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Table 3 Barrier and facilitator subthemes identified within each theme and exemplary quotes

From: Adolescents’ perceived barriers and facilitators to seeking and accessing professional help for anxiety and depressive disorders: a qualitative interview study

Theme Barrier and facilitator subthemes Description Exemplary quotes (Pseudonym, age, ADIS-C/K-SADS diagnoses)
Making sense of difficulties (‘I just thought I was my kind of normal’) Recognising anxiety and depression symptoms and knowing where to get help Adolescents report recognising some anxiety and/or depression symptoms, especially those related to physical sensations and behaviour. In addition, they often ‘classify’ themselves or other people as anxious/depressed based on someone else’s (e.g. their parent’s, friend’s, GP’s) naming of symptoms as anxiety/depression. Adolescents are also often not aware of available help for their problems, apart from the support offered in their schools ‘if they would be breathing really faster they’ll probably have anxiety attack…depression is like when they’ve got a head in their hands or something or they’ve like got a really sad face on their face all the time’. (Savannah, 11, SocA, GAD)
‘when I asked my mum about it, once I asked her if we know anyone who had it (anxiety), mum would say that a lot of my cousins have it’ (Zara, 12, GAD, SocA)
‘I know the student support centre (in school) can help me and he (the school counsellor) can most likely help me…and that’s about it’ (Hannah, 14, PD, SocA, Agor, GAD)
  Beliefs about mental health and help-seeking Adolescents’ understanding of their difficulties appears to be influenced by their beliefs about mental health and help-seeking, such as a belief that help-seeking is brave and that mental health problems are common and (not) ‘normal’. Adolescents that described themselves as ‘not normal’ compared to other people, especially their peers, tended to be the ones without a prior experience of professional help ‘I’d think they (friends) would be quite brave for doing that (seeking help) and I’d be proud of them for getting help’ (Lilly, 16, GAD, SocA, PD, Agor, MDD, Dyst, SepA)
‘…Not many people that I’ve met personally go through the same things that I am. Like fears and stuff like that. They’re just like, I guess you can say normal’. (Chris, 15, PD, GAD, Agor)
  Taking opportunities to learn about mental health Adolescents report wanting to have more opportunities to learn about specific mental health problems and available help, however, their engagement in existing opportunities appears to be relatively low, and even if they are provided with the information directly (e.g. given leaflets with information resources), adolescents do not seem to engage fully in these opportunities. Distributing information via popular social media (e.g. Instagram and Snapchat) is suggested as a way of facilitating their engagement ‘…They could make like links on the computers to, to healthcare websites…It would be like the phone numbers, and places you could go to to get healthcare and talk about what you are going through’. (Ben, 12, MDD, GAD)
‘…I’ve not personally used it (Kooth), but I know it’s there’ (Isaac, 13, MDD, PD, SocA, GAD, SpecP)
‘…When it comes to the social media, it would have to be something that is already in that apps that people use now. Because I don’t think anyone would like, there’s always the idea of like ‘oh let’s make a mental health app’, like not many people would actually get that to help themselves’ (Alex, 15, GAD, SocA)
  Differentiating between anxiety/depression symptoms and a person’s attributes Adolescents, parents and teachers struggle with differentiating between anxiety/depression symptoms and adolescent’s attributes. For instance, some parents and adolescents report always perceiving their child/themselves as shy and not confident, and therefore perceiving their (child’s) difficulties as personality traits and, consequently, not considering help-seeking. Furthermore, parents often attribute adolescents’ behaviour to characteristics of adolescence (e.g. moodiness, constant worry). Adolescents suggest that some school-based interventions (e.g. mental health screening, mental health assemblies) could help themselves and others identify anxiety/depression symptoms that require professional help ‘Well she’s naturally quite a shy child…you know, she’s not a sort of outgoing child, she is naturally quite shy, so I think that’s hold her back a lot’. (Victoria (mother), 11, SocA)
‘I think possibly he’s got lots of things going on with his mind, but I think he’s kind of a typical fifteen year old’ [Chris (mother), 15, PD, GAD, Agor]
‘…Basically doing the whole school (screening). Like, I think it should be like, in the law. Like someone every, maybe two, one or 2 years a person comes in like a teacher in the room and just like we’re part of like counselling thing and if you have any worries, we can help you’ (Tina, 15, GAD, SocA, Dyst)
Disclosing problems (‘I was scared of telling people how I feel’) Worrying what other people will think Adolescents are concerned about being negatively evaluated if they disclose their problems to anyone, and that includes formal and informal sources of help. Although this is less commonly expressed by boys, their parents indicate that they also have these concerns. Concerns about being judged by other people were particularly marked among adolescents with self- and/or parent-reported comorbid gender and sexual identity issues ‘I was scared of telling people how I felt. Cos I thought they will judge me and then they’ll think that’s there’s something wrong with me, and stuff like that…’ (Tina, 15, GAD, SocA, Dyst)
‘…I’d be thinking about, maybe they think I’m….I don’t know, they just might think I’m weird’ (Sophie, 16, GAD, SocA, Dyst)
‘I think it’s more about what other, what his friends are gonna think, cos we’re having this discussion at the moment because he, he’s trying to make up his mind whether he’s bisexual, if he’s gay, if he’s straight…so I think it’s more about his image, you know, he doesn’t want to ask for it (help), because it’s gonna make him look bad with his friends’ [Isaac (mother), 13, MDD, PD, SocA, GAD, SpecP]
  Ability to verbalise feelings Adolescents report that they can struggle to verbalise their feelings and that this then makes it difficult to be able to disclose their problems to other people. Parents describe how this can lead to anger outbursts, particularly among younger adolescents or those with self-/parent-reported comorbid ADHD (traits) and major depressive disorder diagnosis ‘I don’t really like saying much cos I don’t really know what to say’ (Katie, 13, PD, Agor, GAD, SocA)
‘She just finds it hard to express herself because she doesn’t have the mental capacity to explain in the way that other people can understand…she just tends to lash out cause she finds it easier to express it with anger and physicality, rather than with words’. [Claire (father), 12, MDD, GAD]
  Asking for help Adolescents commonly struggle with initiating a conversation about mental health and asking for help. They are more likely to share their feelings when a parent or a professional initiates the conversation ‘…I didn’t know how to erm, like, ask for the help. Cos, I don’t know, it's just a lot like, I know I can, but can’t just really go up to someone and say ‘hey, can you help me with this?’ (Alex, 15, GAD, SocA)
‘Well, I always thought that, even though people say they’re fine, you should always take like person out of class, all of the people and students, and just like sit with them, and just be like ‘are you sure’, like ‘everything’s okay, you’ve got no worries?’, erm, and stuff like that. Cos I know if that happened, then I, then I could reach out and get help’ (Tina, 15, GAD, SocA, Dyst)
  Ability to trust other people Being able to trust other people and perceiving other people as trustworthy is a common reason why adolescents (do not) speak about their feelings to anyone. There are differences in which settings or with whom adolescents feel most able to talk about their difficulties without concerns about information being shared with others; for example, whether this is inside or outside the school environment, with friends or teachers/professionals. Inability to trust other people appears to be particularly pertinent among those with past (negative) experience of professionals or negative life experiences (e.g. family violence) ‘I just don’t really trust teachers, I don’t know, cos they (.), they could be like ‘oh we won’t tell anyone’, but then like, really they get talking to someone, talking to other students what people said or something’. (Joe, 16, SocA, GAD)
‘I have spoken to some (friends) about it but not like everybody…(and to) family members…Cos they won’t like tell anyone else I think’ (Luke, 11, SpecP, GAD, SepA, SocA)
‘…I just don’t really have a lot of trust in anyone’ (Anna, 15, GAD, PTSD, SocA)
  Anxiety and depressive symptoms interfere with help-seeking The very nature of having an anxiety disorder or depression can get in the way of successful help-seeking. In particular, adolescents report struggling to speak to other people due to their shyness/social anxiety, lack of confidence and feelings of hopelessness ‘I just don’t really feel that confident to do that…to speak to anyone I think’. (Lilly, 15, GAD, SocA, PD, Agor, MDD, Dyst, SepA)
‘I carry on and just keep going. Just kind of… do the same thing. Cause nothing is going to change anything’ (Sophie, 16, GAD, SocA, Dyst)
  Concerns about the impact on others Although adolescents’ friends and families usually represent a first source of help for adolescents, adolescents do not always share their feelings with these people as they do not want them to worry about them or make their parents angry. This barrier is common among older adolescents and also voiced by parents of adolescent boys ‘It’s just, it’s like, it’s almost uncomfortable cos I don’t want them (parents), I don’t want to tell them cos I don’t want, want them to worry about me’. (Isaac, 13, MDD, PD, SocA, GAD, SpecP)
‘…I don’t like talking about myself to them (friends), I’d rather listen to what they have to say and that stops them from worrying about me…I thought that she (mother) was going to be angry with me (if I tell her)’. (Hannah, 13, PD, SocA, Agor, GAD)
‘Ben keeps all for himself. I think it’s because I have girls and he’s the oldest he doesn’t want to put any stress on me’ (Ben (mother), 12, MDD, GAD)
Ambivalence to seeking professional help (‘There’s like a part of me that wants help and a part that doesn’t’) Desire to be self-reliant Adolescents report a preference to rely on themselves when facing emotional difficulties, and wanting to show themselves and others that they are strong enough to cope on their own. As such, they can perceive help-seeking to be in conflict with their perceptions of themselves. Parents sometimes explain their children’s self-reliance by referring to their own ways of coping with difficult emotions. Similarly, parents of boys report barriers related to their sons appeared to see help-seeking as conflicting with the idea of what it is to be male ‘…because I think that’s something that I have to do by myself…cos I’m a tough person’ (Chris, 15, PD, GAD, Agor)
‘I think it’s just my pride… cos I think I can do everything by myself.’ (Victoria, 14, SocA)
‘I think cos I’ve got my own problems and I don’t ask for help and I do everything by myself I think she thinks she’s got to be the same’ [Savannah (mother), SocA, GAD]
  Other’s reactions Adolescents are often concerned about being treated differently or being perceived as wanting attention if they reach out for help. Concerns about other people’s reactions appear to be particularly common among those without prior experience of professional help, older adolescents and adolescent males ‘So, I don’t want people to be like, ‘oh, she wants attention' or like, I just don’t like things to be all about me’ (Sophie, 16, GAD, SocA, Dyst)
‘I just don't want people to treat me differently and like take pity on me, I'd rather them just treat me normally…than just be like ‘oh, he’s depressed, you gotta be careful with him,', so yea’. (Frank, 14, MDD, GAD, SocA)
  Fears and expectations about professional help Not knowing what to expect from professional help (e.g., what professional help will consist of and how the adolescent will react), and whether this will be helpful, represent notable barriers to help-seeking. Adolescents report wanting more information about what professional help looks like, which could reduce their anxiety and help them decide whether to seek help or not. Past (positive) experiences of professional help can also reduce adolescents’ fears and create more realistic expectations about professional help ‘…he’s got himself quite stressed and anxious about the doctor's appointment, he didn’t sleep the night before that and then he got tearful while we were waiting…and I was trying to explain that they won’t do anything, we're just gonna come and have a chat, they're not gonna remove him or anything..’ [Ben (mother), 12, MDD, GAD]
‘I'm happy and scared, like I'm happy cos I’m getting help but then I'm also scared of what will actually happen’ (Lilly, 15, GAD, SocA, PD, Ago, MDD, Dyst, SepA)
‘…I was scared to get help in Year 6 because I didn’t know what’s going to happen, but it kind of comforted me because I knew it’s going to be, I knew it’s not going to be anything scary…It was just something nice’. (Zara, 12, GAD, SocA)
The instrumental role of others (‘If it wouldn’t be for X, I would still be suffering’) Recognising the need for professional help and initiating the process of help-seeking Adolescents’ parents and teachers are crucial in the process of accessing professional help. However, although they might identify symptoms of anxiety/depression in an adolescent, they do not always recognise the need for professional help and/or initiate the process of help-seeking. Parents/professionals who perceive an adolescent's symptoms as risky or severe (e.g. self-harming) and interfering (e.g. child not being able to go to school) are likely to initiate the process of help-seeking for a young person ‘He does sometimes have panic attacks…sometimes he just has to erm take himself out of his lessons, but I think, he’s kind of getting into grips with that’. [Chris (mother), 15, PD, GAD, Agor]
‘My mum ran the doctors to book an appointment, cos she said like, she wants me to get help I need’ (Anna, 15, GAD, PTSD, SocA)
‘I think the school's done it (arranged help) when he first started and he was getting quite distressed in a couple of days, I think they’ve obviously assigned him to her (school nurse) and he’s just carried it on with her’. (Luke (mother), 11, SpecP, GAD, SepA, SocA)
  Knowledge of services Knowing where to seek help is an important facilitator, and adolescents and their parents indicate that schools are most commonly the first nominated source of help for adolescents and their families. Besides from schools, families also turn to their child's GP to seek support. Parents generally lack knowledge about child and adolescent mental health services, unless they have personal or professional experience of CAMHS ‘…mum called up to school to say like, I don’t want to come into school anymore’ (Tina, 15, GAD, SocA, Dyst)
‘…I actually didn't know there was help for erm the children’. [Frank (mother), 14, MDD, GAD, SocA]
‘…I also work for the NHS Trust so I know a lot of services that are available, cos obviously I work for the NHS company’ (Luke (mother), 11, SpecP, GAD, SepA, SocA)
  Family’s resources and resilience Adolescents and their parents describe the high demand on local child and adolescent mental health services as preventing access and that persistence is required to successfully access services. Parents with sufficient resources (e.g., emotional and financial resources) appear most likely to be able to access specialist support, and this sometimes means accessing help privately. Where parents lack these resources, they may not attempt to seek help for their child. The role of the school seems to be especially important in families with limited resources ‘Nothing stopped us it’s just erm I mean obviously for a while we were waiting to see if we can get somewhere through the doctor but, so that stopped us for a little while, but then we just said ‘no we gotta deal with it’ and we paid for it once, I mean if people haven’t got money, huh, that leaves them there doesn’t it?’ [Joe (mother), 16, SocA, GAD]
‘I’ve been trying to get hold of them (CAMHS) for quite a while now….but to be honest with you…things were going on at the time, do you know what I mean…I just had so much going on I didn’t know if I was coming or going to be honest with you’ [Maya (mother), 13, Agor, SocA, GAD, Hallucinations and Delusions]
  Caregivers and schools working together Families vary significantly in their experiences of support from other agencies (e.g. schools, GP) when trying to access help. Parents and adolescents describe the importance of feeling well supported by their child’s school to be able to successfully access professional help ‘so me and my husband went into school and said ‘look, we need help, what do we do’, obviously we didn’t, I wouldn’t know how to deal with something like that and they basically helped us and we helped them, if you know what I mean, so we worked together’ [Isaac (mother), 13, MDD, PD, SocA, GAD, SpecP]
  Young person’s engagement with help-seeking Adolescents may not feel ready for professional help or engage in the process of help-seeking after this has been initiated by parents/schools (e.g. making an appointment with the GP). In these situations, parents report feeling frustrated and hopeless ‘she absolutely had a meltdown when I said I was going to take her to the doctors, to discuss what’s going on and I think she needs help’. [Katie (mother), 13, PDD, Agor, GAD, SocA]
‘at the same time Alex, he refused to to to talk to anybody at this stage and now if Alex, he refuses he wouldn’t, erm so we are stuck for those year, two years’ time completely stuck’ [Alex (mother), 15, GAD, SocA]
  1. Agor agoraphobia, Dyst dysthymia, GAD generalised anxiety disorder, MDD major depressive disorder, PD panic disorder, SocA social anxiety disorder, SpecP specific phobia