Children's and adolescents’ enrolment in psychosocial care: determinants, expected barriers,
and outcomes
Nanninga, Marieke
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Nanninga, M. (2018). Children's and adolescents’ enrolment in psychosocial care: determinants, expected barriers, and outcomes. Rijksuniversiteit Groningen.
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4
Determinants of
enrolment in and
use of psychosocial
care by children
and adolescents: A
systematic review
Nanninga M, Tuinstra J, Knorth EJ, Reijneveld SA, Jansen DEMC.
ABSTRACT
Background: An up-to-date comprehensive literature review is lacking concerning the
determinants of enrolment in and use of psychosocial care for children and adolescents. Therefore, the aim of this study was to systematically review the literature on this subject.
Methods: We searched publications in Medline, PsycINFO, SocINDEX, and ERIC (January
2000 – February 2015). Studies that investigated determinants of enrolment in and use of psychosocial care for children and adolescents were included. Three reviewers independently assessed the eligibility and methodological quality of the studies. Only high-quality studies were included and categorized according to the four steps in the pathway to care -consultation/help-seeking, professional problem recognition, referral to specialized care, admission to inpatient care- and the actual use of care.
Results: Twenty-two studies were included. Main child factors identified that increased
the likelihood of enrolment in and use of care were psychosocial problems, urban area residence, life events, past treatment, and academic problems. Varying effects across care steps or use of care were found for age, gender, ethnicity, and place of residence. Main family factors identified that increased enrolment in and use were single-parent family and socioeconomic status (varying effects).
Conclusions: Care enrolment and use are not only determined by children’s psychosocial
problems but also by other child and family characteristics. Professionals and policymakers should be aware that the system of care is less accessible for children with specific characteristics. Further, additional high-quality evidence is needed on potential organizational, professional-related, psychological, and social determinants of enrolment in psychosocial care.
INTRODUCTION
Approximately 7-24% of children and adolescents experience mild to serious emotional or behavioural problems [1-5]. Psychosocial care for them and their families, is provided through a range of services, of which the main ones are: primary care, child and youth social care, and child and youth mental health care. Despite the wide range of services, only a minority of children and adolescents with psychosocial problems receives care [3, 6-13]. Identification of the determinants of children’s enrolment in and use of psychosocial care is needed to improve children’s access to services.
Goldberg and Huxley’s Pathways to Care model provides a useful basis for structuring determinants of enrolment in and use of psychosocial care by children and adolescents [9, 14-16]. Where other models such as the Health Behaviour model and the Gateway Provider model have their focus on determinants, i.e. multiple influences dynamically affecting attitudes towards and actual use of care [17-19], the Pathways to Care models has its focus on the process of enrolment. This provides a good starting point to define care enrolment. The Pathways to Care model postulates that children enter the system of care by passing filters in order to reach more specialized levels of care (Figure 1). The filters that separate the levels comprise (1) the decision to consult a professional/seek help, (2) the recognition of psychosocial problems by a professional, (3) the referral to specialized outpatient care, and (4) the admission to inpatient care. Enrolment is defined as either entering the care system by passing the first filter or moving through the care system by passing one of the subsequent filters to more specialized care.
An up-to-date comprehensive literature review concerning the determinants of enrolment in psychosocial care for children and adolescents is lacking. Reviews on this topic concern those of Zwaanswijk and colleagues –literature up to 2001–,of Sayal – literature up to 2003–, and of Ryan et al – literature up to 2013- but these do not provide a full overview of the determinants of entering and the use of the broad field of psychosocial care for children and adolescents [9, 15, 20]. These reviews concerned only a limited range of care, regarded moving into and through only some filters of the
Pathways to Care model [9, 20], or they only involved younger children [15]. Moreover,
they defined enrolment in care differently by including parental recognition of problems [9, 15]. Finally, they did not differentiate between studies on help seeking and studies on use of care [9].
The aim of our study was to systematically summarize the available literature on the determinants of enrolment in and use of psychosocial care for children aged 0-18 years, according to the filters of the Pathways to Care model [14]. Our review covers all types of care aimed at reducing or making manageable psychosocial problems of both children
and adolescents, and it covers both entering care, passing to more specialized levels of care (all filters) and use of care.
Figure 1 Filters in entrance into psychosocial care for children and adolescents based on
the Pathways to Care model of Goldberg & Huxley [14]
METHODS
Search method
We searched the literature published in English during the period from January 2000 to February 2, 2015 in the Medline, PsycINFO, SocINDEX, and ERIC databases, using the online reference system EBSCOhost, with assistance of a librarian. Combinations of terms belonging to the following topics were used: children and adolescents, psychosocial problems, enrolment/use, and care (see appendix). We examined whether known key articles were among the search results. A pilot was performed to improve the search method.
Community
Filter 1 decision to consult
Filter 2 recognition by a professional
Filter 3 referral to specialised care
Filter 4 decision to admit Outpatient care
Primary care
Psychosocial care
Study selection
The search method resulted in 3,594 records, of which title and abstract were independently screened for eligibility by three authors (MN all, JT and DEMCJ half). A study was eligible if data were presented on determinants of passing one of the filters (decision to consult a professional/seek help, recognition of problems by a professional, referral to specialized care, or admission to inpatient care) or use of any care aimed at reducing or making manageable psychosocial problems (emotional, behavioural, social, or mental health problems) of children aged 0-18 in high-income countries (countries with a gross national income per capita over 12,276 United States Dollar in 2010 according to the World Bank’s list of high-income economies). Studies that focused on the general child population or on children with a specific type of psychosocial problem were included. Studies that selected a specific group based on a certain demographic characteristic − for example, studies including only boys, low-income families, children living in a rural area, or only ethnic minorities − were also included as long as it was compared with a group which was representative of the community, or when it regarded children in care, compared with other children in care. Qualitative studies, evaluation studies, single-case studies, reviews, editorial letters, and books were also excluded. This resulted in the exclusion of 3,203 records based on their title and abstract (Figure 2). Interrater Cohen’s kappas for inclusion/exclusion were 0.75 (MN/JT) with ppos=0.79 and
pneg=0.97, and 0.70 (MN/DEMCJ) with ppos=0.73 and pneg=0.97 [21, 22]. It is important to note that we just indicated one reason of exclusion per paper in Figure 2, i.e. the first observed issue leading to its exclusion, but a paper could actually meet more than one exclusion reason in the selection process.
Full texts of the remaining 391 studies were independently reviewed by the three authors, leading to the exclusion of 245 studies for various reasons (Figure 2). Interrater Cohen’s kappas for inclusion/exclusion were 0.72 (MN/JT) with ppos=0.82 and pneg=0.90, and 0.74 (MN/DEMCJ) with ppos=0.84 and pneg=0.90 [21, 22]. Discrepancies between reviewers, both in screening title/abstract and full-text, were resolved by discussion or by consultation of the other reviewer.
Quality assessment
The remaining 146 studies underwent quality assessment and content extraction by using modified versions of the tools of Gyorkos and colleagues [23, 24]. Study quality was assessed by scoring the following dimensions: (1) sample/cohort selection including response rate and generalizability, (2) inclusion of sufficient confounding factors in multivariable analyses among which the child’s psychosocial problems, (3) clarity of measurement of determinants and (4) outcome variables, and (5) completeness of
follow-up in the case of cohort studies. Subsequently, based on the score, studies were classified into three categories: weak (N=22), moderate (N=102), or strong quality (N=22) (Figure 2). Interrater Cohen’s weighted kappas were 0.66 (M.N./J.T.), with ppos=0.50 and
pneg=0.95, and 0.44 (M.N./D.E.M.C.J.), with ppos=0.55 and pneg= 0.88 [21, 22]. ‘Strong’ quality meant that no major flaws threatened the internal validity of the study, i.e. regarding any of the five dimensions, implying minor chances of selection bias, information bias, and uncontrolled confounding. Quality was scored as ‘moderate’ when at least in one of the dimensions a flaw occurred that challenged the confidence that could be attached to the results. Examples were: no adjustment for confounders, or a low response rate with selective non-response or lack of non-response information. In case major and/or severe flaws occurred, the quality was scored ‘weak’. We only included strong studies in order to obtain unbiased and meaningful evidence [25].
Figure 2 Flow-chart on the identification of studies
Data synthesis and reporting
In order to structure the results, each study outcome was attributed to one or more of the filters of the Pathways to Care model or to use of care [14]. A narrative synthesis of the results was undertaken because of the diversity of study methodologies and measurements of variables. Both general characteristics of the studies and the results for the determinants for each filter and use were reported. A factor was reported as a determinant if it was shown to contribute with statistical significance in at least one study (p-value<0.05). Records identified in Medline n=2,707 Records after duplicates removed n=3,594
Records excluded for various reasons n=3,203
entrance/use not studied (993) not a quantitative study (885) emotional/behavioural problems
not studied (505)
determinants not studied (353) children not studied (199) specific groups (183) not a high-income country (82) not English (3)
Records excluded for weak (n=22) or moderate (n=102) quality Records identified in PsycINFO n=676 Records identified in SocINDEX n=353 Records identified in ERIC n=306 Full-text articles selected n=391
Records excluded for various reasons n=245
entrance/use not studied (81) specific groups (51) determinants not studied (38) not a quantitative study (32) emotional/behavioural problems
not studied (27) children not studied (15) not a high-income country (1)
Articles that met inclusion criteria n=146 Articles included in systematic review, strong quality n=22
RESULTS
General study characteristics
Table 1 shows the general characteristics of the studies. Two studies concerned the filter “decision to consult a professional” [26, 27], four studies “problem recognition by a professional” [6, 7, 26, 28], four “referral to specialized care” [6-8, 28], one study “decision to admit to inpatient care” [29], and sixteen studies concerned use of care [26, 30-44]. Most studies investigated one filter or use of care only (N=18) [8, 27, 29-44], three studies assessed two filters [6, 7, 28], and one study assessed two filters and use of care [26].
Most studies were conducted in the United States (U.S.) (N=14) [26, 29, 31, 32, 34-41, 43, 44], followed by the Netherlands (N=6) [6-8, 28, 30, 42], Finland (N=1) [27], and Puerto Rico (N=1) [33]. Seventeen studies were based on cross-sectional data [6-8, 26-28, 31-34, 36-39, 41, 43, 44], and five on longitudinal data [29, 30, 35, 40, 42]. Most of the studies collected data via questionnaires; one study from child welfare records [29], and one study combined questionnaire-data with register data [42]. Respondents were parents/caregivers (N=3) [31, 38, 39], children (N=4) [35, 37, 41, 43], or a combination of parents/caregivers, children, and/or teachers or professionals (N=14) [6-8, 26-28, 30, 32-34, 36, 40, 42, 44]. Most of the studies covered the general child population (N=9) [6-8, 27, 28, 30, 31, 33, 35]. The remaining ones covered: children with psychosocial problems (N=2) [39, 42], with a psychiatric disorder (N= 1) [42], with an attention deficit hyperactivity disorder (ADHD) (N=2) [26, 36], with anxiety disorders (N=1) [34], with suicidal symptoms (N=2) [41, 43], with reported maltreatment (N=2) [32, 40], in custody of a child welfare agency (N=1) [29] or in family foster care (N=2) [37, 38]. Most studies focused on a wide range of psychosocial care for children (N=15) [27, 30-41, 43, 44]. Seven studies concerned a specific type of care: care by child health professionals (N=3) [6, 7, 28], ADHD treatment (N=1) [26], specialized mental health care (N=2) [8, 42], and inpatient care (N=1) [29]. Finally, three sets of two studies overlapped in their samples (Table 1) [32, 36, 39, 40, 43, 44].
Determinants of enrolment in and use of psychosocial care for children and adolescents
Table 2 summarizes the findings for each filter and for use of care. It shows that consulting a professional for psychosocial problems –the first filter- is determined by a child’s psychosocial problems [27], and is more likely for boys [26], Caucasian children [26], children with a regular source of routine pediatric care [26], and for children living in biological two-parent families [27].
Regarding the second filter, recognition by a professional was more likely when the child had psychosocial problems [6, 7, 26, 28], had more severe psychosocial problems [26], was of primary school age [6, 7], was male [26], was from Caucasian ethnicity [26], lived in a highly urbanized area [6], had experienced a life event [6], had academic problems [6], had received past treatment for psychosocial problems [6, 7, 28], and was a toddler not receiving day care [7]. Furthermore, recognition of problems by a professional was more likely when it concerned children of other than a biological two-parent family and of low-educated two-parents [7].
Regarding the third filter, referral to specialized care was more likely when the child had psychosocial problems [6-8, 28], was of non-Caucasian or Mediterranean descent [8], followed lower education [8], had academic problems [6, 8], had experienced life events [6], and had received past treatment for psychosocial problems [6, 7]. In addition, children living in other than a biological two-parent family [8], children who experienced a change in family composition [8], and children of low-educated parents [7] were more likely to be referred to specialized care.
Regarding the fourth filter, admission to inpatient care was more likely when children had more criminal or delinquent behaviour, had inappropriate sexual activities and were registered as at risk of running away or as a low risk of committing suicide [29]. Furthermore, child admittance to inpatient care was more likely with older age, fewer medical problems, living in a home setting, past psychiatric inpatient treatment, and the caregiver’s inability to provide supervision or other family dysfunctioning [29].
Finally, care use was more likely when the child had psychosocial problems [26, 30-44], or had more severe psychosocial problems [42], when the problem was a burden for the child [39], when the child was more impaired in global functioning [33], had comorbid disorders [34], had a poor health [40], was of white or Caucasian ethnicity [26, 32, 35, 37-42, 44], lived in an urban area [36], was insured [34, 36, 39, 41], had academic problems [33, 39], received special education services [26], participated in extracurricular activities [41], or experienced life events [31]. Regarding gender and age findings were mixed. Five studies [26, 33, 35, 42, 44] showed that boys used care more often, whereas one study –among suicidal children–, showed that girls used care more often [41]. For age, four studies showed that older children were more likely to use care [33, 38-40], whereas one study showed that children aged 9-13 were more likely to use care than children aged 4-8 and 14-17 years [36]. For place of residence, two studies showed that children placed out of home, as compared to those living at home [32, 40], and children placed in a group home, as compared to a family foster home [37], were more likely to use care. Furthermore, use of care was more likely for children of other than biological two-parent families [31, 41, 44], of concerned parents [332], of parents
who talked with a paediatrician about the child’s problems [310], of parents who experienced a burden due to their child’s difficulties [34, 39], of parents with a mental illness [32], of parents with higher socioeconomic status (SES) [26, 30, 365, 41], and of parents experiencing financial stress [31]. Children who were sexually abused [32, 38], physically abused [38], or abandoned [40] were more likely to have used care. One study showed that non-neglected children were more likely to use care than neglected children [38]. Finally, children identified in a mental health affiliated sector used care more often than children identified in other sectors [34].
Ta b le 1 M ai n c h ar ac te ri st ic s an d fi n d i ng s o f t he inc lu d e d st ud i es ( n= 2 2) S tu d y C o u n tr y D e si g n (s tu d y p e ri o d ) P o p u la ti o n R e sp o n d e n ts (N ) A g e : r an g e (m e an ) O u tc o m e (s ta n d ar d iz e d m e as u re m e n t/ ti m e p e ri o d ) a D e te rm in a n ts a ss o ci a te d w it h o u tc o m e a, b Fi lt e r 1: D e ci si o n t o c o n su lt ( n = 2) B u ss in g e t al . [2 6 ] U n it e d S ta te s C ro ss -s e ct io n al (1 9 9 9 -2 0 0 0 ) C h ild re n w it h A D H D P ar e n ts , te ac h e rs (n = 3 8 9 ) 5-11 ( 7. 8 ) S e e ki n g a ss e ss m e n t fo r A D H D f ro m p ri m ar y ca re p h ys ic ia n ( p e d ia tr ic ia n s/ fa m ily p ra ct it io n e r) o r m e n ta l h e al th s p e ci al is t (i .e ., g e n e ra l/c h ild p sy ch ia tr is t, p sy ch o lo g is t, s o ci al w o rk e r) ( e ve r so u g h t) M al e , C au ca si an e th n ic it y, h av in g r e g u la r so u rc e o f ro u ti n e p e d ia tr ic c ar e S o u ra n d e r e t al . [2 7] Fi n la n d C ro ss -s e ct io n al (1 9 8 9 , 1 9 9 9 ) G e n e ra l p o p u la ti o n C h ild re n , p ar e n ts , te ac h e rs (1 9 8 9 n = 9 0 5, 19 9 9 n = 8 25 ) 8 -9 S o u g h t h e lp /t re at m e n t fo r e m o ti o n al / b e h av io u ra l p ro b le m s (i n p as t ye a r) P sy ch o so ci al p ro b le m s (l o w e r p sy ch o lo g ic al h e al th (t e ac h e r-re p o rt )) , l iv in g in o th e r th an b io lo g ic al tw o -p ar e n t fa m ily ( o n ly 1 9 9 9 s am p le ) Fi lt e r 2: R e co g n it io n b y a p ro fe ss io n a l ( n = 4 ) B ru g m an e t al . [ 6 ] th e N e th e rl an d s C ro ss -s e ct io n al (1 9 9 7-19 9 8 ) G e n e ra l p o p u la ti o n C h ild re n , p ar e n ts , ch ild h e al th p ro fe ss io n al s (n = 3 39 0 ) 5-15 Id e n ti fi c a ti on of p s yc ho s oc ia l pr ob l em by c hi ld h e a lt h p ro fe ss io n al ( at t h is m o m e n t) P sy ch o so ci al p ro b le m s (t o ta l s co re , in te rn al iz in g , e x te rn al iz in g , w it h d ra w n , a n x io u s/ d e p re ss e d , so ci al p ro b le m s, a n d a g g re ss iv e b e h av io u r) , yo u n g e r ag e ( 4 -1 1 vs . 1 2-16 ), u rb an r e si d e n ce , l if e e ve n ts ( e .g . h o sp it al iz at io n , d e a th o f a fa m ily m e m b e r, p ar e n ta l d iv o rc e ) , a ca d e m ic p ro b le m s, p as t p sy ch o lo g ic al /m e d ic al /o th e r tr e at m e n t fo r p sy ch o so ci al p ro b le m s B u ss in g e t a l. [2 6 ] S e e fi l t er 1 S e e fi l t er 1 S e e fi l t er 1 S e e fi l t er 1 S e e fi l t er 1 O b ta in in g a p ro fe ss io n a l A D H D d ia g n o si s (e ve r) P sy ch o so ci al p ro b le m s (s e ve re b e h av io u r p ro b le m s) , m al e , C au ca si an e th n ic it y K le in V e ld e rm an e t al . [ 28 ] th e N e th e rl a n d s C ro ss -s e ct io n a l (2 0 0 2-20 0 3) G e n e ra l p o p u la ti o n P ar e n ts , ch ild h e al th p ro fe ss io n al s (n = 7 0 1) 14 m o n th s Id e n ti fi c a ti on of p s yc ho s oc ia l pr ob l em by c hi ld h e al th p ro fe ss io n al ( at t h is m o m e n t) P sy ch o so ci al p ro b le m s (t o ta l s co re , i n te rn al iz in g , an d d ys re g u la ti o n p ro b le m s) , p as t/ cu rr e n t tr e at m e n t fo r p sy ch o so ci a l p ro b le m s R e ijn e ve ld e t al . [ 7] th e N e th e rl a n d s C ro ss -s e ct io n al (1 9 9 7-19 9 8 ) G e n e ra l p o p u la ti o n P ar e n ts , ch ild h e al th p ro fe ss io n al s (n = 2 0 6 3) 21 m o n th s – 4 y e ar s Id e n ti fi c a ti on of p s yc ho s oc ia l pr ob l em by c hi ld h e al th p ro fe ss io n al ( at t h is m o m e n t) P sy ch o so ci al p ro b le m s (t o ta l s co re , e x te rn al iz in g , o p p o si ti o n al , o ve ra ct iv e , a n d s le e p p ro b le m s) , o ld e r ag e ( 3. 5 to 4 v s. 2 1 to 2 7 m o n th s) , o n e -p a re n t fa m ily , l o w p ar e n ta l e d u ca ti o n al le ve l, n o d ay ca re , p a st p sy ch o lo g ic al /m e d ic al t re at m e n t fo r p sy ch o so ci al p ro b le m s Fi lt e r 3: R e fe rr al t o s p e ci al is t ca re ( n = 4 ) B ru g m an e t al . [ 6 ] S e e fi l t er 2 S e e fi l t er 2 S e e fi l t er 2 S e e fi l t er 2 S e e fi l t er 2 R e fe rr al f o r p sy ch o so ci al p ro b le m s b y ch ild h e a lt h p ro fe ss io n al ( at t h is m o m e n t) P sy ch o so ci al p ro b le m s (t o ta l s co re , i n te rn al iz in g , e x te rn al iz in g , s o ci al p ro b le m s, a n d a g g re ss iv e b e h av io u r) , s o m at ic c o m p la in ts , l if e e ve n ts ( e .g . h o sp it al iz at io n , d e at h o f a fa m ily m e m b e r, p ar e n ta l d iv o rc e ), a ca d e m ic p ro b le m s, p as t m e d ic al /o th e r tr e at m e n t fo r p sy ch o so ci al p ro b le m s
Ta b le 1 ( C o n ti n u e d ) S tu d y C o u n tr y D e si g n (s tu d y p e ri o d ) P o p u la ti o n R e sp o n d e n ts (N ) A g e : r an g e (m e an ) O u tc o m e ( st an d a rd iz e d m e as u re m e n t/ ti m e p e ri o d ) a D e te rm in a n ts a ss o ci a te d w it h o u tc o m e a, b Fi lt e r 3: R e fe rr al t o s p e ci al is t ca re ( n = 4 ) K le in V e ld e rm an e t al . [ 28 ] S e e fi l t er 2 S e e fi l t er 2 S e e fi l t er 2 S e e fi l t er 2 S e e fi l t er 2 A n y ac ti o n ( ad vi ce , f o llo w -u p , r e fe rr al , co n su lt at io n w it h o th e rs ) fo r p sy ch o so ci al p ro b le m s b y ch ild h e al th p ro fe ss io n al ( at t h is m o m e n t) P sy ch o so ci al p ro b le m s (t o ta l s co re , i n te rn al iz in g , an d d ys re g u la ti o n p ro b le m s) R e ijn e ve ld e t al . [ 7] S e e fi l t er 2 S e e fi l t er 2 S e e fi l t er 2 S e e fi l t er 2 S e e fi l t er 2 R e fe rr al f o r p sy ch o so ci al p ro b le m s b y ch ild h e a lt h p ro fe ss io n al ( at t h is m o m e n t) P sy ch o so ci al p ro b le m s (t o ta l s co re , e x te rn al iz in g , an d o p p o si ti o n al p ro b le m s) , l o w p ar e n ta l e d u ca ti o n al le ve l, p as t p sy ch o lo g ic al /m e d ic al tr e at m e n t fo r p sy ch o so ci al p ro b le m s Z w aa n sw ijk e t al . [ 8 ] th e N e th e rl an d s C ro ss -s e ct io n al (1 9 9 3) G e n e ra l p o p u la ti o n C h ild re n , p ar e n ts (n = 1 12 0 ) 11 -1 8 R e fe rr al f o r sp e ci a liz e d m e n ta l h e a lt h c ar e ( in p as t ye ar ) P sy ch o so ci al p ro b le m s (t o ta l s co re , e x te rn a liz in g , an x io u s/ d e p re ss e d , a n d t h o u g h t p ro b le m s) , o n e -p ar e n t fa m ily , c h an g e o f fa m ily c o m p o si ti o n , l o w ad o le sc e n ts ’ e d u ca ti o n al le ve l, m o re c o m p e te n ce in a ct iv it ie s, le ss s ch o o l c o m p e te n ce , N o n -C au ca si an /M e d it e rr an e an e th n ic it y Fi lt e r 4 : D e ci si o n t o a d m it ( n = 1) P ar k e t al . [ 29 ] U n it e d S ta te s C o h o rt , Lo n g it u d in al (2 0 0 1-20 0 3) C h ild re n in cu st o d y o f ch ild w e lf ar e r e fe rr e d to p sy ch ia tr ic cr is is s e rv ic e s S e rv ic e s re co rd s (n = 6 0 3) 7 - 1 8 Fi rs t re si d e n ti al c ar e p la ce m e n t (p la ce m e n t in g ro u p h o m e /in st it u ti o n al s e tt in g s th ro u g h c h ild w e lf ar e s ys te m ) (i n p as t ye ar ) P sy ch o so ci al p ro b le m s (c ri m in al -d e lin q u e n cy , r is k o f ru n aw ay , i n a p p ro p ri at e s e x u al a ct iv it ie s, a n d le ss s u ic id e r is k) , o ld e r ag e , f am ily d ys fu n ct io n in g , co m o rb id it y w it h m e d ic al s ta tu s, c ar e g iv e r’ s in ab ili ty f o r su p e rv is io n , p as t p sy ch ia tr ic h o sp it al iz a ti o n , l iv in g in h o m e s e tt in g ( vs . n o n -ki n sh ip f o st e r ca re ) U se o f ca re ( n =1 6 ) A m o n e -P ’O la k e t al . [ 30 ] th e N e th e rl a n d s C o h o rt , Lo n g it u d in al (T 1 20 0 1-20 0 2 T 2 20 0 3-20 0 4 ) G e n e ra l p o p u la ti o n C h ild re n , p ar e n ts , te ac h e rs (n = 2 14 9 ) 12 -1 5 ( 13 .6 ) U se o f sp e ci al ty m e n ta l h e a lt h c ar e ( in p at ie n t, o u tp at ie n t) ( p as t tw o y e ar s) P sy ch o so ci al p ro b le m s (i n te rn al iz in g a n d e x te rn al iz in g p ro b le m s) , h ig h e r S E S , h ig h e r m at e rn al e d u ca ti o n B e va ar t e t a l. [4 2] th e N e th e rl a n d s C o h o rt , Lo n g it u d in al (T 1 20 0 8 -2 0 0 9 T 2 ca se r e g is te r 20 0 8 -2 0 11 ) C h ild re n w it h e m o ti o n a l a n d / o r b e h av io u ra l p ro b le m s P ar e n ts , te ac h e rs ( n = 12 6 9 ) D at a fr o m p sy ch ia tr ic ca se r e g is te r 5-9 (T 1 5. 3 T 2 7. 6 ) U se o f sp e ci al is t m e n ta l h e al th c ar e ( o u tp at ie n t, cr is is in te rv e n ti o n , s h e lt e re d h o m e s, d ay ce n te rs a n d p sy ch ia tr ic h o sp it al s, in fo f ro m c as e re g is te r) ( tw o y e ar s af te r si g n al in g e m o ti o n al an d /o r b e h av io u ra l p ro b le m ) P sy ch o so ci al p ro b le m s (s e ve ri ty o f p ro b le m b e h av io u r (t e ac h e r-re p o rt )) , m al e , D u tc h e th n ic it y (v s. M o ro cc an /T u rk is h a n d o th e r) B ri g g s-G o w an e t al . [ 31 ] U n it e d S ta te s C ro ss -s e ct io n al (1 9 8 8 -1 9 8 9 ) G e n e ra l p o p u la ti o n P ar e n ts (n = 1 0 6 0 ) 1-9 ( 7. 2) 1. T al ke d t o p e d ia tr ic ia n a b o u t p ro b le m w it h b e h av io u rs , e m o ti o n s/ n e rv e s (p as t ye ar ) 1. P sy ch o so ci al p ro b le m s (a n y d is o rd e r) , h ig h e r fi n a nc ia l st re s s 2. U se o f m e n ta l h e al th c ar e ( [s ch o o l] p sy ch o lo g is t, p sy ch ia tr is t, c o u n se llo r, t h e ra p is t, so ci al w o rk e r) 2. P sy ch o so ci a l p ro b le m s (a n y d is o rd e r) , t a lk t o p e d ia tr ic ia n a b o u t ch ild ’s b e h av io u r/ e m o ti o n al p ro b le m , o n e -p ar e n t h o m e , n e g at iv e li fe e ve n ts (t w o o r m o re n e g at iv e c h ild o r p ar e n t e ve n ts , e .g . p a re n ta l d iv o rc e , d e at h o f a fa m ily m e m b e r o r cl o se fr ie n d , l o ss o f jo b b y p ar e n t)
Ta b le 1 ( C o n ti n u e d ) S tu d y C o u n tr y D e si g n (s tu d y p e ri o d ) P o p u la ti o n R e sp o n d e n ts (N ) A g e : r an g e (m e an ) O u tc o m e ( st an d a rd iz e d m e as u re m e n t/ ti m e p e ri o d ) a D e te rm in a n ts a ss o ci a te d w it h o u tc o m e a, b B u rn s e t al . [ 32 ] c U n it e d S ta te s C ro ss -s e ct io n al (1 9 9 9 -2 0 0 0 ) C h ild re n in ve st ig at e d b y ch ild w e lf ar e af te r re p o rt e d m al tr e at m e n t C h ild re n , p ar e n ts , te ac h e rs , ch ild w e lf ar e w o rk e rs (n = 3 21 1) 2-14 U se o f m e n ta l h e a lt h c ar e ( fo r e m o ti o n al / b e h av io u ra l p ro b le m s in cl . o u tp at ie n t, re si d e n ti al ) (C h ild a n d A d o le sc e n t S e rv ic e s A ss e ss m e n t (C A S A )/ p as t ye ar ) P sy ch o so ci al p ro b le m s (t o ta l s co re ), s e x u al a b u se (a g e 2 -5 ), w h it e e th n ic it y (a g e 6 -1 0 ), p la ce d o u t o f h o m e ( ag e 6 -1 4 ), p ar e n ta l m e n ta l i lln e ss ( ag e 1 1-14 ) B u ss in g e t al . [2 6 ] S e e fi l t er 1 S e e fi l t er 1 S e e fi l t er 1 S e e fi l t er 1 S e e fi l t er 1 U se o f A D H D t re at m e n t (c u rr e n t) M al e , C au ca si an e th n ic it y, f u ll p ay -lu n ch s u b si d y st at u s, u se o f sp e ci al e d u ca ti o n s e rv ic e s C ab iy a e t al . [ 33 ] P u e rt o R ic o C ro ss -s e ct io n al (1 9 9 9 -2 0 0 0 ) G e n e ra l p o p u la ti o n C h ild re n , p ar e n ts (n = 1 8 9 6 ) 4 -1 7 U se o f m e n ta l h e al th c ar e ( in p at ie n t, o u tp a ti e n t, sc h o o l) (S e rv ic e a ss e ss m e n t fo r ch ild re n a n d ad o le sc e n ts ( S A C A )) ( p as t ye ar ) P sy ch o so ci al p ro b le m s (s e ve re e m o ti o n al d is tu rb an ce a n d d is ru p ti ve d is o rd e r) , m o re im p ai re d g lo b al f u n ct io n in g , ( im p ai re d ) m al e , o ld e r ag e ( 11 -1 7 vs . 4 -1 0 ), p ar e n ta l c o n ce rn , d iff ic u l ty w i th sc h o o l w o rk C h av ir a e t al . [3 4 ] U n it e d S ta te s C ro ss -s e ct io n a l (1 9 9 7) C h ild re n w it h a n x ie ty d is o rd e rs in p u b lic s e ct o rs o f ca re C h ild re n , p ar e n ts (n = 1 6 2) 6 -1 8 ( 13 .9 ) 1. U se o f in p at ie n t m e n ta l h e al th c ar e ( S e rv ic e as se ss m e n t fo r ch ild re n a n d a d o le sc e n ts ( S A C A )/ p as t ye ar ) 1. C o m o rb id d is o rd e rs , i d e n ti fi e d fr om me n t al -h e al th a ff il i at ed se c to r s 2. U se o f o u tp at ie n t m e n ta l h e al th c ar e ( S e rv ic e as se ss m e n t fo r ch ild re n a n d a d o le sc e n ts ( S A C A )/ p as t ye ar ) 2. N o s ig n ifi c a nt r es ul ts 3. U se o f sc h o o l m e n ta l h e a lt h c ar e ( S e rv ic e as se ss m e n t fo r ch ild re n a n d a d o le sc e n ts ( S A C A )/ p as t ye ar ) 3. Id e n ti fi e d fr om me n t al -he a l th af fi li a te d s ec t or s 4 . U se o f n o n -s p e ci al ty o u tp at ie n t m e n ta l h e al th ca re ( in cl . f am ily d o ct o r, p e d ia tr ic ia n , e m e rg e n cy ro o m , i n -h o m e c o u n se lli n g f o r e m o ti o n a l/ b e h av io u ra l p ro b le m s) (S e rv ic e a ss e ss m e n t fo r ch ild re n a n d ad o le sc e n ts ( S A C A )/ p as t ye ar ) 4 . C ar e g iv e r st ra in , c o m o rb id d is ru p ti ve b e h av io u r d is o rd e r C o st e llo e t al . [4 4 ] d U n it e d S ta te s C ro ss -s e ct io n al (2 0 0 1-20 0 4 ) A d o le sc e n ts w it h a p sy ch ia tr ic d is o rd e r C h ild re n , p ar e n ts (n = 2 75 7) 13 -1 7 U se o f se rv ic e s fo r e m o ti o n al o r b e h av io u ra l p ro b le m s (b ro ad : g e n e ra l c ar e t o s p e ci al iz e d m e n ta l h e al th c ar e ) (p as t ye ar ) M al e , n o n -H is p an ic w h it e e th n ic it y (v s. n o n -H is p an ic b la ck ), o th e r th an a b io lo g ic al t w o -p ar e n t fa m ily C u ff e et a l. [3 5] U n it e d S ta te s C o h o rt , Lo n g it u d in al (T 1 19 8 7-19 8 9 T 2 19 9 1-19 9 4 ) G e n e ra l p o p u la ti o n C h ild re n (T 1 n = 5 79 T 2 n = 4 8 8 ) A d o le sc e n ts (T 1 12 .8 3, T 2 18 .6 5) U se o f o u tp at ie n t ca re ( P re se n t e p is o d e v e rs io n o f th e s ch e d u le f o r af fe c tive di so r de r s an d sc h iz o p h re n ia f o r sc h o o l-a g e d c h ild re n ( K -S A D S )/ p as t ye ar ) P sy ch o so ci al p ro b le m s (d e p re ss iv e sy m p to m a to lo g y (o n ly T 1) , n o n -a ff e c tive di so r de r (o n ly T 1) , a ff e c ti ve di so r de r , an d af fe c t iv e c om o r b id w it h n o n -a ff e c ti ve di so r de r ), wh i te ma l es ( on l y T1 ) C u ff e et a l. [3 6] e U n it e d S ta te s C ro ss -s e ct io n al (2 0 0 1) C h ild re n w it h A D H D C h ild re n , p ar e n ts (n = 2 78 ) 4 -1 7 1. V is it t o a g e n e ra l d o ct o r fo r e m o ti o n al p ro b le m s (g e n e ra l p ra ct ic e , p e d ia tr ic s, f am ily m e d ic in e , o r in te rn al m e d ic in e ) (p as t ye a r) 1. P ri m ar y sc h o o l a g e ( 9 -1 3 vs . 4 -8 /1 4 -1 7) , h e al th in su ra n ce ( vs . n o in su ra n ce ) 2. S e e in g a m e n ta l h e al th p ro fe ss io n al (p sy ch ia tr is t, p sy ch o lo g is t, p sy ch ia tr ic n u rs e , cl in ic al s o ci al w o rk e r) ( p as t ye a r) 2. P sy ch o so ci al p ro b le m s (e m o ti o n al p ro b le m s) , u rb an r e si d e n ce , h ig h e r fa m ily e d u ca ti o n
Ta b le 1 ( C o n ti n u e d ) S tu d y C o u n tr y D e si g n (s tu d y p e ri o d ) P o p u la ti o n R e sp o n d e n ts (N ) A g e : r an g e (m e an ) O u tc o m e ( st an d a rd iz e d m e as u re m e n t/ ti m e p e ri o d ) a D e te rm in a n ts a ss o ci a te d w it h o u tc o m e a, b G ar ci a e t al . [ 37 ] U n it e d S ta te s C ro ss -s e ct io n al (2 0 0 2-20 0 3) C h ild re n in fo st e r ca re C h ild re n (n = 7 32 ) 17 -1 8 U se o f p sy ch o lo g ic a l o r e m o ti o n al c o u n se lli n g (p as t ye a r) P sy ch o so ci al p ro b le m s (t o ta l s co re ), C au ca si an / o th e r e th n ic it y (v s. A fr ic an -A m e ri ca n ), li vi n g si tu at io n : g ro u p c ar e ( vs . f o st e r h o m e ) G ar la n d e t al . [3 8 ] U n it e d S ta te s C ro ss -s e ct io n al (1 9 9 0 -1 9 9 1) C h ild re n in fo st e r ca re C ar e g iv e rs (n = 6 5 9 ) 2-17 ( 7. 6 ) U se o f ca re f o r e m o ti o n al , b e h av io u ra l, so ci al , sc h o o l, o th e r ad ju st m e n t p ro b le m s (p as t h al f ye ar ) P sy ch o so ci al p ro b le m s (t o ta l s co re ), o ld e r ag e , w h it e A m e ri ca n e th n ic it y, s e x u al a b u se , p h ys ic al ab u se , n o n e g le ct H u sk y e t al . [4 3] d U n it e d S ta te s C ro ss -s e ct io n al (2 0 0 1-20 0 4 ) A d o le sc e n ts w it h s u ic id al sy m p to m s C h ild re n (n = 5 58 ) 13 -1 8 U se o f se rv ic e s fo r e m o ti o n al o r b e h av io u ra l p ro b le m s (b ro ad : g e n e ra l c ar e t o s p e ci al iz e d m e n ta l h e al th c ar e ) (p as t ye ar ) P sy ch o so ci al p ro b le m s (s u ic id e id e at io n a n d s u ic id e p la n ) A m o n g a d o le sc e n ts w it h s u ic id e id e at io n : e at in g , b e h av io u r d is o rd e r, 2 -5 m e n ta l d is o rd e rs A m o n g a d o le sc e n ts w it h s u ic id e p la n : m o o d d is o rd e r A m o n g a d o le sc e n ts w it h s u ic id e a tt e m p t: a n y d is o rd e r, 2 -5 m e n ta l d is o rd e rs S im p so n e t al . [3 9 ] e U n it e d S ta te s C ro ss -s e ct io n al (2 0 0 1, 2 0 0 3, 20 0 4 ) C h ild re n w it h e m o ti o n a l/ b e h av io u ra l p ro b le m s P ar e n ts (n = 1 4 23 ) 4 -1 7 1. V is it o r co n ve rs at io n w it h m e n ta l h e al th p ro fe ss io n al ( p sy ch ia tr is t, p sy ch o lo g is t, c lin ic al so ci al w o rk e r o r p sy ch ia tr ic n u rs e ) ab o u t th e h e al th ( p as t ye ar ) 1. P sy ch o so ci al p ro b le m s (s e ve re p sy ch o so ci al sy m p to m s) , o ld e r ag e ( 8 -1 7 ye ar s vs . 4 -7 ), n o n -H is p an ic w h it e e th n ic it y, p ri va te h e al th in su ra n ce (v s. n o in su ra n ce ), f am ily b u rd e n , d iff ic u lties af fe c ting ch i ld’ s lei su r e ac ti vi ti es 2. U se o f sp e ci a l e d u ca ti o n s e rv ic e s (p as t ye ar ) 2. P sy ch o so ci al p ro b le m s (s e ve re p sy ch o so ci al sy m p to m s) , c h ild ’s d if fi c u l ti es a ff ec t in g f ri en d s h ip s, le is u re a ct iv it ie s, le a rn in g S ta h m e r e t al . [4 0 ] c U n it e d S ta te s C o h o rt , Lo n g it u d in al (1 9 9 9 ) C h ild re n in c h ild w e lf ar e a ft e r al le g a ti o n s o f ab u se /n e g le ct P ar e n ts , ch ild w e lf ar e w o rk e rs (n = 2 8 13 ) 0 -5 U se o f ca re ( e d u ca ti o n , m e n ta l h e al th , p ri m ar y ca re ) (C h ild a n d A d o le sc e n t S e rv ic e s A ss e ss m e n t (C A S A )/ p as t ye ar ) P sy ch o so ci al p ro b le m s (d e ve lo p m e n ta l a n d b e h av io u ra l n e e d ), o ld e r ag e ( 3-5 vs . 0 -2 y e ar s o ld ), w h it e /n o n -H is p an ic e th n ic it y, b e in g a b an d o n e d , liv in g in o u t-o f-h o m e c ar e W u e t al . [ 4 1] U n it e d S ta te s C ro ss -s e ct io n al (2 0 0 0 ) C h ild re n t h at at te m p te d su ic id e C h ild re n (n = 8 77 ) 12 -1 7 1. U se o f in p at ie n t m e n ta l h e al th c ar e ( p as t ye ar ) 1. P o o r se lf -p e rc e iv e d h e al th , w h it e e th n ic it y, c h ild n o t liv in g w it h b o th p a re n ts 2. U se o f o u tp at ie n t m e n ta l h e al th c ar e ( p as t ye ar ) 2. P sy ch o so ci al p ro b le m s (a n x ie ty a n d d is ru p ti ve b e h av io u r p ro b le m s) , f e m al e , w h it e e th n ic it y, h ig h e r fa m ily in co m e , M e d ic ar e o r M e d ic ai d in su ra n ce ( vs . n o in su ra n ce ), p ar ti ci p at io n e x tr ac u rr ic u la r ac ti vi ti e s 3. U se o f sc h o o l m e n ta l h e al th c a re ( p as t ye ar ) 3. P ar ti ci p at io n in e x tr ac u rr ic u la r ac ti vi ti e s a T e rm in o lo g y as u se d is c o n si st e n t w it h t h e o ri g in al s tu d ie s. b O n ly s ig n ifi c a nt re su lt s co rr e ct e d f o r co n fo u n d e rs . c B u rn s e t al . ( 20 0 4 ) an d S ta h m e r e t al . ( 20 0 5) h av e o ve rl ap in t h e ir s am p le s. d C o st e llo e t al . ( 20 14 ) an d H u sk y e t al . ( 20 12 ) h av e o ve rl ap in t h e ir s am p le s. eC u ff e et a l. (2 00 9 ) a nd Si mp s on et a l . ( 20 0 9 ) h a ve ov er la p in th e i r sa m p l es .
Table 2 Summary of results per outcome (filters and use of care)
Outcome Determinants (outcome more likely for): n / N*
Filter 1: Decision to consult Child characteristics: Psychosocial problems 1/2** Male gender 1/2 Caucasian (vs. African-American) ethnicity 1/1 Regular source of routine pediatric care 1/1 Non-significant findings for: psychosocial problem severity, age, health insurance, school performance, receiving exceptional student education (all n=1)
Family characteristics:
Biological two-parent family 1/1 Non-significant findings for: socioeconomic status (n=2)
Filter 2: Recognition by a professional Child characteristics: Psychosocial problems 4/4 Psychosocial problem severity 1/1 Primary school age (3.5-4 years old vs. 21-27 months old, and 4-11 vs. 12-16 years old)
2/3 Male gender 1/4 Caucasian (vs. African-American) ethnicity 1/4 Highly urbanized area 1/2 Life events 1/3 Academic problems 1/1 Past treatment for psychosocial problems 3/3 Not receiving day care (21 months to 4 years) 1/1 Non-significant findings for: chronic illness or handicap (n=3), health insurance (n=1), receiving exceptional student education (n=1), negative pregnancy outcome (pregnancy duration <37 week, birth weight <2500 g) (n=2), instrumental delivery (n=2), hospitalization after birth (n=1) Family
characteristics:
Other than a biological two-parent family 1/3 Lower socioeconomic status 1/3 Non-significant findings for: siblings (n=3)
Filter 3: Referral to specialist care Child characteristics: Psychosocial problems 4/4 Non-Caucasian or Mediterranean (vs. Dutch) descent 1/3 Low educational level (adolescent) 1/1 Academic problems 2/2 More competence in activities 1/1 Life events 1/3 Past treatment for psychosocial problems 2/3 Non-significant findings for: gender (n=3), age (n=2), ethnicity (n=2), urbanization (n=2), receiving day care (n=1), chronic illness or handicap (n=3), negative pregnancy outcome (pregnancy duration <37 week, birth weight <2500 g) (n=2), instrumental delivery (n=2), hospitalization after birth (n=1) Family
characteristics:
Other than a biological two-parent family 1/4 Change in family composition 1/1 Lower socioeconomic status 1/4 Non-significant findings for: siblings (n=3)
Filter 4: Decision to admit
Child characteristics:
Risk behaviour and functioning (criminal/ delinquent behaviour, risk of runaway, inappropriate sexual activities, less suicide risk)
1/1
Older age 1/1
Comorbidity with medical status 1/1 Living in a home setting (vs. living in non-kinship foster care) 1/1 Past psychiatric hospitalization 1/1 Non-significant findings for: gender, ethnicity, number of placement changes, number of crisis episodes (all n=1)
Outcome Determinants (outcome more likely for): n / N*
Family characteristics:
Caregiver’s inability for supervision 1/1 Family dysfunctioning 1/1 Non-significant findings for: neglect, abuse (all n=1)
Use of care Child characteristics:
Psychosocial problems 15/16** Psychosocial problem severity 2/4 Burden for child 1/1 Impairment in global functioning 1/2 Comorbid disorders 1/1 Poor health 1/1 Age: Older age Age 9 -13 (vs. 4 - 8 and 14 -17) 4/11 1/11 Gender: Male gender
Female gender (among suicidal children)
5/15 1/15 White/ Caucasian ethnicity 10/13 Urban residence 1/2 Place of residence:
Placed out of home (vs. living at home) Place in a group home (vs. family foster home)
2/3 1/3 Insured children 4/5 Academic problems 2/2 Receiving special education services 1/1 Participation in extracurricular activities 1/1 Negative life events 1/1 Non-significant findings for: region, involvement in criminal justice system (all n=1)
Family characteristics:
Other than a biological two-parent family 3/7 Parental concern 1/1 Parental talk with a paediatrician about problems 1/1 Experienced burden by parents due to child’s difficulties 2/2 Parental mental illness 1/3 Higher socioeconomic status 4/11 Parental financial stress 1/1 Child maltreatment: Sexual abuse Physical abuse Non-neglected (vs. neglected) Being abandoned 2/4 1/4 1/4 1/4 Non-significant findings for: birth order, siblings, marital status parent, emotional abuse, social support, parenting skills, caregiver absence (all n=1) Organizational
characteristics:
Child identified from mental health affiliated sector 1/1 *n/N number of studies that found positive association of determinant with outcome/total number.
DISCUSSION
Our systematic review of the literature on the determinants of enrolment in and use of psychosocial care by children and adolescents resulted in 22 relevant studies of high quality. Results showed that many child and family characteristics were associated with enrolment in and use of psychosocial care. The main identified child determinants were psychosocial problems, urban area residence, life events, academic problems, and past treatment. For age, gender, ethnicity, and place of residence, varying effects were found. The main identified family determinants were living in another than a biological two-parent family, and SES (varying effects).
Interpretation and comparison with earlier reviews
To our knowledge, this review is the first providing a very broad overview of studies on determinants of both enrolment in and use of a broad field of psychosocial care for both children and adolescents. We encountered large differences between the included studies. Differences existed not only within countries and care systems, but also in study designs, study populations, children’s age ranges and measures of both outcomes and determinants.
Regarding the results on determinants for which varying effects were found, this heterogeneity could be partly due to different effects of these characteristics on different stages of passing the care system, because of setting-specific factors. For example, regarding place of residence, children living at home were more likely to be admitted to inpatient care compared to children in non-kinship foster care [29], whereas these children were less likely to use care compared to children placed out of home – that is, living in (non-)kinship foster care or in group homes and residential care– [32, 40]. Regarding gender, the varying effect might be due to the type of psychosocial problems, i.e. the study showing a higher likelihood of using care for girls was among those who attempted suicide [41], whereas the studies showing a higher likelihood for boys were among children with psychosocial problems and among the general child population [26, 33, 35, 42, 44]. The effect of age varied across filters as well. Problem recognition was highest in children of primary school age [6, 7], whereas admittance to inpatient care and use of care were mostly more likely in older children [29, 33, 38-40]. Possible explanations may be that passing through the system takes time, causing mean age to increase at higher filters, or a reluctance to start the most specialized care for very young children. Regarding ethnicity, enrolment in and use of care were more likely for white/Caucasian children in U.S. studies [26, 31, 32, 34-41, 43, 44] and also in one Dutch study [42], whereas in another Dutch study non-Caucasian adolescents or adolescents
with a Mediterranean background were more likely to be referred to specialized care [8]. This may indicate that in the Netherlands attempts to refer ethnic minorities to specialized care have been more successful than in the U.S., but evidence for this is lacking.
The family factor with the greatest impact was living in another than a biological two-parent family, suggesting a universal effect across countries. The effects of SES varied. The effect of SES may be different between health care systems of different countries, with for example income being more important in case of high-out-of pocket payments in health care. In Dutch studies, lower SES increased the likelihood of passing through the care system –i.e., professional problem recognition and referral–, whereas in U.S. studies higher SES did so.
Our findings reflect those of Sayal [15] regarding the role of psychosocial problems, age, gender, and SES. Regarding life events, past treatment, academic problems, ethnicity, and living in a single-parent family we found these to determine the passing of more than one filter or use of care, whereas Sayal found this for the passing of only one filter. In addition, we found evidence concerning the role of urban area and place of residence. Finally, Sayal also reported professional-related determinants, but these came from studies of moderate or weak quality and were thus excluded by us.
Our findings mostly reflect those of Zwaanswijk and colleagues [9] regarding the role of psychosocial problems, age, and academic problems on help-seeking. However, Zwaanswijk and colleagues also reported some determinants of help-seeking that we did not identify, that is, family burden, parental attitudes and beliefs, family educational level, family stress, parental mental health problems and parental receipt of treatment, family size, and type of abuse. In contrast, we found that living in a single-parent family increased the likelihood of help-seeking, whereas Zwaanswijk and colleagues did not identify this determinant. Differences in the definition of help-seeking might explain this: Zwaanswijk and colleagues included use of care in their definition of help seeking whereas we strictly distinguished help-seeking from use of care to provide more insight. Our more strict quality assessment of studies may be an additional explanation.
Regarding problem recognition by a professional, the determinants we identified are mainly similar to those of Zwaanswijk and colleagues [9]. In addition, though, we found ethnicity, urban residence, and lower SES to be related to professional problem recognition. This might be explained by our inclusion of studies on problem recognition by a wide range of professionals instead of by only the general practitioner.
Gaps in knowledge and methodological issues of the included studies
Our review shows that literature on determinants of use of care is rather strong, whereas it is rather limited regarding entering and passing through the care system. Evidence was also scarce for potential organizational, professional-related, psychological, and social determinants [45]. Next, a major gap was the large variation in included studies regarding their samples, studied determinants and outcomes. This largely limits the potential to draw conclusions based on the available evidence. Methodological difficulties may explain these gaps, as this concerns rather hard to study topics. However, additional evidence, is needed to understand why certain children and adolescents enter care and others do not.
Strengths and limitations
Strengths of our review were the use of a comprehensive search strategy with broad search terms in order not to miss any possibly relevant study and the restriction to high quality studies to obtain the strongest evidence. However, our review also had some limitations. We did not search grey literature or literature in languages other than English, and neither did we search through the reference lists of the included studies. It seems unlikely that this would have led to missing any major studies, but we cannot fully exclude this. Finally, use of the Pathways to Care model facilitated structuring the study results [14]. However, other models might better represent enrolment involving multiple pathways rather than a linear one as the model we used suggests [46].
Implications
Our review shows that enrolment in and use of care is not only determined by children’s and adolescents’ psychosocial problems but also by other child and family characteristics. This implies that, while having similar problems, the likelihood that a child will enter and receive care is not the same for all children. Professionals and policymakers should be aware that the system of psychosocial care is less accessible for some children, and that these children are hindered in passing through the system. Policies need to be improved to address this.
Gaps in evidence in particular concern enrolment and determinants other than child and family socio-demographic characteristics. Longitudinal, high-quality research is needed to fill this gap, in particular regarding organizational, professional-related, psychological, and social determinants. This may highly improve the psychosocial health of children.
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