Help seeking among adolescents in foster care: A qualitative study
Introduction
Children and adolescents in foster care are at high risk for mental health problems, with prevalence rates as high as 59% in some samples (Scozzaro & Janikowski, 2015). Accordingly, they utilize more mental health services than others who are not in care. However, studies have shown that as many as two thirds of children and adolescents in foster care who are identified as being in need of mental health support do not receive services, and factors other than symptomology may impact service use decisions (e.g., type of maltreatment experience, demographic variables, and caregiver perceptions of problems) (Burns et al., 2004, Garcia and Courtney, 2011, Garland et al., 1996). It has been suggested that adolescents in foster care have decisions regarding their health made for them by caregivers (Unrau, Conrady-Brown, Zosky, & Grinnell, 2006). Suggestions in research that many adolescents in care who are in need of mental health support do not receive it imply that decisions being made by caregivers regarding service provision may not adequately address adolescents' needs. Research on help seeking may help to address this issue.
Help seeking is defined as any action taken to obtain assistance with a problem, in this case a mental health, emotional, or behavioral difficulty, from a formal source (e.g., a social worker, psychologist, medical doctor, or school counselor) or an informal source (i.e., peers and family). It has been identified as a learnable skill which reduces psychological distress (Ciarrochi et al., 2003, Unrau et al., 2006). This skill becomes vital as adolescents exit the foster care system and are required to independently seek any needed help (Unrau & Grinnel, 2005). This is especially important given research findings that foster care alumni show increased risk for mental health difficulties (Jones, 2014), and that receipt of health services drops by as much as 60% once individuals leave foster care (McMillen & Raghavan, 2009). Despite this, the help seeking behaviors of this population are not well understood, and research on this topic is scarce. This qualitative study sought to address this gap in the literature by examining the subjective experiences and perceptions related to mental health and help seeking of adolescents in foster care.
Adolescents in foster care have increased rates of mental health difficulties compared to the general population, and these rates exceed those of other disadvantaged children who are not in care (Farmer et al., 2001, Pecora et al., 2009). According to a review of the psychological wellbeing of children and adolescents in foster care in the United States, individuals in care have higher rates of both internalizing and externalizing behavior problems compared to those in the general population (Jones & Morris, 2012). Another study (Burge, 2007) examined the case files of 429 Canadian children and adolescents in care who were under the age of 18 to examine the prevalence of mental health problems in this group. According to mental health diagnoses listed in the files, the prevalence rate of mental health disorders was 31.7%, compared to 18% among the general population of children and adolescents. Boys were two times more likely than girls to have a mental health diagnosis. Those with mental health diagnoses had entered care at a significantly older age (mean age of 4 years, 7 months) than those without a diagnosis (mean age of 2 years, 10 months), and were more likely to have experienced maltreatment.
Several theoretical models of help seeking have been proposed (Andersen, 1995, Cauce et al., 2002, Kessler et al., 1981, Logan and King, 2001, Srebnik et al., 1996). As described by Kessler et al. (1981), the help seeking process includes three stages: 1) problem recognition (i.e., recognizing a mental health problem), 2) perceived need for help (believing that professional help is needed to resolve the problem), and 3) obtaining help, that is, formal help seeking. In a quantitative study with youth in grades 7 to 12, Kessler et al. (1981) found that 25% of the sample indicated that they had a personal, emotional, behavioral, or mental health problem (stage 1). However, only 50% of those who endorsed stage 1 perceived a need for help (stage 2), and only 50% of those who endorsed stage 2 actually sought help for the problem (stage 3). Thus, there was a large discrepancy between the stages of help seeking, particularly between stages 2 and 3. This highlights the importance of conceptualizing help seeking as a process, and indicates that many adolescents do not seek help for their troubles.
The “Behavioral Model of Health Service Use” (Andersen, 1995) distinguishes three types of factors that influence an individual's likelihood of utilizing health services: 1) Predisposing factors (i.e., factors that exist prior to the illness or need for services, including sex, ethnicity, attitudes and beliefs, and previous illness and service use); 2) Enabling factors (i.e., factors that allow an individual to utilize services, such as financial resources, knowledge of sources, and social support), and 3) Level of need (perceived need and evaluated need [i.e., by a health professional] for services). This model has been used by researchers as a framework to describe the factors that influence adolescent help seeking (e.g., Bergeron et al., 2005, Unrau and Grinnel, 2005).
Previous research has identified many influential factors and barriers in the help seeking process during adolescence. Identified predisposing factors include being female, older age, lower self-worth, Caucasian ethnicity, higher levels of emotional competence, and positive prior help seeking experiences (Raviv et al., 2009, Rickwood et al., 2005, Saunders et al., 1994, Wilson and Deane, 2001). Higher socioeconomic status and informal help seeking may act as enabling factors (Saunders et al., 1994), and greater need has been linked to help seeking (Rickwood & Braithwaite, 1994). Identified barriers include stigma, concerns about confidentiality and trust, difficulty knowing when to seek help, low emotional competence, negative attitudes toward help seeking, and need for autonomy (Gulliver et al., 2010, Rickwood et al., 2005, Wilson and Deane, 2012).
Accompanied by their increased rates of mental health problems and the likelihood that decisions about their health are made for them without their input, adolescents in care may lack a familial support system and experience frequent geographic moves, resulting in disruptions to peer support networks (Jones and Morris, 2012, Magnuson et al., 2015). This is significant, given adolescents' tendency to access informal supports, and the positive impact informal help seeking can have on rates of formal help seeking.
The limited existing studies about help seeking behavior among adolescents in foster care highlight the need for further research. In one study, it was found that the experience of living in care may act as an enabling factor in seeking help for conduct problems, and a predisposing factor for help seeking for depressive symptoms (Unrau & Grinnel, 2005). However, this study had important limitations. The sample was comprised of adolescents who had already sought help at a health clinic, and thereby were already known to be willing to seek help. Further, the study did not examine the help seeking process or informal help seeking. Other researchers have provided a narrow perspective of the topic with specific samples (e.g., African American male youths), analyzed records of service use as a proxy for help seeking behavior, inquired about help seeking by foster parents on behalf of youth, and employed surveys, case files, or medical records to research this topic. These methodologies are not sufficient to address adolescents' perceptions and subjective experiences related to help seeking (Timlin-Scalera, Ponterotto, Blumberg & Jackson, 2003).
Two qualitative studies have made important contributions to the understanding of the mental health needs of adolescents in care. Blower, Addo, Hodgson, Lamington, and Towlson (2004) found that children and adolescents in care in Scotland were “highly discriminating in selecting what to discuss with whom” (p. 122). Participants felt that they were not included in decisions about their mental health. They were more reluctant to discuss difficult topics, and preferred to talk to people who were trustworthy or important to them (e.g., foster parents and case workers). Similarly, a qualitative study conducted with foster adolescents aged 12 to 19 in the United Kingdom found that stigma of being in care was sometimes a barrier to confiding in others who were not in care, and participants preferred to confide in others who had been in the system or who had similar experiences. Many participants had participated in some type of mental health service and felt that having control in their mental health-related experiences was important (Stanley, 2007). These studies shed light on issues relevant to help seeking for adolescents in care; however, they did not directly examine the help seeking process, nor the associated predisposing, enabling, or level of need factors. Thus, there remains a need to further explore these individuals' subjective perceptions and help seeking processes.
This qualitative study of adolescents in foster care is guided by the model of three stages of help seeking (Kessler et al., 1981) and the Behavioral Model of Health Service Use (Andersen, 1995), described previously. These models, which are often cited in research on help seeking behavior of adolescents, guided the development of the research questions. We sought to explore the following research questions: 1) What types of distress and emotional problems are being experienced or have been experienced by adolescents in care, and how severe is/was the problem? 2) What knowledge of emotional and mental health difficulties and sources of help do adolescents in care possess? 3) What are their feelings toward mental health problems and sources of help? 4) Do they feel that they are in control of their own mental health and related needs? 5) How often are informal and formal sources of help consulted by adolescents in care for emotional problems or mental health problems, and who specifically is consulted? and 6) Are there differences in ability or willingness to identify a problem, perceive need, and obtain help, and what factors influence each stage of the process?
Section snippets
Participants
Participants were seven (6 females, 1 male) Canadian adolescents and young adults aged 16 to 20 years old (M = 17, SD = 1.53). All participants were presently or previously under permanent legal guardianship of the child protection agency, and were either in foster care or were enrolled in a continuing care program (i.e., they were over the age of 18 and lived independently, however they attended post-secondary education and continued to receive financial support and the support of a continuing care
Results
Results are organized thematically, in line with previous research and existing theoretical models, as a basis for understanding the conceptual model of help seeking among adolescents in care (Fig. 1). Categories and concepts were given labels consistent with the language used in existing theoretical models.
Discussion
The findings from this study speak to the uniqueness of the foster care population with regards to adolescent help seeking behavior. Results showed that participants in this study had many unique life stressors. All of the participants had some experience with therapy, and consistent with previous findings that help seeking intentions are related to the quality of the result of prior help seeking (Wilson & Deane, 2001), participants who described negative previous therapy experiences expressed
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Acknowledgments
The authors would like to thank the youth who participated in this research study.
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