Why is it difficult for parents to talk to practitioners about their children’s mental health?

What is this resource about?

This paper is about why it is difficult for some parents to talk to practitioners about their children’s mental health and what practitioners can do to make it easier for parents to have those conversations.

Who is this resource for?

This resource is intended for practitioners who work with the parents of children aged 0–12 years. The resource is for practitioners who interact with parents in universal health, education and community services, including early childhood education and care professionals, general practitioners, family support workers and child and maternal health nurses.

A substantial proportion of Australian infants and children¹ experience mental health difficulties such as attachment difficulties, anxiety, depression and conduct disorder (Lawrence et al, 2015). When children with mental health difficulties receive appropriate and timely support it can prevent the development of more serious disorders in the long-term (National Scientific Council on the Developing Child, 2012; The Royal Australian and New Zealand College of Psychiatrists, 2010). However, many Australian children with mental health difficulties do not get the professional support they need (Johnson et al, 2018; Lawrence et al, 2015; Oh et al, 2015; Oh & Bayer 2015).

Parents play a critical role in ensuring children who experience mental health difficulties get adequate support. Parents decide when and where to seek help for their children, as well as providing permission for any interventions (Heflinger & Hinshaw, 2010; Sayal et al, 2010). The fact that many children with mental health difficulties are missing out on the support they need is not due to parents’ lack of concern for their children’s mental health (Oh & Bayer, 2015). Rather, some of the most significant barriers to children’s access to and use of child mental health services relate to:

• parents’ awareness and understanding of child mental health difficulties: parents may not know that their child has a mental health difficulty, or may not know that children can have mental health difficulties
• parents’ knowledge about supports and services: parents may not know that supports and services exist or how to access them
• parents’ concerns about the consequences of seeking help: parents may fear that their child will be labelled or that they will be blamed for the child’s difficulties (Anderson et al, 2017; Dempster et al, 2015; Reardon et al, 2017).

The purpose of this paper is to inform practitioners in universal health, education and community services settings about why it might be difficult for some parents to talk to them about their children’s mental health, and what practitioners can do to make that process easier.

Specifically, this paper is intended to give practitioners:

• an insight into the important role they play in having conversations with parents about their children’s mental health
• an insight into why those conversations can be difficult for parents
• some tips on how to address some of the difficulties surrounding those conversations.

The information in this paper is based upon evidence from research, including research which draws upon parents’ experiences. It highlights some of the common factors identified in this research about why it might be difficult for parents to have conversations with practitioners about children’s mental health.

¹We use the term ‘children’ in this paper to refer to infants (0–3) and children (4–12), unless otherwise specified.

There are a range of circumstances when parents and practitioners might talk to each other about a child’s mental health in a universal service setting. Those conversations could be initiated by parents or practitioners.

In some cases, parents will have concerns about their child’s wellbeing or development but not know the child has a mental health difficulty. For example, a parent may express a concern about their toddler’s physical complaint (e.g. tummy pains) to their child and maternal health nurse which then leads the nurse to ask about issues relating to the child’s social and emotional wellbeing. In other cases, parents will raise direct concerns about their child’s social and emotional wellbeing. A parent might express concerns to their general practitioner, for example, about their eleven-year-old child’s tendency to worry excessively.

There will be some circumstances where a practitioner raises concerns with a parent about their child’s mental health. An early childhood educator, for example, might talk to a parent about a change in a three-year-old child’s behaviour. In other cases, a practitioner may have no concerns about a child but initiate a conversation with parents to raise their awareness about the importance of child mental health generally.

In this paper, we envisage the role of the practitioner in all these circumstances to be to:

• enhance parents’ awareness about child mental health and child mental health difficulties
• where necessary and appropriate, share information with parents about services and supports for their child.

Such conversations do not require specialist mental health qualifications. Nor are they about diagnosing the child. Rather, they are about having a conversation with parents about an important aspect of their child’s development and ensuring parents have the information they need to support their child’s social and emotional wellbeing.

Parents are most likely to benefit from these conversations when you work with them in a respectful, strengths-based, empathic and non-judgmental way. Working in this way will help you and the parent combine your expertise – your expertise as a professional and the parent’s expertise of their own child – to ensure that any support offered meets the child’s and family’s unique context and circumstances.

The outcome of such conversations will vary. For example:

• a parent may develop a better understanding of child mental health
• a parent who was concerned about their child may be reassured by a practitioner that their child’s behaviour is typical for their age and stage and development
• a parent may decide to have their child assessed by a child mental health specialist
• a parent may decide to seek advice about what to do from a trusted, non-professional person in their life (e.g. family member, religious advisor, friend)
• a parent and practitioner might decide to monitor the child and pursue additional support if the problem escalates.

Stigma

Evidence indicates negative public attitudes towards mental health difficulties among children (Mukolo et al, 2010; Mukolo & Helfinger, 2011), with some evidence indicating that stigma is even greater towards children with mental health difficulties than adults with mental health difficulties (Pescosolido, 2008). The targets of stigma are not always just the children with mental health difficulties: their parents, families and associates may also be stigmatised, as may the services that support them (Mukolo et al, 2010).

Research demonstrates that just as the stigma surrounding mental health difficulties is a key barrier to adults accessing and utilising mental health services, it is also a barrier to parents seeking out help for their children (Heflinger & Hinshaw 2010; Owens et al, 2002).

There are a range of ways in which the stigma of child mental health difficulties may impact upon parents’ help-seeking behaviour. For example, parents may be concerned about negative perceptions of the public towards a child’s potential mental health difficulties (otherwise known as public stigma), or they may be concerned about the negative perceptions of their family, friends and acquaintances (otherwise known as personal stigma) (Heflinger et al, 2014; Alexander et al, 2013). Some parents express concerns that if their child is found to have a mental health difficulty, the child will be ‘labelled’ (Reardon, 2017; Sayal et al, 2010; Alexander et al, 2013) which can be stigmatising in and of itself (Heflinger & Hinshaw, 2010).

The possibility that a child has a mental health difficulty may affect the self-esteem and self-worth of the child’s parents; especially if parents believe that their child’s mental health difficulty has come about because of poor parenting (otherwise known as self-stigma) (Heflinger & Hinshaw, 2010). Even if parents don’t believe that about themselves, they may encounter other people who judge them as parents – and judge their parenting – because their child has a mental health difficulty (otherwise known as ‘stigma by association’) (Heflinger & Hinshaw, 2010; Dempster et al, 2015; Sayal et al, 2010).

There is some evidence to indicate that the stigma associated with child mental health difficulties impacts upon parents’ willingness to raise concerns about their child’s social and emotional wellbeing with practitioners in universal settings (Reardon, 2015; Sayal et al, 2010). For example, research undertaken in the UK indicates that one of the reasons why parents are reluctant to discuss concerns about their child’s mental health with general practitioners is that it may lead to stigma either for their child or for themselves (Sayal et al, 2010).

The extent to which stigma influences parents’ help-seeking behaviour for a child with a potential mental health difficulty differs depending on a range of factors. For example:

• cultural background can impact upon the extent to which parents are concerned about stigma and the specific types of stigma that parents are concerned about (e.g. personal as opposed to public stigma) (Dempster et al, 2015)
• geographic location can influence parents’ help-seeking behaviour; research undertaken in the United States indicates that there are higher rates of stigma around child mental health difficulties in rural areas when compared to metropolitan areas (Heflinger et al, 2014)

Public stigma about child mental health is also condition specific; people may respond differently to children with mental health difficulties depending upon the label the child has (or is assumed to have) (Mukolo et al, 2010; Walker et al, 2008).

Not recognising or misunderstanding child mental health difficulties and treatments

The belief that children do not (or cannot) have mental health difficulties is common (Davey, 2010; Kendall-Taylor & Lindland, 2013). Even if parents are aware that children can have mental health difficulties, they may not view them as requiring treatment (Pescosolido et al, 2008), and may not recognise those difficulties in their own children (Oh & Bayer, 2015; Pavuluri et al, 1996).

Parents’ perceptions of whether a child needs help for a potential emotional or behavioural issue is a major factor that determines whether they seek help for that child (Johnson, 2018; Ryan et al, 2015; Sawyer et al, 2004). An Australian study found that those parents who recognised their child’s problematic behaviour were seven times more likely to access professional help than parents who didn’t recognise their child’s problematic behaviour (including help from mental health, general health, educational and other community settings) (Oh & Bayer, 2015).

Not knowing who to go to for help for a child’s potential emotional or behavioural difficulty is another factor impacting upon the willingness of parents to seek help for their child (Anderson et al, 2017; Reardon et al, 2017). Parents may not be aware that universal service providers can help them with children’s emotional and behavioural difficulties (Sayal et al, 2010). For example, research in the UK suggests that one of the reasons why parents are unlikely to raise issues regarding their child’s behaviour with a GP is that they don’t believe it is relevant to the GP’s role (Sayal et al, 2010).

Another barrier to parents seeking out help for a child’s emotional or behavioural difficulties is parents’ misunderstandings and misconceptions about the treatment of child mental health issues (Reardon, 2017), such as the fear that their child will be unnecessarily medicated (Anderson et al, 2017) or even institutionalised (Sayal et al, 2010).

Lack of trust and confidence in practitioners

Parents report a range of factors relating to trust and confidence in practitioners that impact upon their willingness to seek help for their child’s potential mental health difficulties. These include beliefs about the treatment they will receive from practitioners, and previous experiences of treatment, such as:

• practitioners not taking the problem seriously, not listening or not being interested in the problem
• being ‘bounced’ from one service to another without a satisfactory resolution
• delayed, ineffective or inappropriate treatment
• practitioners failing to explore what the parent wants for their child and, instead, focusing on a diagnosis (Anderson et al, 2017; Sayal et al, 2010; Reardon, 2017).

Parents may be uncertain that practitioners are skilled enough or have time to identify social and emotional disorders in young children (Alexander et al, 2013). Research among parents in general practice settings suggest that some of the factors that may make parents more confident about discussing their child’s social and emotional wellbeing include:

• familiarity with the practitioner
• a good relationship with the practitioner
• practitioners’ knowledge of their / their child’s history (Sayal et al, 2010).

There are a number of things that practitioners can do to make it easier for parents to talk to them about child mental health including: talking with parents, giving parents information and being aware of and sensitive to parents’ fears and experiences.

Talk with parents

1. Routinely incorporate information about children’s mental health into your conversations with parents. Promoting the importance of child mental health is just as important as educating parents about child mental health difficulties.

The Raising Children Network has information for parents about children’s social and emotional wellbeing at different ages and stages.

2. Let parents know that they can talk to you about concerns they have about their child’s development – including their social and emotional development. Let them know that although you may not always be able to answer all their questions, you can work with them to find the answer or to find someone who can.

3. By applying the principles of effective engagement with parents, you can help build trusting relationships with them. Trusting parent–practitioner relationships are important because when parents trust practitioners, they will be more likely to share concerns they have about their child.

More information about the principles of effective engagement can be be found in the Engaging Parents: An Introduction e-learning course.

Give parents information

4. Provide parents with evidence-based, quality information about child mental health and child development – including social and emotional development (see McDonald, 2018). This information may help to enhance parents’ awareness about the concept of ‘child mental health’ and may also help them identify mental health difficulties for their child should they arise.

5. Take care not to overload parents with information – especially if they are anxious or concerned about their child – because it may make it hard for them to take that information in. You could start by giving them one or two of the most relevant and appropriate resources and provide them with more information later (see McDonald, 2018).

6. Where parents have asked you for information because they are concerned about their child (e.g. a list of local services), follow up with them to see whether the information was useful. Where appropriate, encourage parents to come back to you if they need further support finding information to meet their needs.

Be aware of and sensitive to parents’ fears and experiences

7. Parents may fear that you will dismiss their concerns about their child’s social and emotional wellbeing. It is important therefore to acknowledge a parent’s concerns and spend some time talking with them about those concerns. The aim of talking to them about their concerns is to help identify useful and appropriate information and resources (see McDonald, 2018).

8. Thank parents for raising their concerns with you and let them know they have done the right thing by doing so. If you don’t have time to talk to parents about their concerns in that moment, arrange to talk to them at another time. Both actions will help reassure parents that you are not dismissing their concerns.

9. Parents may be reluctant to share their concerns about their child’s social and emotional wellbeing with you because they believe the situation is their (i.e. the parent’s) fault and fear being blamed or judged. The parents of children who are struggling may have already faced blame and judgement within their own social networks (e.g. judgmental attitudes of family members and friends). For this reason, when a parent does raise concerns about their child, it is important to acknowledge the parent’s strengths. Even if you don’t know that parent well, you can acknowledge their commitment to seeking out help for their child (i.e. by raising the concern with you).

10. Parents may feel they have ‘failed’ if their child is struggling. So, acknowledge the child’s strengths. If you don’t know the child, ask the parent what is going well for the child and highlight this as a strength of the child. If you do know the child, perhaps focus on something that the parent has not acknowledged about their child in your conversation – such as a child’s interests or a positive relationship in the child’s life.

11. Be aware that parents may have had negative experiences with other service providers when seeking help for their child’s social and emotional wellbeing. This may impact upon how they interact with you. For example, if a parent has had their concerns for their child repeatedly dismissed by other practitioners, they may be especially sensitive to any indication (whether real or perceived) that you don’t believe them or don’t trust their judgement.

12. Acknowledge parents’ expertise. Parents’ expertise comes from their unique insight into their children’s histories, relationships, behaviours and emotions. Drawing upon parents’ expertise will not only help you narrow down which type of information and resources will be useful to them, it may also help to reinforce parents’ self-worth.

13. Cultural values, beliefs and attitudes can influence how people understand concepts such as ‘emotional wellbeing’, ‘mental health’ and ‘mental health difficulties’. To make sure you can work with the parent effectively, check to make sure you both understand relevant terms in the same way. For example, if you’re talking to a parent about mental health you might say: “When I talk about “good mental health” I mean coping well with challenges, expressing emotions, the ability to form relationships. Is that how you understand that term?’

Challenge stigmatising language and environments

14. Encourage the people you encounter in your professional life to:

• focus on children as individuals, rather than labelling them or their behaviour according to a diagnosis, or perceived diagnosis, e.g. ‘The bipolar kid’ (see Heflinger & Hinshaw, 2010)
• rethink the idea that children cannot (or should not) have mental health difficulties
• focus on the strengths of parents and families of children with mental health difficulties, rather than any perceived dysfunction.

15. When people you encounter in your professional life use stigmatising language and or reinforce stigmatising attitudes, explain how these can impact upon children’s self-concept (e.g. self-stigma) and upon their parents’ help-seeking behaviour.

Parents play an integral role in supporting their children’s social and emotional wellbeing and mental health. Practitioners who interact with parents in universal settings can help to support parents in that role. However, they can only do that if parents feel comfortable talking to practitioners about children’s mental health, especially when they have concerns about their child’s social and emotional wellbeing.

By talking to parents about child mental health, practitioners can help parents better understand their children’s social and emotional wellbeing. Providing information to parents when they have concerns about their children’s mental health can help parents get the support their child and family needs. Challenging stigmatising language, attitudes and beliefs can help to change the broad social norms that influence parents’ help-seeking behaviours.

Further resources

Emerging Minds Child Mental Health online course

Emerging Minds Supporting Infants and Toddlers online course

Emerging Minds Building Blocks for Children’s Social and Emotional Wellbeing online course

Emerging Minds Engaging Parents: An Introduction online course

Sharing Information with Parents about Children’s Social and Emotional Wellbeing: A step by step approach

Emerging Minds Families has developed free online resources for parents about child mental health, child development and supporting children’s wellbeing in many different contexts (such as experiencing bullying, a disaster or parental separation, for example). All our resources are evidence-based and informed by the experience of families and practitioners who support families.

Alexander, K. E., Brijnath, B., & Mazza, D. (2013). Can they really identify mental health problems at the age of three? Parent and practitioner views about screening young children’s social and emotional development. Australian & New Zealand Journal of Psychiatry, 47(6), 538–545.

Anderson, J. K., Howarth, E., Vainre, M., Jones, P. B., & Humphrey, A. (2017). A scoping literature review of service-level barriers for access and engagement with mental health services for children and young people. Children and Youth Services Review, 77, 164–176.

Davey, L. (2010). How to Talk About Children’s Mental Health: A Frameworks MessageMemo. Washington, DC: Frameworks Institute. Available here.

Dempster, R., Winders Davis, D., Jones, V.F., Keating, A., & Wildman, B. (2015). The Role of Stigma in Parental Help-Seeking for Perceived Child Behavior Problems in Urban, Low-Income African American Parents. Journal of Clinical Psychology in Medical Settings, 22, 265–278.

Heflinger, C. A., & Hinshaw, S. P. (2010). Stigma in Child and Adolescent Mental Health Services Research: Understanding Professional and Institutional Stigmatisation of Youth with Mental Health Problems and their Families. Administration and Policy in Mental Health and Mental Health Services Research, 37, 61–70.

Heflinger, C. A., Wallston, K. A., Mukolo, A., Brannan, A.M. (2014). Perceived Stigma Toward Children with Emotional and Behavioral Problems and Their Families: The Attitudes About Child Mental Health Questionnaire (ACMHQ). Journal of Rural Mental Health, 38(1), 9–19.

Johnson, S. E., Lawrence, D., Sawyer, M., & Zubrick, S. R. (2018). Mental disorders in Australian 4- to 17- year olds: Parent-reported need for help. Australian & New Zealand Journal of Psychiatry, 52(2), 149–162.

Kendall-Taylor, N., & Lindland, E. (2013). Modernity, Morals and More Information: Mapping the Gaps Between Expert and Public Understandings of Early Child Development in Australia – A Frameworks Research Report: February 2013. Washington, DC: FrameWorks Institute. Available here.

Lawrence, D., Johnson, S., Hafekost, J., Boterhoven De Haan, K., Sawyer, M., Ainley, J., Zubrick, S. R. (2015). The Mental Health of Children and Adolescents. Report on the second Australian Child and Adolescent Survey of Mental Health and Wellbeing. Canberra, ACT: Department of Health.

McDonald, M. (2018). Sharing information with parents about children’s social and emotional wellbeing: A step-by-step approach. National Workforce Centre for Child Mental Health, Emerging Minds. Available here.

Mukolo, A., Heflinger, C. A., & Wallston, K. A. (2010). The stigma of childhood mental disorders: A conceptual framework. Journal of the American Academy of Child and Adolescent Psychiatry, 49(2), 92–198.

Mukolo, A., & Heflinger, C. A. (2011). Factors Associated with Attributions About Child Health Conditions and Social Distance Preference. Community Mental Health Journal, 47(3), 286–299.

National Scientific Council on the Developing Child. (2012). Establishing a Level Foundation for Life: Mental Health Begins in Early Childhood (Working Paper 6). Available here.

Oh, E., Mathers, M., Hiscock, H., Wake, M., & Bayer, J. (2015). Professional help seeking for young children with mental health problems. Australian Journal of Psychology, 67, 187–195.

Oh, E., & Bayer, J. (2015). Parents’ help-seeking processes for early childhood mental health problems. Child and Adolescent Mental Health, 20(3), 149–154.

Owens, P., Hoagwood, K., Horowitz, S., Leaf, P., Poduska, J., & Kellam, S. (2002). Barriers to children’s mental health services. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 731–738.

Pavuluri, M.N., Luk, S., & McGee, R. (1996). Help-seeking for behavior problems by parents of preschool children: A community study. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 215–222.

Pescosolido, B. A., Jensen, P. S., Martin, J. K., Perry, B. L., Olafsdottir, S., & Fettes, D. (2008). Public Knowledge and Assessment of Child Mental Health Problems: Findings from the National Stigma Study – Children. Journal of the American Academy of Child and Adolescent Psychiatry, 47(3), 339–349.

Reardon, T., Harvey, K., Baranowska, M., O’Brien, D., Smith, L., & Creswell, C. (2017). What do parents perceive are the barriers and facilitators to accessing psychological treatment for mental health problems in children and adolescents? A systematic review of qualitative and quantitative studies. European Child & Adolescent, 26, 623–647.

Ryan, S. M., Jorm, A. F., Toumbourou, J. W., & Lubman, D. I. (2015) Parent and family factors associated with service use by young people with mental health problems: A systematic review. Early Intervention in Psychiatry, 9(6), 433–446.

Sawyer, M. G., Rey, J. M., Arney, F. M., Whitham, J. N., Clark, J. J., & Baghurst, P. A. (2004). Use of health and school-based services in Australia by young people with Attention-Deficit/Hyperactivity Disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 43(11), 1355–1363.

Sayal, K., Tischler, V., Coope, C., Robotham, S., Ashworth, M., Day, C., Tylee, A., & Siminoff, E. (2010). Parental help-seeking in primary care for child and adolescent mental health concerns: qualitative study. The British Journal of Psychiatry, 197, 476–481.

The Royal Australian and New Zealand College of Psychiatrists. (2010). Prevention and early intervention of mental illness in infants, children and adolescents: Planning strategies for Australia and New Zealand. Melbourne, Australia.

Walker, J. S., Coleman, D., Lee, J., Squire, P. N., & Friesen, B. J. (2008). Children’s stigmatisation of childhood depression and ADHD: magnitude and demographic variation in a national sample. Journal of the American Academy of Child and Adolescent Psychiatry, 47(8), 912–20.

Acknowledgements

Many thanks to Angela Obradovic, Angela Scuderi, Ann Weston, Courtney Schuurman, Dan Moss, Elly Robinson, Lydia Trowse, Rhys Price-Robertson and Stuart Weston for their valuable contributions, input and feedback.