Lawrence et al., 2015) – barriers which are clearly related to low mental health literacy.
Appropriate help-seeking following recognition of a child mental health problem is facilitated by parental knowledge about what interventions are available, how to access them and their effectiveness. Thus, parents play a central role in facilitating help for their children’s mental health. Current evidence shows that there are low levels of parental help-seeking for child mental health problems in Australia and low levels of knowledge about how to access professional help. For example, a survey with Australian parents found that only 30% of parents of children with high levels of behavioural problems reported lifetime participation in a parenting programme or a treatment for their child’s behaviour (Tully et al., 2017). Similarly, the second Australian Child and Adolescent Survey found just under half of 4- to 11-year-olds with a mental health disorder had seen a health service provider in the past year (Lawrence et al., 2015). Furthermore, only 35% of parents who reported that their child (aged 4–11 years) needed help for emotional or behavioural problems indicated that their child’s needs had been fully met (Lawrence et al., 2015).
One of the key barriers for accessing treatment for child mental health problems appears to be a lack of parental knowledge about where to access help. The second Australian Child and Adolescent Survey found that not knowing where to get help was endorsed as a barrier by 40% of parents of 4- to 11-year-olds with mental disorders and was the second most frequently endorsed barrier following cost of the service (Lawrence et al., 2015). However, lack of knowledge about where to get help may also be due to limited services available, so this may be less of a CMHL issue and more of an issue of service availability. Along with the lack of knowledge about the services available, parental attitudes around help-seeking also appear to be a significant barrier to seeking appropriate professional services. Research with Australian parents has found that they are more likely to seek informal help, such as advice from family and friends, rather than engaging in formal treatment through professional services (Tapp et al., 2017). Similarly, just over one-third of parents in the second Australian Child and Adolescent Survey indicated that they would prefer to handle their child’s difficulties by themselves or with family/friends (Lawrence et al., 2015). As parents are gatekeepers to their child’s treatment access, it is important to increase parents’ knowledge of appropriate services, including face-to-face services in the community, and self-help interventions, such as online programmes.
Evidence of stigmatising attitudes towards child mental health disorders
Community stigma has been identified as an important barrier to help-seeking for mental health disorders, and interventions to increase MHL have been found to reduce stigma (Morgan et al., 2018). Thus, the goals of increasing MHL and reducing stigma in relation to mental health problems are closely aligned, and both may result in improved help-seeking. Available evidence on stigma in relation to child mental health disorders suggests that there may be high levels of perceived stigma (i.e. the reaction of the general public towards stigmatised groups), particularly for ADHD, which has been subject to the most research to date (e.g. Lebowitz et al., 2016). Perceived stigma can be targeted towards the child with mental health problems and/or their parents. In relation to stigma towards children, there is evidence of negative public attitudes towards children with mental health disorders (e.g. Mukolo et al., 2010).
In relation to stigma towards parents, which is known as affiliate (or courtesy) stigma, research has found high levels of parent-blaming for child mental health disorders, which reflects a belief that parents are incompetent in their parenting role and thus are to blame for their child’s condition. Pescosolido et al. (2007) found that 36% of participants in the NSS-C reported that if a child received mental health treatment, then the parent would feel like a failure. Thus, when considering that there is a tendency to blame child mental health disorders on poor parenting and the unique role of parents in accessing help, this places children and their families in unique stigmatising contexts, which have not been adequately researched to date (Mukolo et al., 2010).
While there is a lack of research on the experience of self-stigma by children and their parents, some research suggests that parents of children with mental health problems experience high rates of self-stigma (Mukolo et al., 2010), which includes feelings of shame, as well as fears of judgement and rejection related to the child’s mental health disorder. Parents’ help-seeking decisions will likely also be influenced by how they believe stigma from receiving treatment will impact them and their child. While Australian surveys of parents have found that practical factors (e.g. cost) and lack of knowledge about services available are more important barriers to help-seeking than stigma (Lawrence et al., 2015; Tully et al., 2017), these surveys have included only single items examining broad notions of stigma, and there is a need for research with more comprehensive measures of stigma. Thus, there is a need to further examine current rates of perceived self-stigma, and parent-blaming stigma in relation to child mental health problems in Australia, and to examine the degree to which stigma impacts on help-seeking.
What would a national CMHL initiative involve?
Given the paucity of prior investigation into CMHL, research is needed to better understand the constructs of CMHL, benchmark current levels of CMHL in the Australian community, and develop resources that could bring about change. Any approach to increasing CMHL should also consider levels of stigma, given evidence that the two constructs are inter-related. Given the high rates of comorbidity between child mental health disorders (Lawrence et al., 2015), there is a need to take a broad focus, avoid focusing on any one specific disorder, but rather target the major and overlapping diagnoses of childhood including DBD, AD, ADHD and ASD. Thus, any national CMHL initiative would need to develop a comprehensive validated tool to measure CMHL and stigma, examine baseline levels of CMHL and stigma in the community, and implement interventions to increase CMHL and reduce stigma in the community. Such interventions may include whole-of-community campaigns, including Mental Health First Aid training, and information websites.
Schools are key targets in interventions to increase CMHL, as school staff are important in identifying child mental health disorders, as well as recommending and providing treatment. According to the results from the second Australian Child and Adolescent Survey, one-third of children aged 4–11 years with mental health disorders received services through schools (Lawrence et al., 2015). In Australia, there have been a number of school-based initiatives. For example, a randomised controlled trial found that Mental Health First Aid training for high-school teachers improved teachers’ mental health knowledge, reduced stigmatising attitudes and increased confidence in providing help (Jorm et al., 2010). However, such school-based interventions have mainly focussed on adolescents in secondary schools, which, we would argue, are implemented too late for childhood onset of mental health disorders. Furthermore, school-based interventions often do not target parents, who are the primary gatekeepers to children’s treatment. We would also argue that the recognition of child mental health disorders should not be left to parents and teachers alone, but that other supportive adults (e.g. extended family members and friends) also play a role in identifying and discussing child mental health problems with parents. Thus, we propose that a community-wide CMHL initiative, much like
In terms of the content of a CMHL initiative, there are three key areas that appear particularly important. First is the importance of increasing knowledge about the signs and symptoms of child mental health problems and how to differentiate emerging mental health problems from developmentally normal and transient issues. In relation to this, we believe that carefully worded explanations of terminology commonly used in the child mental health literature, particularly diagnostic terms, are needed. Anecdotal evidence suggests that many mental health professionals either use diagnostic terms without providing families with adequate explanation or simply avoid diagnostic terms all together. We would argue that both approaches likely contribute to confusion and stigma and that an approach based on education about the meaning of such terms is far preferable. In support of this, an Australian study with young people aged 12–25 years found that use of accurate diagnostic labels appeared to help counter stigmatising attitudes (Wright et al., 2011), although such research has not been conducted with children under the age of 12 years. Second, we believe that appropriate explanations about risk factors for, and causes of, child mental health disorders are also critical, as this information may influence stigma directed towards parents and children and perceptions around treatment effectiveness. In recent experimental research that compared psychosocial and biological explanations for childhood ADHD, a biological explanation yielded less stigma towards the child, but led to the perception of the child’s symptoms were more difficult to treat (Lebowitz et al., 2016). Notwithstanding that there is a need for further research to examine how different explanations impact stigmatising attitudes and perceptions of treatment, it is imperative that any CMHL initiative includes biopsychosocial explanations for child mental health disorders. Finally, a CMHL initiative must provide information about how to seek help and the effectiveness of different treatments. It must include extensive information about the range of services available including self-help interventions such as bibliotherapy and online interventions, along with professional services.
It is also important that any CMHL initiative examines potential unintended negative effects of increasing CMHL. For example, one possible iatrogenic effect associated with increasing CHML is creating appropriate versus unwarranted help-seeking by parents. Just as everyone experiences ‘symptoms’ of depression at some point in their life, even healthy children show transient ‘symptoms’ of mental health problems (such as anxiety, aggression and impulsivity) at some point. Thus, exposure to educational materials about child mental health conditions could potentially increase parental anxiety and unwarranted help-seeking from overburdened services. A critical feature of any future CMHL initiative will therefore be to directly measure appropriate versus unwarranted help-seeking. Furthermore, increased CMHL could increase appropriate help-seeking but potentially overwhelm already overburdened child mental health services, leading to insufficient services available to meet increased treatment need. It would be important that any CMHL initiative tracks rates of referrals to specialist services to monitor significant increases. In this regard, it should be noted that improved CMHL has the potential in the longer term to also improve the availability of appropriate child mental health services, since improved CMHL has the potential to empower consumers and improve advocacy for increased service provision. In addition to focussing on treatment services, a CMHL initiative needs to focus on increased prevention and early intervention with greater involvement of a range of health professionals who engage with children and families (Centre for Community Child Health, 2018).
Conclusion
There is now considerable evidence that childhood interventions are effective, yet evidence-based treatments are rarely accessed, and the prevalence rates of childhood mental health disorders are therefore not decreasing. One reason for the low uptake of evidence-based interventions may be low levels of CMHL. Over the last decade, there has been significant research on mental health literacy, both in adolescents and adults, and population-level interventions have demonstrated that targeted campaigns can improve mental health literacy. However, there is a dearth of research conducted on CMHL, both in Australia and internationally. Research is urgently needed to develop and validate measures of CMHL and stigma; obtain benchmark levels of CMHL and stigmatising attitudes in the Australian community and develop, implement and evaluate community campaigns to increase CHML and reduce stigma. We believe that an Australian initiative focussed on enhancing CMHL may subsequently increase the likelihood that Australian children would be able to access evidence-based early interventions for mental health problems, thereby helping to reduce the prevalence and burden of child mental health problems in the Australian community.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.
