Education, Faculty of
Educational and Counselling Psychology, and Special Education (ECPS), Department of
DSpace
UBCV
Yu, Christine Margaret Shung-Bun
Doctor of Philosophy - PhD
University of British Columbia
Mental health is a fundamental component of overall health and well-being. However, a lack of service utilization for children and adolescents with mental health concerns is well documented in several countries. Anxiety is the most common mental health disorder across the lifespan. Multiple barriers to treatment have been identified in the literature and several models of help-seeking have been proposed. However, a unifying theory or model of help-seeking for child mental health services is lacking. One step to improve rates of service use for children with anxiety is to better understand the help-seeking process that parents engage in when seeking services. A Straussian grounded theory approach was used to investigate the process that parents engage in when seeking professional mental health services for their children struggling with anxiety. Ten semistructured interviews were conducted with parents, in addition to follow-up sessions to discuss additional or clarifying questions and incorporate participant feedback on the emerging theory. From the findings, being an advocate emerged as the core category. The core category facilitated parents’ movement through five phases of the help-seeking process for their children with anxiety: (a) recognizing anxiety as problematic, (b) deciding to seek professional mental health services, (c) initiating professional mental health services, (d) receiving professional mental health services, and (e) if necessary, reinitiating or being redirected to other professional mental health services. Movement through the phases was nonlinear and resulted from complex interactions of a variety of factors and environments. Parents often found themselves stuck in a loop, cycling between phases. The findings are contextualized within the extant literature, and implications for practice and policy are discussed.
THE HELP-SEEKING PROCESS FOR PARENTS OF CHILDREN WITH ANXIETY: A GROUNDED THEORY by CHRISTINE MARGARET SHUNG-BUN YU B.A., Simon Fraser University, 2005 M.A., University of British Columbia, 2012 A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES (Counselling Psychology) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) April 2025 ã Christine Margaret Shung-Bun Yu, 2025 ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the dissertation entitled: The help-seeking process for parents of children with anxiety: A grounded theory Submitted by Christine Margaret Shung-Bun Yu in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Counselling Psychology Examining Committee: Dr. Laurie Ford, Associate Professor, School and Applied Child Psychology, UBC Supervisor Dr. Richard Young, Professor Emeritus, Counselling Psychology, UBC Co-supervisor Dr. Anusha Kassan, Associate Professor, School and Applied Child Psychology, UBC Supervisory Committee Member Dr. Thomas Schanding, Associate Professor, School and Applied Child Psychology, UBC University Examiner Dr. Shelly Ben-David, Associate Professor, School of Social Work, UBC-Okanagan University Examiner Dr. Christina Rinaldi, Professor, Educational Psychology Department, University of Alberta External Examiner iii Abstract Mental health is a fundamental component of overall health and well-being. However, a lack of service utilization for children and adolescents with mental health concerns is well documented in several countries. Anxiety is the most common mental health disorder across the lifespan. Multiple barriers to treatment have been identified in the literature and several models of help-seeking have been proposed. However, a unifying theory or model of help-seeking for child mental health services is lacking. One step to improve rates of service use for children with anxiety is to better understand the help-seeking process that parents engage in when seeking services. A Straussian grounded theory approach was used to investigate the process that parents engage in when seeking professional mental health services for their children struggling with anxiety. Ten semistructured interviews were conducted with parents, in addition to follow-up sessions to discuss additional or clarifying questions and incorporate participant feedback on the emerging theory. From the findings, being an advocate emerged as the core category. The core category facilitated parents’ movement through five phases of the help-seeking process for their children with anxiety: (a) recognizing anxiety as problematic, (b) deciding to seek professional mental health services, (c) initiating professional mental health services, (d) receiving professional mental health services, and (e) if necessary, reinitiating or being redirected to other professional mental health services. Movement through the phases was nonlinear and resulted from complex interactions of a variety of factors and environments. Parents often found themselves stuck in a loop, cycling between phases. The findings are contextualized within the extant literature, and implications for practice and policy are discussed. iv Lay Summary Mental health is a key part of overall health and well-being, but mental health concerns in children and adolescents are often undertreated. A unifying theory or model of help-seeking for children’s mental health is lacking. Anxiety is the most common mental health disorder across the lifespan; however, mental health services for childhood anxiety are grossly underutilized. One step to improving service use is to better understand the help-seeking process. This study used grounded theory to develop a theory of help-seeking for parents of children with anxiety. Results show that the core category, being an advocate, helped parents move through five stages of help-seeking: (a) recognizing anxiety as problematic, (b) deciding to seek professional mental health services, (c) initiating professional mental health services, (d) receiving professional mental health services, and (e) if necessary, reinitiating or being redirected to other professional mental health services. The findings and implications for practice are discussed. v Preface This dissertation is original, unpublished, independent work by the author, C. M. Yu, conducted under the supervision of Drs. Richard Young and Laurie Ford (coresearch supervisors) and Dr. Anusha Kassan, supervisory committee member. Generative AI was not used for any aspects of the work. Ethics approval for this research was issued by the Behavioural Research Ethics Board at the University of British Columbia (certificate number: H19-03574). vi Table of Contents Abstract ......................................................................................................................................... iii Lay Summary ............................................................................................................................... iv Preface ............................................................................................................................................ v Table of Contents ......................................................................................................................... vi List of Tables .............................................................................................................................. xiii List of Figures ............................................................................................................................. xiv Definitions of Key Terms ............................................................................................................ xv Acknowledgements .................................................................................................................... xvi Dedication ................................................................................................................................. xviii Chapter 1: Introduction ............................................................................................................... 1 Overview ..................................................................................................................................... 1 Study Rationale ........................................................................................................................... 3 Purpose and Research Question .................................................................................................. 4 Summary ..................................................................................................................................... 4 Chapter 2: Literature Review ...................................................................................................... 6 Overview ..................................................................................................................................... 6 Child and Adolescent Mental Health .......................................................................................... 6 Overview .................................................................................................................................. 6 Trends in Child and Adolescent Mental Health ...................................................................... 7 COVID-19 and Mental Health ................................................................................................. 8 Mental Health Help-Seeking ..................................................................................................... 10 Overview ................................................................................................................................ 10 vii Information Seeking. ......................................................................................................... 11 Pathways to Care. .............................................................................................................. 12 Models of Help-Seeking ........................................................................................................ 15 Behavioural Model of Health Services Use. ..................................................................... 16 The Gateway Provider Model. .......................................................................................... 19 Integrated Behavioural Model of Mental Health Help-Seeking ....................................... 21 Model of Mental Health Help-Seeking Behaviour in Adolescent Males With Symptoms of Anxiety ......................................................................................................................... 23 Service Utilization of Mental Health Services .......................................................................... 23 Overview ................................................................................................................................ 23 The Role of Parents in Accessing Child and Adolescent Mental Health Services ................ 27 Predictors of Service Use ....................................................................................................... 34 Parental Perceptions of Barriers and Facilitators to Treatment. ....................................... 35 Systemic Issues Within the Mental Health System. ..................................................... 35 Parent Perceptions of Treatment. .................................................................................. 37 Knowledge and Understanding of Mental Health Concern and Help-Seeking. ........... 37 Family Circumstances. .................................................................................................. 38 Child and Adolescent Perceptions of Barriers and Facilitators. ....................................... 39 Childhood Anxiety .................................................................................................................... 41 Overview ................................................................................................................................ 41 Core Features of Anxiety ....................................................................................................... 43 Treatment for Childhood Anxiety ......................................................................................... 48 Summary ................................................................................................................................... 49 viii Chapter 3: Methods .................................................................................................................... 50 Overview ................................................................................................................................... 50 Positionality of the Researcher .................................................................................................. 50 Reflexivity ............................................................................................................................. 50 Philosophical Underpinnings ................................................................................................. 53 Methodological Framework ...................................................................................................... 55 Criteria for Participant Selection ............................................................................................... 58 Recruitment and Theoretical Sampling ..................................................................................... 59 Procedure ................................................................................................................................... 61 Data Collection .......................................................................................................................... 63 Participants ................................................................................................................................ 65 Overview ................................................................................................................................ 65 Participant Profiles ................................................................................................................. 66 Leigh. ................................................................................................................................ 68 Alisha. ............................................................................................................................... 69 Sarah. ................................................................................................................................ 70 Erin. ................................................................................................................................... 71 Nicola. ............................................................................................................................... 72 Eleanor. ............................................................................................................................. 73 Olivia. ................................................................................................................................ 74 Anna. ................................................................................................................................. 74 Addison. ............................................................................................................................ 75 Diane. ................................................................................................................................ 76 ix Data Analysis ............................................................................................................................ 77 Overview ................................................................................................................................ 77 Coding .................................................................................................................................... 79 Open Coding. .................................................................................................................... 79 Axial Coding. .................................................................................................................... 80 Selective Coding. .............................................................................................................. 81 Bronfenbrenner’s Process-Person-Context-Time Model. ................................................. 82 Memos ................................................................................................................................... 83 Constant Comparative Analysis ............................................................................................ 83 Saturation ............................................................................................................................... 85 Ensuring Rigour ........................................................................................................................ 87 Criteria for Evaluating Grounded Theory .............................................................................. 87 Practices and Strategies for Ensuring Rigour ........................................................................ 89 Theoretical Sensitivity and Reflexivity. ........................................................................... 89 Triangulation. .................................................................................................................... 91 Intercoder Agreement. ...................................................................................................... 93 Summary ................................................................................................................................... 94 Chapter 4: Results ....................................................................................................................... 95 Overview ................................................................................................................................... 95 Overview of the Grounded Theory ........................................................................................... 95 The Core Category of Being an Advocate ................................................................................ 97 Overview ................................................................................................................................ 97 Enhancing Mental Health Literacy ...................................................................................... 103 x Phase 1: Recognizing Anxiety as Problematic ........................................................................ 106 Noticing Initial Flags ........................................................................................................... 106 Observing Symptoms of Anxiety ........................................................................................ 107 Recognizing Functional Impairment ................................................................................... 108 Recognizing Impact on Family ............................................................................................ 109 Phase 2: Deciding to Seek Professional Mental Health Services ............................................ 110 Shift in Balance .................................................................................................................... 110 Deterrents to Seeking Help .................................................................................................. 113 Considering Mental Health Service Options ....................................................................... 114 Phase 3: Initiating Professional Mental Health Services ........................................................ 115 Service Availability ............................................................................................................. 117 Practical Considerations ...................................................................................................... 119 Clinician Selection ............................................................................................................... 120 Considering the Service Setting ........................................................................................... 120 Phase 4: Receiving Professional Mental Health Services ....................................................... 121 Child’s Experience of Service ............................................................................................. 121 Therapeutic Process ............................................................................................................. 122 Assessing Goodness of Fit ................................................................................................... 124 Perceived Level of Effectiveness ......................................................................................... 125 Phase 5: Reinitiating or Being Redirected to Other Professional Mental Health Services ..... 127 Engaging With Multiple Points of Mental Health Services Contact ................................... 128 Experiencing Unmet Needs ................................................................................................. 129 Ineffectiveness of Current Services. ............................................................................... 129 xi Dealing With Bureaucracy. ............................................................................................. 131 Encountering Systemic Barriers .......................................................................................... 131 Summary ................................................................................................................................. 133 Chapter 5: Discussion ............................................................................................................... 134 Overview ................................................................................................................................. 134 Situating the Grounded Theory ............................................................................................... 134 In Relation to Theoretical Frameworks ............................................................................... 135 Transtheoretical Model of Change. ................................................................................. 135 The Grounded Theory Through a Process-Person-Context-Time Model and Transtheoretical Model of Change Lens. ........................................................................ 136 In Relation to Extant Literature ........................................................................................... 138 Implications for Practice and Policy ....................................................................................... 147 Limitations of the Present Study ............................................................................................. 149 Strengths of the Present Study ................................................................................................ 150 Future Directions ..................................................................................................................... 152 Filling Gaps in the Literature ............................................................................................... 152 The Need for Practice-Based Implementation Research ..................................................... 154 Conclusion ............................................................................................................................... 155 References .................................................................................................................................. 157 Appendices ................................................................................................................................. 198 Appendix A: Interview Guide ................................................................................................. 198 Appendix B: Screening Questionnaire .................................................................................... 199 Appendix C: List of Community and Online Resources ......................................................... 200 xii Appendix D: Demographic Questionnaire .............................................................................. 201 Appendix E: Parent Consent Form .......................................................................................... 202 xiii List of Tables Table 1 Participant Demographics ................................................................................................67 Table 2 Participant Backgrounds ..................................................................................................68 Table 3 Overview of Primary Categories and Subcategories .......................................................96 xiv List of Figures Figure 1 Overview of the Model of the Help-Seeking Process for Parents of Children with Anxiety ............................................................................................................................................98 xv Definitions of Key Terms Anxiety. Anxiety is an emotion that is characterized by feelings of apprehension and distress about a threatening, yet ambiguous event. It is similar to fear and involves a state of elevated arousal, but is often more pervasive and enduring (Rachman, 2020). Anxiety disorders. As operationalized in the Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev., DSM-5-TR; American Psychiatric Association, 2022), anxiety disorders represent clinically significant levels of dysfunctional anxiety and fear. Help-seeking behaviour. Help-seeking behaviour is an adaptive process in which an individual attempts to obtain external assistance, formal or informal, to deal with a particular problem (Rickwood & Thomas, 2012). Mental health. A state of well-being, including social, emotional and psychological aspects, which allows individuals to realize their own abilities, cope with the normal stresses of life, and actively participate and contribute to society is referred to as mental health (World Health Organization, 2013). Mental disorders. Mental health disorders are a range of mental or behavioural patterns causing significant distress and impairment of functioning that fall within the DSM-5-TR (American Psychiatric Association, 2022). Psychological treatment. Interventions incorporating techniques based in psychological sciences that are specifically tailored to target pathological processes causing impairment or distress in an individual are called psychological treatment. Psychological treatment may stem from a range of theoretical approaches (Barlow, 2004). Service utilization. The extent to which people engage in services available to them is called service utilization. xvi Acknowledgements The completion of this research would not have been possible without support from many people. I wish to thank the parent participants for openly sharing their experiences and being generous with their time. Their dedication to their children and desire to improve families’ access to mental health services is inspiring. I am immensely grateful to my dissertation committee, who struck a magical balance between flexibly supporting me through numerous challenges and keeping me on track so that I could reach the finish line. My co-supervisors, Dr. Laurie Ford and Dr. Richard Young, have supported me every step of my doctoral studies and helped me form meaningful connections with peers and other grounded-theory early researchers. Their guidance and feedback helped transform my thoughts into a feasible dissertation. Dr. Ford’s humour, faith in my abilities and good practical advice also helped me to remain grounded and calm when the stress threatened to bubble over. Dr. Young’s open invitation to discuss any questions or be a sounding board helped me to stretch my learning edges as a novice qualitative researcher. Their understanding, positivity, thorough reviews (and quick turnarounds), and challenging questions helped prepare me to confidently defend my research. I also want to express my appreciation to Dr. Anusha Kassan, who encouraged me to apply to the program and serendipitously served as my committee member, again. Her calm encouragement and dedication to supporting my academic journey have been invaluable. To my critical friends who worked tirelessly to help me analyze data and commiserated with me at just the right moments: I am grateful to AR for reviewing my audit trail and spending countless hours coding (and discussing codes), and to LB for her unwavering encouragement, and insight, and perspective when helping me pull it all together. The Pom Gals deserve special xvii recognition for keeping me accountable and working at my computer for 25 minutes at a time, and for motivating me with their kindness. I also wish to thank Erin Seatter for her editing services, and Parisa Moghadam for her assistance with refining the Figure 1. A heartfelt thank you to Dr. Lynn Miller, who started me on this journey almost 15 years ago and predicted this day would come. She generously opened doors for me throughout my professional and academic development, and nudged me along when I needed it. This dissertation is supported in part by funding from the Social Sciences and Humanities Research Council and the Canadian Psychological Association. xviii Dedication To my parents, who have continually sacrificed to provide me with opportunities not available to them growing up. In their own ways and styles, they inspired me to further my education and pursue graduate studies. By example, they taught me never to give up in the face of adversity and instilled in me the work ethic and determination to complete this degree. Without their love, patience, gentle encouragement, and unfailing instrumental and emotional support, I would certainly still be working on this dissertation. 1 Chapter 1: Introduction Overview Mental health is a fundamental component of overall health and well-being (Mental Health Commission of Canada, 2012; World Health Organization [WHO], 2013). Individual attributes and social, cultural, economic, political, and environmental factors are some of the determinants of mental health. To adequately address mental health concerns, comprehensive strategies for promotion, prevention, treatment, and recovery in a whole-of-government approach is required (WHO, 2013). The burden of mental disorders and the importance of mental health are being recognized globally. However, to date, the response to the burden of mental disorders by health systems is insufficient, leading to a growing discrepancy between the need and the provision of treatment and services worldwide (WHO, 2013). In Canada, the government is recognizing how essential mental health is to quality of life. A mental health strategy has been developed, with recommendations for action and calls to action for various levels of government, leaders in the private and public sectors, and citizens to improve outcomes for Canadians experiencing mental health problems (British Columbia Ministry of Mental Health and Addictions, 2019, 2023; Mental Health Commission of Canada, 2012). A lack of service utilization for children and adolescents with mental health concerns is well documented in several countries (Reardon et al., 2017). Several barriers to accessing treatment for children with mental health concerns, such as poor mental health literacy and attitudinal and logistical factors, have been identified (Gulliver et al., 2010; Reardon et al., 2017). When compared to children and youth with externalizing disorders, children and youth with internalizing disorders are less likely to access services (Merikangas et al., 2011). 2 Anxiety is the most common mental health disorder, with adolescent lifetime prevalence rates estimated to be as high as 32% (Merikangas et al., 2010) and worldwide pooled prevalence rates estimated at 6.5% in children and adolescents (Polanczyk et al., 2015). The median age of initial onset for anxiety disorders is 6 years (Merikangas et al., 2010). In a longitudinal study exploring anxiety disorder across four developmental stages, incidence rates were significantly higher in childhood and adulthood, compared to adolescence and emerging adulthood (Essau et al., 2018). Untreated childhood anxiety is associated with a host of deleterious effects, including increased substance use, lower academic performance, adult psychopathology, decreased family cohesion, and increased interpersonal problems (Essau et al., 2014; Grover et al., 2007; Öst & Treffers, 2001; Swan & Kendall, 2016). Costs of anxiety disorders also impact society directly and indirectly and include costs related to health care utilization, sick leave, unemployment, and remedial education services (Dupont et al., 1996; Greenberg et al., 1999; Koerner et al., 2004). In Canada, the economic burden of generalized anxiety disorder alone is estimated at $17.3 billion (Sutherland & Stonebridge, 2016). The negative outcomes of untreated childhood anxiety are well documented, and there is a wealth of research on efficacious treatment (Crowe & McKay, 2017; Seligman & Ollendick, 2011; Wolitzky-Taylor et al., 2015). Anxiety disorders are often responsive to psychological intervention (Barrett et al., 1996; Kendall et al., 2000), and cognitive behavioural therapy (CBT) has been identified in the Canadian Clinical Practice Guidelines as the psychological treatment of choice for children and youth with anxiety disorders (Katzman et al., 2014). However, less than 18% of adolescents with anxiety disorders are receiving treatment of any kind (Merikangas et al., 2011). Even fewer receive specialized mental health treatment (Costello et al., 2014) or evidence-based treatments (Alonso et al., 2018). Compared to children with behavioural 3 disorders, children with anxiety disorders have lower rates of service use (Merikangas et al., 2011). Given the negative trajectory of untreated anxiety and the decrease of service engagement with child age (Yeh et al., 2003), exploration of the underutilization of services for children with anxiety is warranted. Theories and models of help-seeking have focused on exploring the process of help-seeking, as well as on determinants and correlates influencing service use. Historically, frameworks and models of help-seeking centred on adults. As children rarely seek out help on their own (Costello et al., 1998; Reardon et al., 2017; Srebnik et al., 1996; Stiffman et al., 2004), adult models of help-seeking cannot be directly applied to children and must be adapted. Although research has generated knowledge about help-seeking for children with mental health concerns in more recent decades, a cohesive theory or model of help-seeking for children with mental health concerns is lacking. When considering anxiety, specifically, there is a paucity of research. A small number of studies have focused on barriers to services or on parents’ experiences of accessing mental health treatment for anxiety for their child (Woodgate et al., 2023). Study Rationale Research has explored the unmet mental health needs of children and adolescents; however, gaps in the literature remain. To explain the discrepancy between mental health service need and mental health service utilization, studies have investigated predictors of service use, such as parent and child characteristics, and contextual factors. The barriers and facilitators that parents face when trying to access treatment have also been explored in an attempt to better understand the discrepancy. One step to improve rates of service utilization is to better understand the processes underlying the help-seeking of parents. Several models of help-seeking 4 have been proposed; however, a unifying theory or model of help-seeking for mental health, and childhood anxiety, specifically, is lacking. More consideration of contributing and contextual factors in relation to accessing services, and how these factors influence each other is vital to identifying how to better support parents in the help-seeking process. Purpose and Research Question The purpose of this study is to gain an understanding of the process parents engage in when seeking help for their children with anxiety and their engagement in psychological treatment. Gaining insight into this process for parents may illuminate the factors and context contributing to the discrepancy between prevalence rates and service utilization for childhood anxiety and anxiety disorders. Because the purpose of the study focused on better understanding a process, I chose grounded theory as the methodology for the study. The goal of grounded theory is to explore and understand a process through the development of an explanatory theory that is grounded in the data (Heath & Cowley, 2004; Tie et al., 2019). The aim of this research was to produce a substantive grounded theory to explain parents’ process of seeking psychological treatment for their child with anxiety. Using a grounded theory approach, I investigated the following research question using semistructured, video-recorded, virtual interviews involving parents of children with anxiety and anxiety disorders: What is the process parents engage in when seeking professional mental health services for their children struggling with anxiety? Summary Mental health is vital to overall health and well-being, yet trends demonstrate an increase in children experiencing mental health challenges. The literature consistently shows that children often do not receive the mental health services they need. Children with internalizing behaviours 5 are less likely to receive services compared to children with externalizing behaviours. Anxiety is the most common mental health concern across the life span. Due to the gap between service use and service need, a better understanding of the help-seeking process for mental health is needed. Because children rarely seek help independently, understanding the process parents engage in to seek out mental health services for their child is crucial. A comprehensive framework for help-seeking for children with anxiety is lacking. I used qualitative methods—specifically, grounded theory—to gain a better understanding of the help-seeking process for parents of children with anxiety. 6 Chapter 2: Literature Review Overview This chapter presents a review of the relevant literature. The broad context of child and adolescent mental health, including trends and the impact of the COVID-19 pandemic on mental health, is discussed before a focus on a review of the literature on help-seeking in a mental health context. Several models of help-seeking for mental health are outlined. Determinants of service use, including barriers and facilitators to mental health treatment, are also discussed. There is a paucity of research on services utilization and help-seeking models specific to anxiety. When available, anxiety-specific research is highlighted. This chapter concludes with an overview of the most common mental health concern, anxiety, and its treatment. Child and Adolescent Mental Health Overview Mental health can be viewed as a state of mental well-being existing on a continuum (WHO, 2022b). It is a critical component of overall health that allows individuals to cope with life stressors, reach their potential, learn and work to the best of their ability, and contribute to their communities. In addition to individual and community development, mental wellness is integral to broader socioeconomic development. According to the WHO (2022b), mental health conditions include mental disorders, along with psychosocial disabilities, impairment in functioning, or the risk of self-harm. In this study, the terms “mental health conditions” and “mental health challenges” are used interchangeably. Global Burden of Disease studies have identified mental and substance use disorders as the leading cause of disability worldwide (Whiteford et al., 2016). In 2019, an estimated one in eight people around the world were living with a mental disorder (WHO, 2022a). Among 10- to 7 19-year-olds, an estimated one in seven experience mental health conditions (WHO, 2024). Anxiety disorders are the most common, with 301 million people, including 58 million children and adolescents, meeting the criteria (see WHO, 2022a). In Canada, lifetime prevalence of a mental disorder across age groups is estimated at 20% (Canadian Institute for Health Information, 2015). Determinants of mental health can protect or compromise mental health (WHO, 2022b). These determinants can include individual psychological and biological factors, such as social skills and genetics; social, economic, geopolitical, and environmental conditions; and their interactions with each other (Sturgeon, 2006). Mental health promotion and prevention strategies aim to identify individual, social, and structural determinants of mental health. These strategies also work to decrease risk, foster resilience, and create environments that support mental health (WHO, 2022b). Numerous protective and risk factors can impact mental health. Risk factors occurring during developmentally sensitive periods, such as early childhood and adolescence, may be particularly detrimental (Center on the Developing Child, 2021; WHO, 2022b). Trends in Child and Adolescent Mental Health Until approximately a decade ago, there were mixed results in the extant literature investigating changes in prevalence rates of anxiety disorders in children and youth. Differences in methodologies, assessment instruments, and cultural factors may account for such variation in results (Gosmann et al., 2016). However, there has been increasing evidence that mental health conditions in children and adolescents have been on the rise over the past decade (see Mojtabai & Olfson, 2024). In Canada, there is evidence to suggest that the prevalence of childhood anxiety is on the rise. A study analyzing 8 years of data from an annual cross-sectional survey about health information from Canadian residents 12–24 years of age found that professionally 8 diagnosed anxiety disorders increased from 6.0% in 2011 to 12.9% in 2018 (Wiens et al., 2020). The rise in prevalence was the greatest in adolescent females, with increases of 1.6% per year. Trends over the 8-year period also demonstrate changes in mental health more generally, with an increase in rates of self-reported perceived poor and fair mental health (Wiens et al., 2020). This trend of increasing mental health conditions in children and adolescents is of growing concern, and the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and Children’s Hospital Association (2021) have declared a national emergency in child and adolescent mental health. In the declaration, they identified the COVID-19 pandemic as exacerbating the trends observed prior to 2019. COVID-19 and Mental Health The COVID-19 pandemic emerged in 2020, and many have questioned its implications on mental health. Psychological distress from experiencing the pandemic and the many associated uncertainties, along with broader economic and social consequences from countries’ responses to mitigate the spread of the pandemic, contributed to an environment that could affect many determinants of mental health (Kola et al., 2021). Social restrictions, including lockdowns, employment instability, economic downturn, changes in access to health care, and governments diverting their attention from other issues to contain the spread of COVID-19 could considerably influence mental health and well-being (Santomauro et al., 2021). In British Columbia, mass gatherings of more than 50 people were prohibited in March 2020. This included schools and childcare, along with recreational facilities and other social and religious gathering places (British Columbia Ministry of Health, 2020). There is some evidence to support the role that the COVID-19 pandemic and related public health and social measures had in contributing to increased rates of mental disorders and 9 symptoms. Using data from the first year of the pandemic (i.e., 2020), researchers estimated that prevalence rates for anxiety disorders increased by 25.6% worldwide (Santomauro et al., 2021). In Canada, the estimated change in prevalence for anxiety disorders during the COVID-19 pandemic was between 19.1% and less than 21.2% (Santomauro et al., 2021). In contrast, Robinson et al. (2022) conducted a meta-analysis, with the majority of studies included using primarily North American and European samples. They found an increase in mental health symptoms, including symptoms of anxiety disorders, in the early stages (March–April) of the pandemic followed by a significant decrease in symptom severity (May–June), which returned to levels similar to those prepandemic. Daly and Robinson (2022) argued that, from a trauma-informed perspective, an acute increase in anxiety and depression symptoms during the early phase of the pandemic was to be expected. In an umbrella review, Bevilacqua et al. (2023) found an increase in anxiety symptoms in children and youth during the pandemic, as compared to prepandemic levels. There is evidence to suggest that adolescents and females are at significantly higher risk of developing increasing levels of anxiety symptoms compared to children. The majority of the participants included in the review were from Asia. The studies eligible for the umbrella review were either rated as medium or high quality. In Canada, the percentage of youth (ages 12–17 years) who perceived their mental health as very good or excellent decreased from 73.0% in 2019 to 58.1% in 2022. The portion of those perceiving their mental health as fair or poor increased from 6.0% in 2019 to 14.7% in 2022 (Statistics Canada, 2023). No statistics were available for children under 12 years of age. In addition to the impact on individuals, mental health concerns within the family context have been explored. In a national study exploring the preliminary impact of the COVID-19 10 pandemic on families in Canada, parents of children under the age of 18 years living in the home reported a decline in their mental health, a significant difference compared to adults without children (Gadermann et al., 2021). Stressors and worries faced by parents included coping with uncertainty, concerns about mental health impact, physical health risks from the pandemic, relational and financial worries, and juggling childcare while continuing to work. Whereas 59.7% of parents reported no change in their children’s mental health, 24.8% reported a decline in their children’s mental health (Gadermann et al., 2021). This study highlights the importance of recognizing the family context when considering mental health in children and adolescents. An umbrella review commissioned by the WHO (Witteveen et al., 2023) of the impact of COVID-19 on prevalence rates of mental health symptoms and mental disorders indicated several limitations with much of the research. These limitations include a lack of longitudinal designs, low quality ratings for many eligible meta-analyses, high risk of bias, varied screening tools, lack of standardized cut-off scores, and the limited inclusion of diverse populations in study samples. It is also important to consider the difficulty of conducting research during the initial stages of the pandemic due to public health and social measures. Interpreting the findings should be done with caution and further research is required to capture the complexities of how mental health has been impacted by the pandemic. Mental Health Help-Seeking Overview Help-seeking behaviour in a mental health context is an adaptive process in which an individual attempts to obtain positive external assistance to deal with a particular mental health concern (Barker, 2007; Rickwood & Thomas, 2012). It is not a discrete event, but an active process that occurs over time. Sources of help can be informal (e.g., peer and family members, 11 religious leaders, and self-help) or formal (e.g., psychologists, counsellors, and medical professionals), and help can include a service, a referral for service or follow-up care, or talking to another individual (Barker, 2007; Thurston et al., 2018). The focus of the current study is on formal sources of help, specifically, mental health services from a professional (e.g., in the fields of medicine, psychology and counselling, and education). Although predictors of mental health service use for children and adolescents have been well researched (Anderson et al., 2017; Chartier-Otis et al., 2010; Gulliver et al., 2010; Moroz et al., 2020; Pella et al., 2018; Reardon et al., 2017, Salloum et al., 2016), the help-seeking process is not well understood, particularly for parents and caregivers seeking mental health care for their children. It is an underresearched area (Boulter & Rickwood, 2013; MacDonald et al., 2018). The literature has begun to focus on parents’ and caregivers’ experiences of help-seeking for their children (Boulter & Rickwood, 2013; Fearing, 2024; Reid et al., 2011), and to examine factors influencing adolescent help-seeking and sources of help-seeking (e.g., Cakar & Savi 2014; Corry & Leavey, 2017; Leavey et al., 2011); however, less attention has been directed to the help-seeking process for children with anxiety (Woodgate et al., 2023). Information Seeking. Findings from a US study exploring where parents of children between the ages of 4 and 17 years learn about, or would like to learn about, child mental health services suggest that although information is sought from a range of formal and informal sources, pediatricians were one of the most desirable sources of information (O’Connor & Langer, 2019). This was true for parents of youth who had accessed mental health services and parents of those who had not. Other desirable sources of information included other trained 12 professionals (e.g., psychologist or psychiatrist), family members, friends, their child’s preferences for sources, and the internet. Differences in sources of help were noted between parents of youth who had not accessed mental health services and parents of those who had. Specifically, compared with parents of youth who had accessed mental health services, parents of youth who had not accessed mental health services reported using fewer sources of information. They also reported using family and friends most as sources of information, whereas parents of youth who had accessed mental health services endorsed using pediatricians most as a source of information. The differences in sources of help accessed by parents of children with and without previous experiences with mental health services illustrates the notion that help-seeking behaviours and social support need to work in concert in order to achieve adaptive health benefits (Heerde & Hemphill, 2018). In general, parents with and without exposure to youth mental health services rated health care professionals as more trustworthy than information found on the internet (O’Connor & Langer, 2019). However, parents of youth who had accessed mental health services rated mental health providers and psychiatrists as significantly more trustworthy than did those parents of youth without exposure to mental health services. These findings indicate subtle differences in not only the sources of information that parents use but also how trustworthy parents find these sources of information, depending on their exposure to mental health services. Pathways to Care. When people experiencing psychological distress seek help, they, or others significant to them, make efforts to reach out to individuals or organizations, who then respond to the distressed person’s efforts. “Pathways to care” refers to this sequence of contact between the distressed individual and those from whom help is sought, whether laypeople, professionals, or organizations, as well as their responses (Rogler & Cortes, 1993). Pathways to 13 care are influenced by many intersecting variables, including individual, social, cultural, and systemic factors (MacDonald et al., 2018). Research on pathways to care has helped clarify aspects of the help-seeking process, such as barriers and delays to treatment, and contacts critical to the help-seeking process (MacDonald et al., 2018). In a systematic review of 45 quantitative studies from 26 countries focusing on pathways to mental health care for youth (mean age ranged between 11 and 30 years), these pathways were generally found to be complex, with many, diverse help-seeking contacts, and sometimes protracted delays to treatment (MacDonald et al., 2018). It is important to note that the majority of the studies (n = 32) focused on pathways to care for psychosis. The sources of help included medical and nonmedical professionals, social supports, health care institutions, agents of the criminal justice system, traditional or faith-based healers, and technology-enabled services. As pathways to mental health care varied between regions, the impact of contextual factors, such as features of the health care system, availability of services, stigma, and social support, on help-seeking was highlighted. Although quantitative studies afford an overview of the pathways to care, qualitative studies may allow for a better understanding of the lived experience of seeking help for mental health concerns (MacDonald et al., 2021). A meta-synthesis of 31 qualitative studies exploring experiences of pathways to mental health care for individuals aged 11 to 30 years, their careers, or both produced three core themes (MacDonald et al., 2021). The findings add to the evidence that the help-seeking process is nonlinear and comprises complex interactions between individuals, their social supports, and the health care system. These interactions influence the help-seeking, engagement with care and services, and outcomes. The first theme describing the pathways to mental health care was initiating contact with the mental health system. Mental health literacy, structural characteristics, 14 such as transportation and financial resources, and social support impacted the initiation of contact with the mental health care system. Involvement from parents was critical in youth’s pathway to care. For carers, advocacy was a prominent theme, and carers’ social support helped them advocate. The second theme focused on the response from the mental health care system. Youth and their carers experienced complex pathways and described challenges navigating services. Eligibility criteria for services also influenced access to services. For those deemed eligible for available services, waitlists were common, often leading to lengthy delays of treatment commencement. Fragmented care between services and settings and between providers also contributed to complex pathways. The final theme highlighted youth and carer appraisals, both positive and negative, of the care received. Effective collaboration between providers, timely and easily accessible services, patient- and family-centred care, knowledgeable providers, and strong therapeutic alliance with the provider contributed to positive appraisals of services. In contrast, provider insensitivity to and invalidation of youth and carer experiences, logistical challenges with scheduling or reaching providers, exclusion from treatment decisions, lack of information, concerns about confidentiality, and stigma led to negative appraisals of services. In a Canadian study exploring parents’ lived experiences of accessing mental health services for children (10 to 22 years of age) with symptoms of anxiety or a diagnosis of an anxiety disorder, five categories were identified reflecting dimensions of access to care: (a) parents’ ability to perceive the need for mental health care and approachability of the mental health services, (b) parents’ ability to seek mental health services and the acceptability of the services, (c) the availability of mental health services and ability to reach them in a timely manner, (d) the affordability of mental health services, and financial resources serving as barriers or facilitators to accessing services, and (e) engaging with mental health care and the 15 appropriateness of the services (Woodgate et al., 2023). Provider, parent, child, and service characteristics influenced parents’ experience and perceptions of the approachability, acceptability, and appropriateness of mental health services. The findings of the study highlight the need to support parents’ mental health literacy. Models of Help-Seeking Many frameworks and models have been developed to conceptualize help-seeking in a health and mental health context. Traditional models contend that the help-seeking process is a linear pathway, which progresses from problem recognition to a conscious decision to seek help, and then to selecting sources for help (Rickwood et al., 2005; Shanley et al., 2008; Verhulst & Koot, 1992). Help-seeking in this type of framework is viewed as a social transaction between an individual’s internal experience and social relationships, with factors operating at the intersection of the personal and interpersonal domain being of particular importance (Rickwood et al., 2005). Other help-seeking models consider the broader context of the individual or family, such as social, cultural, and systemic factors, in more depth (Andersen, 1995; Clark et al., 2018; Srebni et al., 1996). Alternatives to linear models propose that multiple influences impact how children access and receive mental health services. These models suggest that there are multiple entry points to mental health care, as well as a variety of services available (Shanley et al., 2008). There is evidence to suggest that parents engage in a varied pathway rather than a linear pathway. For example, some parents may seek out service without recognizing their child’s behaviour as problematic. In these situations, the child’s teacher or other school staff may have recognized emotional or behavioural problems and referred the child to services, underscoring the influential role that teachers can have on the help-seeking process (Fearing, 2024; Pavuluri et 16 al., 1996; Zwaanswijk et al., 2005). To illustrate the range of models of help-seeking in the literature, four models are detailed. Behavioural Model of Health Services Use. The behavioural model of health services use (BMHS) was initially developed to both predict and explain the use of formal health services as well as to provide measurable dimensions of access to care (Andersen, 1968, 1995, 2008). The model evolved through several iterations to illustrate multiple influences on health service use and on health status (Andersen, 1995). The most recent version of the model (Andersen, 2008) highlights the need to consider contextual and individual determinants, including predisposing, enabling, and need (both perceived and evaluated) characteristics; health behaviours of the individual and medical care providers; and health outcomes. Predisposing factors are social and cultural factors influencing the likelihood an individual will seek services. These can include demographic variables (e.g., gender, race, age), education, and beliefs (Pescosolido & Boyer, 1999). Enabling characteristics refer to community and personal resources that facilitate access to services, such as finances, availability of time to travel to and from services, availability of facilities or services, and policies of the health system (Andersen, 2008; Pescosolido & Boyer, 1999). Feedback loops are included in this model to demonstrate that health outcomes can impact subsequent predisposing, enabling, and need characteristics. Chavira et al. (2009) applied the BMHS (Andersen, 1995) as a conceptual framework when examining mental health service use in public sectors of care among children ages 6–18 years with anxiety disorders. Although several variables were assessed in the study, only the following were found to significantly predict services use: predisposing characteristics (parent education level), enabling factors (private and government insurance type and mental health–affiliated service sector), and need characteristics (caregiver strain, global functioning 17 impairment, number of comorbid disorders, comorbid disruptive behaviour disorder, generalized anxiety disorder, and obsessive compulsive disorder [OCD]). Of note, Chavira and colleagues (2009) focused on facilitators and inhibitors of services use. Exploring the feedback loops described in the BMHS were outside the scope of the study. Findings from this study can be taken as evidence to support partial application of the BMHS for children with anxiety. The BMHS model (Andersen, 1995) has been tailored and implemented to conceptualize child anxiety mental health service use among Latino children and adolescents, lending mixed support for the model (Zerr & Pina, 2014). The BMHS has been studied more extensively in a medical health care context. A systematic review of 16 quantitative studies conducted between 1998 and 2011 assessed the use and application of the model to adult populations (Babitsch et al., 2012). The review demonstrated that different versions of Andersen’s (1968, 1995, 2008) model have been used to investigate a wide range of variables associated with health services use during the specified time frame. Further, the studied variables mapped onto the theoretical model almost identically. Key variables were identified based on their use in most studies included in the review. The main predisposing variables included age, gender/sex, education, and ethnicity. The main enabling variables were income/financial situation, health insurance, and having a family doctor/usual source of care. Needs factors were more difficult to assess because of the scope of the study. The results indicate that the strength and direction of associations between variables and service use were inconsistent. However, methodological challenges, such as use of secondary data sets and lack of complex statistical methods, and the complexity of the model make it difficult to adequately test the model in full (Babitsch et al., 2012). 18 A model for children’s help-seeking pathways was adapted from a model similar to the BMHS and is referred to as the youth help-seeking service utilization model (Srebnik et al., 1996). Three stages of help-seeking have been identified in the youth model: problem recognition, decision to seek help, and support and service utilization. The model considers how individual, family, and macro-level factors, such as sociocultural values, socioeconomic factors, and policy, influence the linear pathway of help-seeking for children. Clinically evaluated and perceived need as well as family characteristics influence the problem recognition stage of help-seeking. Predisposing characteristics and barriers and facilitators influence both the decision to seek help and the support and service utilization stages. The model also acknowledges that help-seeking sources can be both informal and formal. Srebnik and colleagues (1996) recommended that a range of sources of help (in addition to formal mental health services) as well as a broader conceptualization of units of service, service type, and setting be included in help-seeking research. The first stage of the youth help-seeking and service utilization model was investigated in a study exploring the relationship between the endorsement of child and youth internalizing and externalizing mental health problems in a vignette and parents’ decision to seek help (Thurston et al., 2015). The findings demonstrated that parents who recognized a mental health problem were 21.59 times more likely to report willingness to seek help than parents who did not recognize a problem. An externalizing mental health problem and older parental age were also associated with willingness to seek help. Evidence also suggested that that parents’ perception of need was positively associated with problem recognition (Thurston et al., 2015). Although investigating the full model was outside of the scope of the study, it offers empirical support for the problem recognition phase of the youth help-seeking and service utilization model. 19 The Gateway Provider Model. The gateway provider model is a model for understanding youth access to mental health services. It amalgamates and builds on two existing frameworks: the network episode model (NEM) and decision theory (Stiffman et al., 2004). The NEM explores both individual factors and dynamics of how people respond to health problems over time, as well as social, psychological, economic, cultural, medical, and systems factors that impact how people experience chronic illness, both physical and mental (Pescosolido et al., 1998). The NEM is for adults and cannot be directly applied to children. A revised version of the NEM for child mental health care was developed, taking into account the role of parents in children receiving mental health services, and how mental health care is integrated into pediatric health care (Costello et al., 1998). One of the basic tenets of the children’s version of the NEM is that the response to children’s mental health problems is influenced by key individuals in the children’s lives. These individuals of first contact, known as gateway providers, may not be a formal care provider or even be involved in the mental health care system (Costello et al., 1998). Decisions require an individual to choose the best option available by identifying potential options, evaluating the outcomes of each, and comparing them to each other (Edwards & Fasolo, 2001). The gateway provider model draws from decision theory to elaborate on factors that gateway providers could contemplate in making treatment decisions (Stiffman et al., 2004). Service use is mediated by gateway providers’ perceptions of client need and enabling and predisposing factors. Furthermore, gateway providers’ perceptions and knowledge are influenced by structural and systemic factors in their environments. Gateway providers may offer better informed and more consistent guidance, treatment advice, and referrals if the gateway providers are (a) offered information beyond what is typically available within their scope and (b) that 20 information can be reduced to relevant aspects of the specific client’s needs. This would then lead to better quality of care being offered to clients. Gateway providers can impact a child’s pathway to mental health services via their knowledge, attitudes, preferences, and environment. Access to mental health care for children can be more multisectored than hierarchical, where access to general levels of service is required to access more specialized care (Costello et al., 1998). A gateway provider may identify a youth’s need for services, but whether that youth receives services will also depend on the gateway provider’s knowledge of services and treatments. The gateway provider’s knowledge may not always reflect the resources actually available or best practice recommendations (Stiffman et al., 2004). This model also acknowledges the role of multiple organizational contexts, such as structural and psychological climate, on the provider and the provider’s knowledge of resources. Testing of the gateway provider model has demonstrated the ability of the model, particularly the gateway provider variables, to explain significant variance in service provision (see Stiffman et al., 2001). The children’s version of the NEM (Costello et al., 1998) was empirically applied to Canadian youth ages 14 to 20 years at ultra-high risk for psychosis in a multiple case study approach (Boydell et al., 2013). One-time, in-depth qualitative interviews were conducted with 10 participants, who were recruited from an early intervention clinic, as well as 29 significant others identified by the youth as important in their journey to accessing mental health care. Aspects of the children’s version of the NEM were supported by the findings of the study. Problem recognition was found to involve multiple players, rather than a single gateway provider. Educators and school staff played a larger role in the help-seeking process than acknowledged in the children’s version of the NEM. The youth themselves were also found to 21 actively participate in the problem recognition stage. The problem recognition phase was found to be more complex than postulated, involving the recognition, definition, and legitimization of the mental health problem. Boydell and colleagues (2013) suggested the formal treatment system be considered further. Although the primary care providers are identified as possible gateway providers in the children’s version of the NEM, many of the youth viewed general practitioners as a resource for physical illness and not emotional difficulties. Integrated Behavioural Model of Mental Health Help-Seeking. The integrated behavioural model of mental health help-seeking (IBM-HS; Hammer et al., 2024) offers a framework for understanding what facilitates or hinders seeking mental health care by integrating various constructs in the help-seeking literature and identifying the causal sequence of these constructs. It is adapted from the integrated behavioural model (Montaño & Kasprzyk, 2015) to focus specifically on help-seeking. The premise of the IBM-HS is that help-seeking determinants influence help-seeking beliefs. These beliefs then determine their particular mechanisms, which all influence individuals’ intentions to seek help. The help-seeking intentions guide the resultant help-seeking behaviour. Help-seeking determinants vary widely. They can include structural forces, cultural influences, environmental constraints, past help-seeking experiences, evaluated need by a mental health professional, mental health perceptions, knowledge and skills, social support, and other possible determinants that may exist but have not yet been identified in the literature. These determinants may shape beliefs and be antecedents in the model, as well as moderators of the intention-behaviour relationship (Hammer et al., 2024). Help-seeking beliefs are an individual’s subjective perceptions of help-seeking, and are malleable (Hammer et al., 2024). Beliefs are shaped by direct observation, information from 22 others or media, and inferences made by the individual. They may be rooted in accurate facts or misconceptions. Five help-seeking beliefs are outlined in the IBM-HS: outcome beliefs, experiential beliefs, logistical beliefs, beliefs about other’s expectations and beliefs about other’s behaviours. Help-seeking mechanisms are broad perceptions that are formed unconsciously (Hammer et al., 2024). In IBM-HS, mechanisms include attitude, perceived norms about performing or not performing a behaviour, and personal agency, with each mechanism being shaped by particular beliefs (Montaño & Kasprzyk, 2015). Attitude is influenced by both outcome beliefs and experiential beliefs. Beliefs about important others’ expectations and behaviours influence perceived norms. Beliefs about logistical barriers and facilitators impact personal agency, including autonomy and capacity to seek help (Hammer et al., 2024). Help-seeking intention refers to the level of readiness an individual has to take steps to seek out professional mental health services (Hammer et al., 2024). It is a strong predictor of prospective help-seeking behaviour. However, because the relationship between intention and behaviour is moderated by various determinants in the IBM-HS, intention is necessary but not sufficient for help-seeking (Montaño & Kasprzyk, 2015). In the IBM-HS, prospective help-seeking behaviour refers to observable, voluntary actions to seek formal assistance for mental health issues or psychological distress (Hammer et al., 2024). This model may be less applicable to those who are receiving involuntary mental health treatment. Prospective behaviours can be conceptualized as seeking help or not, the frequency of help received, or duration of help. A reciprocal feedback loop between help-seeking behaviours and determinants is postulated in this model (Hammer et al., 2024). Although there is 23 empirical support for the integrative behavioural model (e.g., Kasprzyk et al., 1998), the IBM-HS, which was recently introduced, has not yet been empirically tested. Model of Mental Health Help-Seeking Behaviour in Adolescent Males With Symptoms of Anxiety. A preliminary model of help-seeking for adolescent males with clinical anxiety has been proposed (Clark et al., 2018). This model focuses on how barriers and facilitators influence different stages of the help-seeking process and suggests that help-seeking is a flexible process. Symptom severity moderates the interaction between barriers and facilitators, and adolescents can move fluidly between phases of help-seeking. For male youth to engage in formal help-seeking for anxiety they must move, with intrinsic motivation, from self-reliance to consideration of informal sources of help. From there, they may transition to more formal sources of help. This model supports the notion that help-seeking is a dynamic and multidimensional process in which the interaction of barriers to help-seeking is complex. Based on their model, Clark and colleagues (2018) recommended the following to improve rates of help-seeking in adolescent males with anxiety: (a) facilitating their recognition of and knowledge about anxiety, (b) exposing them to individuals with lived experience of anxiety disorders, and (c) encouraging opportunities for them to consider help and to move gradually from informal to formal sources of help. This preliminary model has not yet been empirically validated. Service Utilization of Mental Health Services Overview Lack of service utilization for children and adolescents with mental health concerns is well documented in several countries (Reardon et al., 2017). There is evidence that counselling and psychotherapy use has increased in Canada since 2007 (Canadian Institute for Health Information, 2015). To provided updated data on the prevalence of childhood mental health 24 disorders, Barican et al. (2022) conducted a systematic review and meta-analysis focusing on high-income countries. Rates of services use were also investigated when data were available. Of the 14 studies meeting all inclusion criteria for the systematic review, eight provided data on service use for mental health concerns. Approximately 44% of children and youth with mental health disorders received mental health services of any kind. The type of mental health services varied widely and was not exclusive to specialized mental health services. In the study, accessed services included support from school staff, psychological treatment, general medical services from a primary care practitioner, psychiatric pharmacotherapy, youth justice services, self-help services, and support from religious or spiritual leaders, healers, social workers, and crisis hotlines. Intensity and duration of care provision were not examined, and timeframes for service use ranged from the past 3 months to past year. There is also evidence of increased use of treatment services specifically for anxiety disorders in children and adolescents. In a study exploring trends in psychiatric diagnoses of children and adolescents receiving publicly funded mental health treatment in the United States between 2013 and 2021, the increase was greatest for anxiety disorders. The rates of children and youth receiving treatment for a diagnosed anxiety disorder increased from 9.6% in 2013 to 19.2% in 2021 (Mojtabai & Olfson, 2024). Although rates of service use are increasing, there is still a significant unmet need for child and adolescent mental health services (Waddell et al., 2020). When compared with children and youth with externalizing disorders, children and youth with internalizing disorders are less likely to access services (Merikangas et al., 2011). Chavira et al. (2004) examined prevalence rates of childhood anxiety disorders and comorbid conditions as well as rates of service utilization at a primary care clinic. They found that anxiety disorders were the least likely psychiatric disorder to receive treatment, despite being the most common in 25 a primary care setting. Several studies have found that the presence of externalizing symptoms or disorders was predictive of receiving services (Bradshaw et al., 2008; Briggs-Gowan et al., 2000; Chavira et al., 2004; Costello et al., 2014; Hintzpeter et al., 2015; Merikangas et al., 2011; Thurston et al., 2018; Zarger & Rich, 2016). The type of service or service provider accessed may also be influenced, in part, by the type of mental health concern of focus. When examining mental health service use in the public sector, children with a diagnosis of an anxiety disorder were more likely to use inpatient services than were children with a diagnosis of a nonanxiety psychiatric disorder, including mood and behavioural disorders. Furthermore, children and adolescents with a disorder comorbid with anxiety were more likely to receive inpatient services compared to children and adolescents with only an anxiety disorder (Chavira et al., 2009). Delays to seeking help are of concern due to the negative trajectory associated with untreated anxiety. Although data specific to childhood anxiety and anxiety disorders are scarce, there is evidence to show that the longer mental health challenges remain undetected, the less likely one is to seek treatment (Collins et al., 2004). Additionally, research suggests that parents have more difficulties engaging their child in mental health services as the child’s age increases (Yeh et al., 2003; Zerr & Pina, 2014). Further complicating the help-seeking process for mental health is evidence of challenges coordinating between primary care health settings and community-based mental health care (Gandhi et al., 2016). Population-based trends of mental health service use in acute- and primary-care settings from 2006 to 2011 in Ontario, Canada, demonstrate that rates of mental health service use for children and youth are increasing in all sectors, but evidence suggests the greatest rate of increase is in the acute care sector (Gandhi et al., 2016). Anxiety disorders were found to be the most common reason for emergency department visits for children and youth. 26 Racial and ethnic disparities in the receipt of mental health services have been documented in the literature. These disparities have continued despite an overall increase in the use of mental health services (Howell & McFeeters, 2008). Factors that contribute to the underutilization of mental health services for children of racial and ethnic minorities are decreased likelihood of their parents recognizing the need for treatment and seeking out sources of help, attitudinal barriers, parents’ perceptions of barriers, and less mental health literacy (Alegría et al., 2012). In the United States, racial and ethnic minorities were less likely than their White peers to receive services for anxiety, even if severe impairment was reported (Merikangas et al., 2011; Petrenko et al., 2011; Zerr & Pina, 2014). A study exploring mental health services use for social anxiety among Asian American high school students found that Asian American youth reported more distress and clinical levels of anxiety than their peers of other ethnicities but were not more likely to utilize services compared to other ethnic groups (Brice et al., 2015). For White families, the level of engagement in services decreased as the age of the child increased (Zerr & Pina, 2014). Although racial and ethnic differences are considered when investigating disparities in prevalence rates of mental health concerns, immigrant background is often ignored. By jointly considering immigrant generational status, and racial and ethnic correlates, a more nuanced picture can be discerned of those who are at greatest risk of developing mental health concerns (Georgiades et al., 2018). The healthy immigrant effect refers to a phenomenon where the health of immigrants, upon arrival to their destination country, is better than that of the domestic-born population of the destination country. A systematic review, including 58 studies conducted in the United States, Canada, and Europe of the healthy immigrant effect in a mental health context, found inconsistent evidence of a mental health advantage among immigrants (Elshahat et al., 27 2022). There was, however, significant and consistent evidence to suggest that new immigrants’ mental health declines as the length of residency in the destination country increases. Findings from a systematic review of the literature on the healthy immigrant effect in Canada also suggest that the phenomenon is not pervasive (Vang et al., 2015). When exploring the mental health of immigrant children in Canada based on generational status, differences became evident at the national level. First-generation children showed a lower risk for developing mental health problems compared to second- and third-generation children. However, at a subnational level, findings were mixed, with income level and type of mental health disorder (i.e., internalizing or externalizing) influencing mental health quality (Vang et al., 2015). In addition to mental health in general, future research considering racial and ethnic disparities more exhaustively in the field of anxiety is necessary. This is particularly important in a Canadian context, given the growing diversity of Canada’s population (McKenzie et al., 2010). The Role of Parents in Accessing Child and Adolescent Mental Health Services Families and family-based services have been one of the foci to address problems with service access and use. Children and adolescents rarely access help independently, and current research underscores the gatekeeping role that parents play in accessing treatment for their children (Cobb, 2023; Reardon et al., 2017). Parents may be conceptualized as agents of change in procuring and utilizing effective mental health services for their children. Empowering parents to become actively engaged in mental health services for their children would, therefore, be beneficial (Olin et al., 2010). Empowering parents is a process in which parents increase their sense of control over their lives by recognizing, encouraging, and enhancing their abilities to meet their own needs, problem-solve, and organize and utilize necessary resources (Gibson, 1995). It is important to consider parents’ own needs, as parents who have children with mental 28 health concerns and who themselves are struggling with clinical or subclinical levels of psychopathology are undertreated (Collins et al., 2004). Olin et al. (2010) contended that in addition to parent, familial, social, and provider variables, there are larger systemic variables that influence access to mental health care for children and adolescents. A range of family support interventions have been developed to promote parent empowerment. These include enhancing parent’s education about relevant mental health issues, addressing parent stress and barriers, addressing challenges of clinician engagement, and facilitating connection with services through peer-led support (see Olin et al., 2010). These types of interventions focus on increasing parents’ mental health literacy. Individuals are often uninformed about the available range of effective treatments for anxiety (Collins et al., 2004). In an adult sample of individuals with anxiety disorders who visited a medical clinic, only 22% were offered CBT (Wolitzky-Taylor et al., 2015). In a Canadian study, parents rated general information about treatment of childhood anxiety as highly important. In particular, they were interested in the availability of specific treatment options, the content of specific treatments, the effectiveness of treatment, the side effects (both common and uncommon), and the effects of discontinuing treatment (Mak et al., 2017). These findings suggest that parents seeking treatment may not be fully informed about treatment options, despite their desire to be. Although studies are scant, the information needs and decision-making process of parents considering treatment for child anxiety have been considered in research. Mak et al. (2014) conducted a qualitative study using semistructured interviews to explore parents’ views on treatment decision-making and their information needs about treatment options for their children experiencing anxiety. The analysis of findings revealed four themes: parents perceive themselves 29 as protectors, parents want to be involved in decision-making, information is a vital component in decision-making, and parents do not perceive all treatments (psychological versus medication) as equal. Parents value collaboration with professionals but ultimately prefer to make the final decision regarding their children. Despite this strong desire, parents are often not explicitly aware of how and when treatment decision-making regarding child anxiety services occurs (Mak et al., 2014). There is also evidence demonstrating individual differences between mothers’ and fathers’ help-seeking (Sawrikar et al., 2024). For parents of children with internalizing behaviours, mothers reported seeking professional help more often than fathers did, whereas fathers were more likely to approach family and friends for help. Fathers were also less inclined to seek help for internalizing behaviours than mothers were. Without an understanding of parents’ perceptions and needs when deciding how to best support their children, efforts to improve service utilization are compromised. The age range of children in many studies exploring help-seeking or service utilization in children and youth vary widely (see Clark et al., 2018; MacDonald et al., 2021; Rickwood et al., 2005; Woodgate et al., 2023; Zarger et al., 2016). It is, therefore, important to consider developmental differences across such a broad age range, as well as the developmental sequence of anxiety disorder subtypes. Children rarely refer themselves for mental health services and rely on help from adults to seek services. Parents are typically responsible for decision making for children, as well as for the provision of professional health and mental health care (Costello et al., 1998). Adolescence is a time of physical, cognitive, psychosocial, and emotional development (Christie & Viner, 2005). During this developmental stage, individuals begin to orient away from their parents towards their peers, and grow increasingly autonomous (Leigh & Clark, 2018; Rickwood et al., 2005). During adolescence, health and mental health 30 responsibilities transfer from parents to the youth (Christie & Viner, 2005). However, youth tend to lack mental health literacy (Rickwood et al., 2005) and are more likely to seek informal help compared to formal sources of support. For personal and emotional concerns, they prefer to seek help from friends before parents (Rickwood et al., 2005). Although parents may continue to play an influential role in the help-seeking process from childhood to adolescence (Cobb, 2023; Reardon et al., 2017), there is some evidence to suggest that parents of adolescents may become less central in help-seeking, compared to parents of children. As children progress through development into adolescence, they become more active in the help-seeking process and their parents may no longer play a primary role in recognizing mental health concerns in their children (Boydell et al., 2013). Despite the developmental shift towards independence from the family unit, there is also evidence that parents remain involved in the help-seeking process for youth and that parents’ role in help-seeking for mental health services for youth is perceived as vital. When parents were involved in their adolescents’ path to accessing services, the key roles parents played ranged from being the first person their youth confided in about their symptoms, to recommending, initiating and advocating for care (MacDonald et al., 2021). Additionally, youth with internalizing disorders who were identified and encouraged by an adult to seek help were four times as likely to utilize services compared to those who were not identified or encouraged by an adult (Alegría et al., 2012). Mental Health Literacy. Mental health literacy was initially considered an extension of health literacy. It was defined as knowledge and beliefs about mental health disorders that facilitate the recognition, prevention, and management of the disorders (Jorm et al., 1997). Several components of mental health literacy have been identified. These include the ability to 31 recognize specific mental health disorders or psychological distress, knowledge and beliefs about the etiology of mental health disorders and risk factors, knowledge and beliefs about self-help interventions, knowledge and beliefs about available formal help, attitudes that aid in recognizing mental health disorders or psychological distress and appropriate help-seeking, and knowledge of how to seek information about mental health (Jorm, 2000). Mental health literacy has since evolved to include the consideration of mental wellness in addition to mental disorders, and to incorporate the idea of knowledge-stimulating action (Jorm, 2012). Kutcher et al. (2013, 2016) further extended Jorm’s evolved definition and posited that mental health literacy is composed of four aspects: understanding positive mental health and how to obtain and maintain it, understanding mental disorders and their treatments, reducing stigma, and enhancing effective help-seeking. The last component includes knowledge about when, where, and how to seek help, as well as capabilities to seek out appropriate mental health care (Kutcher et al., 2015). This complex definition of mental health literacy is used in this study. The significance of mental health literacy in help-seeking has been directly considered in the literature, highlighting several components of mental health literacy as fundamental to help-seeking. Specifically, Fearing (2024) used grounded theory to investigate the role of caregivers’ mental health literacy in their help-seeking process for mental health services for children between the ages of 6 and 18 years. Jorm’s (2000) definition of mental health literacy was used in the study. Results indicated that the components of mental health literacy that were key to caregivers seeking mental health services for children were caregivers’ ability to recognize psychological distress, knowledge and beliefs about available professional help, attitudes that facilitate recognition and help-seeking, and knowledge of how to seek mental health information. Some parents indicated that the child and the child’s school were instrumental in the recognition 32 of a mental health concern. Ma et al. (2023) conducted a quantitative study of 257 participants in Australia, exploring the role of modifiable parental mental health literacy–related barriers in seeking professional help for their children with anxiety. Almost all participants were female, with the majority being English-speaking and having completed some level of tertiary education. The mean age of participants was 40.3 years. Contrary to previous studies, findings indicated that knowledge of anxiety disorders and help-seeking self-efficacy were not associated with parental help-seeking from professionals. However, as hypothesized, lower personal stigma was associated with help-seeking from psychologists and primary care providers, and positive attitudes toward help-seeking were associated with help-seeking from psychologists. Ma et al. identified that the sample was not representative of Australian parents of children with anxiety, and suggested that the high rates of help-seeking in the sample and the participants’ level of education may account, in part, for the lack of association between knowledge of anxiety disorders and help-seeking self-efficacy. To facilitate parents’ recognition of mental health conditions and seeking of services for children, improving mental health literacy in parents is essential (Fearing, 2024). A challenge with problem recognition during adolescence is the ability of both youth and parents to distinguish between mental health concerns and typical “teen behaviour” or “angst” (Boydell et al., 2013; MacDonald et al., 2021). Using an anxiety specific example to illustrate this difficulty with problem recognition, the emergence of social anxiety in early adolescence coincides with a developmentally appropriate increase in public self-consciousness (Leigh & Clark, 2018). During this time, peer relationships become more emotionally salient, bringing about both rewarding experiences during positive interactions with peers and increased distress and anxiety when faced with peer rejection (Leigh & Clark, 2018). Youth and their caregivers 33 must disentangle which psychosocial and emotional experiences are part of the normative changes associated with adolescence, and which are indicators of emerging mental health condition. This challenge of considering social anxiety within a developmental context emphasizes the importance of mental health literacy for parents, as well as adolescents, in problem recognition. Parents as Advocates. As agents of change, parents may find themselves advocating on behalf of their child. Advocacy is defined in several ways in the literature, with no agreed-upon definition (Burke et al., 2016). According to the American Psychological Association (2018), advocacy is defined as speaking or taking action on behalf of an individual or group to support and defend their rights and position. The Vancouver Coastal Health (n.d.) authority elaborated on advocacy in a public health context, acknowledging the purpose of creating positive change for individuals, as well as their environments. This change results from planning carefully, taking actions, proposing solutions to influence decision-making on a particular issue, and addressing relevant social determinants of health. Parents may engage in different methods of advocacy, which can include gaining knowledge, attending support groups, and asking for services or support (Burke et al., 2016). Parents may seek to gain knowledge about their child’s diagnosis or behavioural and emotional concerns, their rights as well as the rights of their child, and the services available to them (Burke et al., 2016). There are several types of advocacy (Vancouver Coastal Health, n.d.). Self-advocacy, as the name suggests, refers to acting on one’s own behalf and speaking up for one’s rights. Natural advocacy involves speaking up for others in the moment, when they are not able to do so for themselves. Peer advocacy focuses on helping others to speak or act on their own behalf. It may include providing information on the relevant issue. Helping others to ensure that their needs are 34 met by working within systems is referred to as service advocacy. Working to support or ensure the continuation of a program is program advocacy. Lastly, cause or issue advocacy focuses on changing policy or legislation by working with stakeholders and other advocates to influence all levels of government. Predictors of Service Use In the literature, the two main approaches to exploring service use are examining predictors of service use and using models of help-seeking behaviour to conceptualize stages and the processes involved (Zwaanswijk et al., 2003). In this section, the literature on predictors of service utilization—namely, barriers and facilitators to treatment from the perspective of parents as well as children and adolescents—is discussed. The extant literature in this area illustrates a growing interest in seeking out and accessing mental health services. However, there is a dearth of findings specific to childhood anxiety. When available, research specific to anxiety and anxiety disorders in children is discussed. Several barriers and facilitators to accessing treatment for children with mental health concerns, such as attitudinal and logistical factors and poor mental health literacy, have been identified. Such barriers can be categorized as individual or caregiver factors, provider factors, or systemic factors (Collins et al., 2004). Barriers to treatment have been explored from the perspective of children (Pella et al., 2018; Salloum et al., 2016), adolescents (Clark et al., 2018; Gulliver et al., 2010; Zarger et al., 2016), parents (Reardon et al., 2017, 2018; Salloum et al., 2016), and mental health clinicians (Gearing et al., 2012). Facilitators to treatment are understudied in comparison. Despite this paucity in the extant literature, strategies to improve accessibility and increase family engagement have been explored (Anderson et al., 2017). 35 Parental Perceptions of Barriers and Facilitators to Treatment. Reardon and colleagues (2017) conducted a systematic review of both quantitative and qualitative studies assessing parental perceptions of barriers and facilitators to treatment for children and adolescents with mental health problems. Forty-four studies met the inclusion criteria for the review: 20 quantitative studies, 22 qualitative studies, and two studies providing both quantitative and qualitative data. Four themes of perceived barriers and facilitators were identified in the data: systemic issues within the mental health and health system, perceptions and attitudes of parents toward treatment, knowledge and understanding of mental health concerns, and family circumstances (Reardon et al., 2017). These themes are reflected in the concept of mental health literacy discussed above. Each of these themes is summarized below. Systemic Issues Within the Mental Health System. Systemic and structural barriers to treatment include direct and indirect financial costs and logistical challenges, such as appointment times, location, transportation, wait times, and availability of specialist services (Reardon et al., 2017). Strict service criteria and collaboration, or lack of, between agencies also function as systemic barriers (Ma et al., 2023). Of particular interest is that access to services, including lack of specialist services, was identified as an issue in both quantitative and qualitative studies (Reardon et al., 2017). Logistical factors affect services use. The impact of anxiety problems on children in rural areas was found to be greater than the impact on children in urban areas. Children in rural areas were more likely to seek help in primary care and school settings, whereas children in urban setting were more likely to access services through specialized mental health services (Hintzpeter et al., 2015; Lyneham & Rapee, 2007). There was also evidence of service utilization rates varying between states in the United States, although other factors, such as severity of the 36 traumatic event or its impact on infrastructure, may have better accounted for the differences (Storch et al., 2018). Proximity to services and the availability of transportation were associated with increased use (Zerr & Pina, 2014). Furthermore, families living more than 20 minutes away from services were twice as likely to complete diagnostic assessments than those who lived closer. The setting in which children and youth receive services is of importance. Using data from the National Comorbidity Survey Adolescent Supplement (Merikangas et al., 2011), Costello and colleagues (2014) examined the provision of services for adolescent psychiatric disorders from various sectors within a 12-month period. Of youth with any diagnosis, 45% reported accessing treatment from any source. Adolescents with any psychiatric disorder were most likely to be treated in school settings (23.6%) and specialized mental health settings (22.8%), and a smaller portion received services from general medical settings (10.1%). Those with any anxiety disorder were least likely to receive treatment, with 41.4% accessing any kind of treatment. For adolescents with a diagnosis of any anxiety disorder, 22.3% accessed services in specialized mental health settings, 20.9% were treated in a school setting, and 9.3% accessed care in a general medical setting. Another study examined children ages 6–18 years who had a diagnosis of one or more psychiatric disorders and were actively receiving mental health care in the public sector in the United States. The findings indicated that inpatient services (e.g., psychiatric units in hospital, residential treatment, and alcohol and drug treatment) were most often utilized by children with anxiety and a comorbid condition (Chavira, et al., 2009). These findings highlight that improving service utilization is a multifaceted issue and that accessibility of services is a key concern for parents. 37 Parent Perceptions of Treatment. The theme of parents’ perceptions of service providers emphasizes the important role that health care providers can play in improving access to services. The attitudinal barrier reported most often by parents was feeling dismissed or blamed by professionals. Both personal and social stigma are most often reported as the barrier relating to consequences of seeking support. Other factors include trust in the service provider, perceived language barriers, negative self-evaluation of parents for seeking help, and advice from family and friends (Reardon et al., 2017). Another parental factor shown to impact service use is parent perceptions and stigma of mental health services. If parents agreed with screening results identifying anxiety concerns in their children, they were more likely to follow through with recommendations for service use (Poulsen et al., 2015). Parents were more likely to support counselling treatment than medication for child anxiety (Chavira et al., 2003). Furthermore, stigma was identified as a barrier to accessing mental health treatment, especially for Latino youth (Briggs-Gowan et al., 2000). These results demonstrate the complexity of utilizing services for child anxiety. Knowledge and Understanding of Mental Health Concern and Help-Seeking. In the systematic review of quantitative and qualitative studies exploring parental perceptions of barriers and facilitators to mental health treatment for children and adolescents, participants in a large portion (42%) of the quantitative studies identified a lack of knowledge about help-seeking as a barrier to receiving services. Between 14% and 75% of participants in these quantitative studies identified not knowing where and how to get support as negatively impacting help-seeking. Findings from the qualitative studies substantiated these reports and emphasized that a lack of knowledge of the mental health system, more broadly, also served as a barrier to receiving services (Reardon et al., 2017). This finding is consistent with extant literature where 38 lack of awareness of services and limited knowledge about the pathways to appropriate mental health care have been identified as major barriers (Anderson et al., 2017). Problem recognition is a factor influencing service use. In a study examining parent satisfaction with postdisaster school-based screening in Australia, less than 50% of parents reported concerns about their child’s posttraumatic mental health, despite endorsing severe posttraumatic mental health symptoms for their child on screening measures (Poulsen et al., 2015). Problem recognition has also been shown to be associated with greater intention to seek formal and informal services (Thurston et al., 2018). Children and youth who were identified as scoring higher on depression, posttraumatic stress disorder, or a combination of depression, posttraumatic stress disorder, and anxiety screening instruments (J. D. Prochaska et al., 2016) and received recommendations to seek treatment (Petrenko et al., 2011) were more likely to seek out and receive services compared to nonsymptomatic children and youth or those who did not receive recommendations to seek treatment. Similarly, consulting a pediatrician resulted in a threefold increase in mental health service use (Briggs-Gowan et al., 2000). Family Circumstances. Variables included in the family circumstance theme are other responsibilities and commitments that compete with the time commitment involved in seeking help, and the family’s support network. Additional research supports this theme. Several contextual and situational factors have been indicated as influencing service use. Children who were living in nonrelative care, had histories of sexual or physical abuse (Petrenko et al., 2011; Shin, 2005), experienced stressful life situations (Briggs-Gowan et al., 2000; Storch et al., 2018), and experienced more military deployment in their families (Flittner O’Grady et al., 2015) were more likely to use services for mental health and anxiety. Several studies also found that 39 previous mental health service use, by the child or by the parent, was associated with increased service utilization (Arimoto & Murashima, 2008; Chavira et al., 2003; Zerr & Pina, 2014). Parental psychopathology and parenting style (e.g., overprotection) have been shown to hinder service utilization (Arimoto & Murashima, 2008; Jongerden et al., 2015). Contrary evidence indicating that parental psychopathology may facilitate service use is also available. In one study, parental anxiety increased the likelihood of parents discussing concerns about their children’s mental health, including anxiety, with pediatricians and utilizing services for their children (Briggs-Gowan et al., 2000). In some situations, parent employment also hindered seeking and receiving treatment. This is likely related to logistical factors of attending services (Arimoto & Murashima, 2008; Chavira et al., 2009). Child and Adolescent Perceptions of Barriers and Facilitators. From the perspective of children and adolescents, similar barriers have been identified. For children, the most commonly endorsed barriers for school-based treatment for anxiety were concerns about missing class and concerns about peers knowing they were accessing services (Pella et al., 2018). In a systematic review of 22 studies investigating perceived barriers and facilitators in adolescent help-seeking, stigma was identified as the most prominent barrier to seeking help from mental health professionals (Gulliver et al., 2010). This finding is true especially for Latino youth (Briggs-Gowan et al., 2000). The finding that stigma is perceived as a main barrier in this age group was corroborated by Clark and colleagues (2018), who explored factors that act as barriers and facilitators to help-seeking behaviour for clinical anxiety in adolescent males. Adolescent males with and without symptoms of clinical anxiety had concerns about public stigma that were related specifically to being viewed as weak (Clark et al., 2018). Lack of confidentiality and trust in the source of help, lack of insight into symptoms, lack of accessibility, and self-reliance were 40 also indicated as barriers to treatment (Gulliver et al., 2010). Similarly, for male adolescents with anxiety, barriers to help-seeking included a lack of awareness about the symptoms and treatment for anxiety, the discomfort of confronting emotions, and the amount of effort required to seek help (Clark et al., 2018). Facilitators to help-seeking in male adolescents with anxiety were related to the identified barriers. Quick access and low-effort help options were seen as helpful. Specifically, participants reported that easily visible and more immediate communication methods with sources of formal help would increase motivation to seek support. Discreet sources of help and more relatable presentation of mental health material (e.g., speaking to similar-aged peers about their anxiety, and encountering less formal, technical language from informal or formal help sources) were also identified as facilitating factors (Clark et al., 2018). In an online survey of 206 adults residing in Quebec who were diagnosed with social anxiety or panic disorder with agoraphobia, symptomatology variables, such as comorbid depression, duration of symptoms, avoidance, and level of interference of functioning, were correlated to perceived unmet need for services (Chartier-Otis et al., 2010). The barriers reported in this study were consistent with findings of barriers to mental health treatment more generally, with the most common barriers reported by participants being cost of services, not knowing where to get help, lack of insurance coverage, and wait times for services (Chartier-Otis et al., 2010). Service utilization for childhood anxiety problems is a complex process involving many aspects, including the individual, the individual’s social supports and environment, and contextual and societal factors. The services and the setting in which they are provided must also be acknowledged. Although important, identifying these factors does not reveal the underlying 41 processes for service underutilization. Another gap in the literature is demonstrated by the lack of investigation into the frequency or duration of the service being accessed. The majority of studies explored service use as a binary variable, with few studies reporting on the number of sessions, visits, or prescriptions filled (e.g., Arimoto & Murashima, 2008; Chavira et al., 2004; Flittner O’Grady et al., 2015; Lyneham & Rapee, 2007; Merikangas et al., 2011; Whiteside et al., 2016). There is also a dearth of qualitative research exploring the experiences of individuals seeking and receiving services for anxiety concerns. Understanding the underlying process in which these individuals engage can elucidate how to better improve practices to meet the needs of these children and their families. Childhood Anxiety Overview Anxiety is an emotional state that involves elevated arousal. It is characterized by feelings of apprehension and distress about an ambiguous threat, and comprises cognitive, behavioural, affective, and physiological features (Huberty, 1997; Rachman, 2020). When an individual perceives a lack of control over future events, a sense of helplessness may accompany anxiety (Barlow, 2002). From an evolutionary perspective, anxiety is an emotional response pattern shaped by natural selection that serves as a survival mechanism (Whiteside & Ollendick, 2009). It provides an increased ability to cope with threats or to capitalize on opportunities (Marks & Nesse, 1994). When an individual perceives a potential threat, the acute stress response is activated via the sympathetic nervous system, and the individual’s fight, flight, or freeze response is initiated in order to provide protection from the potential threat (Wood & McLeod, 2008). This response can become maladaptive if an individual experiences higher intensity levels of anxiety in the absence 42 of real danger. In fact, children with higher levels of anxiety have higher sympathetic nervous system reactivity compared to their nonanxious counterparts (Wood & McLeod, 2008). Performance is also impacted by anxiety levels, with moderate levels enhancing performance, and low and high levels impeding performance (Beidel & Turner, 2005). Anxiety in children and youth is referred to in several ways in the literature. A distinction between anxiety and anxiety disorders is necessary to understand the difference between developmentally appropriate anxiety and maladaptive, disordered levels of anxiety in children and youth. Anxiety symptoms can be common in the typical development of children and adolescents (Bell-Dolan et al., 1990), and can be helpful for survival (Agorastos et al., 2012). Anxiety can also become more problematic and disordered at the extreme end (American Psychiatric Association [APA], 2013). To meet the criteria for clinical levels of anxiety, one must experience persistent and elevated anxiety symptoms, which cause significant interference and distress, impair functioning, and are chronic (Barlow, 2002). An underlying psychobiological dysfunction is reflected in anxiety disorders (Agorastos et al., 2012; Stein et al., 2021). Cultural contextual factors should be considered when clinicians are determining if anxiety meets clinical levels (APA, 2022). For the purposes of this study, the term “childhood anxiety” is used to encompass subclinical levels of maladaptive anxiety experienced by children and adolescents. In this study, “childhood anxiety disorders” is the term used to refer to clinical levels of dysfunctional anxiety in children and adolescents. Research into childhood anxiety disorders has expanded over the last several decades. Historically, research in this area has been conducted on Western samples (Koydemir & Essau, 2018). Although interest and research on anxiety from a cultural lens has surged in recent decades (Asnaani et al., 2010; Kirmayer, 2001), much more research is needed to understand 43 anxiety from a cross-cultural perspective (Koydemir & Essau, 2018). In North America, the diagnostic classification system for mental health disorders is rooted in Western culture, and caution must be used when universally applying the diagnostic categories to a diversity of individuals, which requires cultural awareness and sensitivity (Kalra et al., 2014). There are some efforts to incorporate cultural consideration into the conceptualization of anxiety disorders, as evidenced by the recognition and inclusion of anxiety-related cultural syndromes, cultural variations in how distress is expressed, and culturally relevant explanatory models of anxiety (Kalra et al., 2014; Koydemir & Essau, 2018; Patel & Hinton, 2020). Core Features of Anxiety The current diagnostic classification system is the Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev., DSM-5-TR; APA, 2022). Although there have been some modifications to the core diagnostic criteria for some anxiety disorders, the core criteria remain largely unchanged. In children and adolescents, seven hallmark features of anxiety disorders have been identified: hypervigilance, reactivity to new stimuli or changes in stimuli, elevated sensitivity to threat, avoidant coping, somatic complaints, catastrophic reactions or explosive outbursts, and parental accommodation (Chiu et al., 2016). The core feature distinguishing various anxiety disorders is the source of anticipated threat (Chiu et al., 2016). The DSM-5-TR (APA, 2022) describes several anxiety disorder subtypes that commonly occur in children and adolescents, including separation anxiety disorder, selective mutism, specific phobia, generalized anxiety disorder, social anxiety disorder, panic disorder, and agoraphobia. OCD, posttraumatic stress disorder, and acute stress disorder were categorized as anxiety disorders in a previous edition of the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; APA, 2000), and are included as anxiety disorder subgroups in 44 many studies reviewed in the literature. In the subsequent edition of the Diagnostic and Statistical Manual of Mental Disorders (5th ed., DSM-5; APA, 2013), OCD, posttraumatic stress disorder, and acute stress disorder were separated from the anxiety disorders category and classified as two distinct categories: obsessive-compulsive and related disorders, and trauma- and stressor-related disorders. This decision is not universally accepted (Palitz & Kendall, 2020). The age of onset for separation anxiety disorder, selective mutism, and specific phobias is typically before 10 years (Beesdo et al., 2009; Rapee et al., 2023). Social anxiety disorder can be diagnosed in childhood, but the onset most commonly occurs in early adolescence (APA, 2022; Rapee et al., 2023). Prospective studies provide evidence for age of onset of generalized anxiety disorder in later adolescence, while retrospective studies indicate its onset in adulthood. The initial onset of both panic disorder and agoraphobia is in adulthood (APA, 2022; Rapee et al., 2023). It is important to note that the DSM-5 has faced considerable scrutiny. One area of criticism focuses on the validity of the new diagnostic categories and criteria. Concerns have been raised about pathologizing what could be considered natural responses to experiences or individual differences in human behaviour, such as loneliness, shyness, sadness, grief, and idiosyncrasies (Gaughwin, 2014; Pickersgill, 2014; Watts, 2012). Arguments have been made that the overmedicalizing of human behaviour will lead to false positives and could have negative implications for individuals being diagnosed with a mental disorder, such as stigma and discrimination (Ben-Zeev et al., 2010; Frances, 2012; Watts, 2012). The addition of disorders and changes in criteria also create the potential for excessive and inappropriate use of medications to treat children and adolescents (Frances, 2012; Gaughwin, 2014; John et al., 45 2015). Below, the core features of anxiety are outlined, including the conceptualization of anxiety prior to the DSM-5. When considering cross-cultural differences in explanations of anxiety, researchers have identified underlying transdiagnostic processes. These processes include repetitive negative thinking, anxiety sensitivity, and somatization (Patel & Hinton, 2020). Repetitive negative thinking, such as rumination and excessive worry, highlights a cognitive vulnerability associated with anxiety (McEvoy et al., 2019). Anxiety sensitivity refers to a fear of sensations related to anxiety. It is a dispositional factor in the development and maintenance of anxiety disorders (Deacon & Abramowitz, 2006; Stewart, 2024). Somatization is the tendency to emphasize somatic symptoms in the experience and expression of psychosocial distress (Zhou et al., 2011). Although these transdiagnostic processes are recognized transculturally, the specific aspects and the role each process plays in explanatory models of anxiety disorders are nuanced and vary from culture to culture (Patel & Hinton, 2020). There is evidence to suggest that cross-cultural differences in the clinical presentation of anxiety exist (Hinton, 2012; Hoge et al., 2006). These differences in presentation include the specific anxiety symptoms that people endorse, the severity of the anxiety symptoms, and beliefs and interpretations about human biology and psychological processes (Hofmann & Hinton, 2014; Marques et al., 2011). For example, when assessing symptoms associated with generalized anxiety disorder, there is evidence of discrepancies in the types of symptoms groups from non-US countries commonly report when compared to US samples. Somatic complaints are more likely to be reported than psychological symptom by people in non-Western countries, such as Nepal (Hoge et al., 2006), China (Zhou et al., 2011), United Arab Emirates (El-Rufaie et al., 1999), and Mexico (Varela et al., 2008). Additionally, prevalence rates for anxiety disorders, as a 46 group as well as individual disorders, vary across cultures and ethnic groups (Ferrari et al. 2022, Javaid et al., 2023; Lewis-Fernández et al., 2010; Marques et al., 2011). Evidence indicates that the prevalence of anxiety disorders also varies between cultural groups within the same multicultural country. When assessing lifetime prevalence rates of anxiety disorders (social anxiety disorder, generalized anxiety disorder, panic disorder, and posttraumatic stress disorder) for adults of different ethnic and racial groups within the United States, evidence suggests a strong influence of culture on prevalence rates for anxiety disorders (Asnaani et al., 2010). In one study, Asian Americans endorsed symptoms of all four anxiety disorders less frequently than did African Americans, Hispanic Americans, and White Americans. White Americans were significantly more likely to endorse symptoms of social anxiety disorder, generalized anxiety disorder, and panic disorder compared to the other racial groups. African Americans met the criteria for posttraumatic stress disorder more frequently than did the three other subgroups. The findings held when demographic variables were controlled (Asnaani et al., 2010). Expressions of somatic complaints, cognitions, and behavioural expressions of anxiety in childhood can differ from those in adulthood. Cognitive and behavioural expressions of anxiety are influenced by age and developmental level (Beidel & Turner, 2005). Somatic symptoms are an important feature in anxiety disorders. Compared to children without an anxiety disorder diagnosis, children diagnosed with generalized anxiety disorder, separation anxiety disorder, or social anxiety disorder reported somatic complaints more frequently (Hofflich et al., 2006). In children and adolescents, somatic complaints have been linked to higher overall severity ratings of anxiety by clinicians, as well as higher functional impairment (Ginsburg et al., 2006). Somatic complaints may serve as a way for children to express their emotional distress and as an avoidant coping strategy (Hughes et al., 2008). The most commonly reported somatic symptoms by 47 children with anxiety disorders include restlessness, stomach aches, blushing, palpitations, muscle tension, sweating, and trembling or shaking (Ginsburg et al., 2006). For adolescents with an anxiety disorder, headaches, difficulty sleeping, stomach pain or aches, head cold, sleeplessness, drowsiness, and nightmares were most commonly reported (Crawley et al., 2014). However, it is important to note that physiological reactions to anxiety vary among children (Beidel & Turner, 2005). Cognitive distortions are a feature of childhood anxiety disorders. Cognitive distortions can include attentional bias, interpretation bias, memory bias, and attributional bias (Kagan et al., 2004; Muris & Field, 2008). These types of cognitive distortions contribute to hypervigilance, reactivity to new stimuli or changes in stimuli, and an increased sensitivity to threat. Although there may be different types of catastrophic cognitions, and the content of these cognitions may vary across cultures, ruminating about past events and worries about the future are considered transcultural (Patel & Hinton, 2020). Catastrophic reactions to anxiety are a behavioural feature of anxiety. They tend to occur after efforts to avoid fears prove futile. These types of reactions are also disproportionate to the situation (Chiu et al., 2016). Behavioural displays of anxiety in children can include obvious displays, such as tantrums, aggression, crying, trembling, somatic complaints, and reassurance seeking (Bagnell, 2011), or more subtle presentations, such as procrastination, negotiating, and persistent questioning (Albano et al., 2003). Parental accommodation aims to prevent or decrease child distress associated with engaging in feared or anxiety-provoking situations but it typically maintains the anxiety and reinforces avoidant behaviours (Thompson-Hollands et al., 2014). Understanding how both developmentally appropriate and clinical levels of anxiety present across child development, from preschool (Spence et al., 2001) to adolescence (Beesdo et 48 al., 2009), improves the identification and diagnosis of anxiety disorders. This understanding is important as childhood anxiety disorders are associated with a vast range of psychosocial and academic difficulties (Ehrenreich & Santucci, 2009) and often remain undetected and untreated. If left untreated, anxiety disorders can cause significant impairment in functioning and persist into adolescence and adulthood (Essau et al., 2014; Grover et al., 2007; Öst & Treffers, 2001; Swan & Kendall, 2016). However, anxiety disorders are often responsive to psychological intervention, and the literature provides evidence that early detection and intervention can lead to the prevention of anxiety disorders (Hirshfeld-Becker et al., 2010). Additionally, the benefits of early intervention and the durability of treatment effects are well established (Ginsburg et al., 2014; Higa-McMillan et al., 2016; Wolk et al., 2015) Treatment for Childhood Anxiety The Canadian Psychological Association’s (2012) guidelines for evidence-based practice identify that the sources of evidence to be considered when recommending or providing treatment should be derived from treatment outcome research, treatment process research, and basic psychological research applicable to clinical practice. CBT and exposure therapy are shown to ameliorate the distressing symptoms of childhood anxiety disorders and improve functioning. CBT is well supported by over 50 years of empirical research (Higa-McMillan et al., 2016), including robust evidence for the use of CBT to effectively treat childhood anxiety disorders (Rapee et al., 2023). The goal of CBT for childhood anxiety and anxiety disorders is to help children and youth better identify their anxiety symptoms and learn coping skills in order to be able to gradually face their fears (Rapee et al., 2009). Unfortunately, delivery of evidence-based treatment, particularly psychological treatment, for mental health disorders has not permeated community mental health settings (Wolitzky-Taylor, et al., 2015; Youn et al., 2020). 49 Summary To improve rates of service utilization for childhood anxiety, a better understanding is needed of (a) the barriers, facilitators, and contextual factors that parents face when trying to access treatment and (b) the help-seeking process in which parents engage. Research has begun to explore these issues; however, gaps in the literature remain. Barriers and facilitators to treatment have been explored and described from various perspectives. How these factors influence the help-seeking process has also been a topic of investigation. Many of the models of help-seeking outlined above suggest that help-seeking is multidimensional, highlighting the need to consider personal factors and characteristics, in addition to the various contexts within which an individual exists. Despite the multitude of models describing or explaining the help-seeking process and engagement in services for mental health, a unifying, empirically validated framework accounting for predictors of treatment use and describing pathways to care for children with anxiety does not yet exist. The aim of the present study is to produce such a theory for help-seeking parents of children with anxiety. 50 Chapter 3: Methods Overview The current study used a grounded theory approach to answer the research question: What is the process parents engage in when seeking professional mental health services for their children struggling with anxiety? This chapter begins with a discussion of my positionality and philosophical underpinnings. An overview of grounded theory methodology follows, including details about participant recruitment and data collection, and the procedure for data analysis. The chapter concludes with a discussion of rigour. Positionality of the Researcher Reflexivity Reflexivity refers to the acknowledgement and examination of the effect the researcher has on the research process, particularly in the interaction between researcher and participant (Payne, 2015). The researcher’s positionality in relation to the research topic can influence the research by (a) impacting the researcher’s access to prospective participants, (b) affecting the formation of the researcher-participant relationship and the information that participants feel comfortable sharing, and (c) shaping the language and communication style used during interviews, the questions asked, and the understanding of the data, thereby influencing the findings (Berger, 2015). Acknowledging and attending to this concept is beneficial as it can demonstrate more transparently how the theory is created from the data. As the researcher of the current study, an important aspect of reflexivity involves the intersection of my social identities. My professional and personal life experiences have shaped my perspectives and belief systems, which inevitably influenced how I viewed and interacted with the data throughout the research process. I identify as a cisgender woman and Canadian of 51 Chinese heritage. My parents immigrated from Hong Kong to North America for postsecondary education, eventually settling in the Lower Mainland of British Columbia, where I was born. I have multiple career-related roles as a clinician, presenter, and graduate student, with a range of employment experience in the field of mental health. In addition, I am the mother of a young, multiracial child and juggle the responsibility of parenting with the responsibilities of work, school, and maintenance of my own mental health. Although I am a parent and have experience from a service provider perspective, I did not have first-hand experience with the phenomenon under study during the interview process and considered myself to hold outsider status in this study. Aware of the intersectionality of both my privileged and marginalized social positions, I continually worked to identify and challenge my biases throughout the research process. One social position of reflection was my experience of growing up as a person of colour in a neighbourhood and community where people were predominantly of European descent. As one of four or five people of colour in my class throughout elementary school, I tended to value assimilation in my efforts to fit in. My family held a mix of values, traditions, and beliefs, influenced by culture, religion, and sociopolitical ideals. Formal education and a strong work ethic were highly valued. My parents sacrificed in many ways to ensure I received quality education in my teenage years in the hopes that I could pursue the postsecondary education of my choosing. Feminist ideals were instilled in me in my home, school, and resulting social contexts. From childhood, my career interest lay in the field of medicine, and I recall having a keen interest in science and the scientific method. During my primary school years, I decided I would become a pediatrician when I grew up. This career goal endured into my first year of university and influenced my epistemological approach. Although mental health was not a common topic of 52 discussion in my family home, I began to gravitate toward the field of psychology in my first year of university. I began volunteering in psychology research labs during my postsecondary education and became immersed in quantitative research. I continued to develop my skills in quantitative research as a graduate student at the master’s level. My work experiences in the field of mental health varied, exposing me to administrative, parent support, and clinical roles. I worked in a range of settings, including an employee and family assistance program, the public sector (i.e., nonprofit mental health organizations), and the private sector. I worked as a registered clinical counsellor for several years before returning to graduate school to complete a PhD in counselling psychology. My main area of focus in clinical practice is childhood anxiety. Another facet of my private practice is providing psychoeducational workshops about a range of child development topics to parents, educators, and counselling professionals. I am trained in and practise from a CBT theoretical orientation, which views the therapist as directive and actively involved in the therapeutic process (Craske, 2017). My practice is also influenced by my training in counselling psychology. I incorporate aspects of person-centred therapy into my therapeutic approach, where the relationship between therapist and client is viewed as central to engaging in therapy and fostering change (Morrill, 2023). My interest in the research topic grew from my experience as a practitioner in private practice working with children and adolescents struggling with anxiety, and their families. Some parents described their uncertainty about why their child seemed to be struggling. Others lacked knowledge about how to help their children manage anxiety, as well as where and what type of service to access. Another motivating factor was hearing from parents that family physicians and pediatricians recommended medication as the first and only line of treatment for anxiety. Upon 53 the initial literature review, I learned that the families I met in clinical practice were not unique in the treatment recommendations they were receiving (Collins et al., 2004). Many parents shared with me their stories of struggle while evidence-based treatment was available in the community as well as in specialized settings. From this anecdotal evidence, lack of knowledge appeared to be a primary factor preventing families from accessing effective help. These stories are corroborated by research about service use and mental health literacy, as outlined in the literature review. Throughout the present study, I had to be mindful of how my upbringing, cultural and educational identities, and resulting biases influenced how I understood and interpreted the data. I also had to be cautious about how my familiarity with the topic and clinical experience were influencing the analysis and creation of the theory. The strategies and practices I used to engage in reflexive practice and challenge my biases are described in more detail later in this chapter. These experiences and my positionalities have shaped and are shaped by my epistemological and ontological views, which have evolved over time from a positivist paradigm to a postpositivist paradigm. Philosophical Underpinnings As with any other research, the methodological framework for this qualitative study is underpinned by philosophical assumptions. I adopted a critical realist position on knowledge and reality. This theoretical approach assumes a singular, stratified reality and highlights the objective nature of reality. It also acknowledges the importance of an interpretive understanding of meaning and that knowledge and experience are socially constructed and influenced by culture, language, and politics (Braun & Clarke, 2013; Sayer, 2000). 54 A central tenet of critical realism is that reality is layered (Danermark et al., 2002). It consists of three ontological domains: the empirical, the actual, and the real (Alvesson & Sköldberg, 2009). Observable phenomena, which are considered data in scientific contexts, fall under the domain of the empirical. The domain of the actual is broader and includes that which exists independently of the researcher and observations of the researcher. The real domain includes causal mechanisms that operate below surface-level phenomena. This reality cannot be observed but can be experienced indirectly (Danermark et al., 2002). Critical realism seeks to identify mechanisms and structures underlying events or phenomena (Alvesson & Sköldberg, 2009). More specifically, according to this paradigm, the purpose of science is to explore the domain of the real and how it relates to the empirical and actual domains (Alvesson & Sköldberg, 2009). Scientific research is viewed as a continual process of deepening knowledge of reality (Danermark et al., 2002). From this positioning, I conducted the current study using a qualitative research design. The philosophical assumptions of critical realism fit well with the purpose of the current study. Alvesson and Sköldberg (2009) suggested that the critical realism orientation values not only explaining the world but also changing it. Given that the purpose of the research is to develop a theory to understand parents’ experiences in relation to seeking treatment for childhood anxiety, critical realism provided a particularly coherent framework from which to conduct the study and placed emphasis on the emergent theme. As discussed, grounded theory aligns with my philosophy of science paradigm and was a suitable method for the phenomenon under investigation and the purpose of the study. The critical realist paradigm offers three arguments for methodologies in social sciences (Danermark et al., 2002). The first two, generalizing claims and examining the validity of 55 generalizations, are crucial in social science research. The definition of generalizing, however, may vary. Induction, deduction, abduction, and retroduction are complementary modes of inference that can help in obtaining knowledge, moving from specifics to generalities. The third guideline relates to the explanatory purpose of social science research. To be able to describe concepts, causal mechanisms giving rise to a particular phenomenon, and the conditions under which this phenomenon occurs, a methodological approach based on abduction and retroduction is required (Danermark et al., 2002). Methodological Framework Grounded theory is a qualitative research method used to generate middle-range theory from data through a rigorous and systematic research process (Danermark et al., 2002). Theory generated from a grounded theory study can be substantive (i.e., specific to a particular field or area) or formal (i.e., having wider applicability; Glaser & Strauss, 2017). The grounded theory method is categorized as a method involving inductive reasoning and abductive inferencing (Bryant & Charmaz, 2007). In essence, it is a flexible and iterative process that moves from a descriptive to a more conceptual level of understanding through verification and justification of theoretical explanations. The process of verification and justification is facilitated through the use of comparative analysis and theoretical sampling (Glaser & Strauss, 2017). In grounded theory, comparative analysis can be used to validate evidence, help formulate generalities from the evidence, and verifying a generated theory for the purpose of further refining the theory. Theoretical sampling is a process in which the collection of data is controlled by the emerging theory. Sampling, therefore, is responsive to the data and the process is open and flexible (Corbin & Strauss, 2008). Data are concurrently collected, coded, and analyzed with an initial purposive sample (Birks & 56 Mills, 2011). In the current study, the initial working of data informed further data collection, coding, and analysis. In this way, an emerging theory was developed, then tested and further abstracted until it could account for all data. Glaser and Strauss (1967) coauthored The Discovery of Grounded Theory, the original book on grounded theory. Their views subsequently diverged, leading to the Glaserian, or classic, approach and Straussian approach to grounded theory. Although many versions of grounded theory now exist, there are three widely used grounded theory approaches (Rieger, 2019; Tie et al., 2019): Glaserian grounded theory (Glaser & Strauss, 1967), Straussian grounded theory (Strauss & Corbin, 1990), and constructivist grounded theory (Charmaz, 2006). My philosophical positioning and familiarity with the phenomenon under study and the extant literature were most congruent with the Straussian approach (Alammar et al., 2019). In line with a postpositivist perspective, Straussian grounded theory views researchers as shaping the data through their interpretations as well as being shaped by the data. Thus, a researcher’s experience and knowledge are combined with induction from the data (Heath & Cowley, 2004). The Straussian approach is also more structured than the others, outlining the coding procedure in a step-by-step manner for novice researchers (Kenny & Fourie, 2015). Pragmatically, the more structured nature of the Straussian approach was a better match for my level of experience as a qualitative researcher. Therefore, the current study was conducted using the Straussian approach. The formulation of the research question and the use of the literature review from a Straussian framework is discussed further below. The Straussian approach to coding is described in more detail in the Data Analysis section. According to the Straussian approach, a more focused research question better establishes the boundaries of the research (Corbin & Strauss, 1990). Bluff (2005) argued that this focused 57 research question does not limit the creation of theory, but rather allows the focus to remain on the evolving theory. Birks and Mills (2011) recommended a balance of methods: finding a research topic broad enough and formulating the research question in a way that reflects a problem-centred perspective on the particular phenomenon. Grounded theory researchers debate the use of a literature review. Three phases of literature review have been identified in Straussian grounded theory: initial, ongoing, and final (Thornberg & Dunne, 2019). Reviewing relevant literature at every stage of the study, although not a comprehensive, exhaustive review, is considered appropriate in the Straussian approach (Alammar et al., 2019; Kenny & Fourie, 2015). The first phase of the literature review provides a broad overview and context to identify the phenomenon and understand existing empirical findings. The initial literature review takes place prior to the collection of data in order for the researcher to become broadly familiar with the research topic. This phase of the literature review should instill confidence in the researcher to move forward with the study (Thornberg & Dunne, 2019). The ongoing phase of the literature review is guided by the data and emerging theory and helps the researcher relate the emerging findings (Thornberg & Dunne, 2019). The researcher seeks out empirical studies to enhance the iterative process of data collection and analysis. The purpose of the final literature review is to contextualize the grounded theory, with the researcher identifying and referencing established theories to highlight how the findings compare and contrast to the extant literature. By conducting a literature review in combination with bracketing a priori assumptions, a researcher can facilitate an open mind to the data. Anxiety and its treatment are often studied from a positivist and post-positivist paradigm using a quantitative, empirical research. Experience, meaning, and context are often not the primary foci of such investigations. Furthermore, a cohesive explanation for the discrepancy 58 between treatment need and service utilization does not yet exist. Grounded theory offered an integrative conceptual framework from which to explore experiential aspects of parents’ process of seeking treatment for their children with anxiety. The result is a comprehensive theory of parents’ experiences with this topic, accounting for its underlying mechanisms. The alignment between my philosophical positioning, aim of my research, and methodological approach led to methodological congruence. Criteria for Participant Selection Ethical approval was obtained from the University of British Columbia’s Behavioural Research Ethics Board before recruitment began. The population of focus in this study was parents living full-time in Canada, and the sample was recruited from Vancouver Island and the Lower Mainland of British Columbia. I used criterion-based, convenience, and snowball sampling strategies to recruit participants. Initially, the inclusion criteria outlined that participants had to (a) be the primary caregiver of a child 18 years of age and under, (b) have lived in Canada for at least the past 5 years, (c) self-report a primary concern of having a child struggling with anxiety, (d) have sought out psychological services targeting childhood anxiety in the past 6 months, (e) be fluent in English (written and spoken), and (f) have access to the internet and a computer or mobile device. I identified fluency in English as an inclusion criterion due to limitations in resources and constraints on time. The government of Canada (Employment and Social Development Canada, 2018) has defined primary caregiver as the person primarily responsible for the care and upbringing of a child. In this study, primary caregiver was defined as the person spending the most time with and primarily responsible for the care and upbringing of a child during the time that the child was experiencing and exhibiting symptoms of anxiety. Children as young as 5 years of age were 59 included because of the initial age of onset for childhood anxiety disorders. The age cut-off of 19 years was used because children 19 years and over do not qualify for child and youth services in the province of British Columbia. A retrospective account from parents was required to gain their reflection on the process of seeking out services and their experiences. Participants were excluded from the study if their child was seeking treatment for a primary diagnosis of a mental health concern other than anxiety disorders or if they were diagnosed with autism spectrum disorder (ASD) or an intellectual disability. The needs of children with these neurodevelopmental disorders and other mental health difficulties vary greatly. Because of the variability in presentation, these children may require individualized support and resources (e.g., occupational therapy and speech-language therapy) that extend beyond psychological treatment. I identified these exclusion criteria due to the scope and purpose of the study, specifically the study’s focus on treatment for childhood anxiety. This initial inclusion and exclusion criteria for participant selection were guided by the boundaries of this research. After the first interview was completed, I identified relevant concepts through the initial analysis, which led to theoretical sampling for the remaining participants. Recruitment and Theoretical Sampling Criterion-based, convenience, and snowball sampling strategies were used to recruit participants. Initial recruitment consisted of social media posts via the British Columbia Confederation of Parent Advisory Councils. Based on theoretical sampling, recruitment then focused on gathering more data about the role and context of parental advocacy and mental health literacy in the help-seeking process for parents. FamilySmart is an organization focused on supporting parents and caregivers of children, youth, and young adults facing mental health 60 challenges. Recruitment ads were posted on FamilySmart’s social media, and information about the study was shared via word of mouth within the FamilySmart Parent-in-Residence (parent peer support) network. Additional attempts at recruitment were made based on theoretical sampling. As the initial sample was demographically homogenous, including educated, well-resourced, dual-parent families, I sought to recruit more demographically diverse participants with access to varying levels of resources and possibly lower levels of mental health literacy. Therefore, I used the Human Early Learning Partnership (HELP, n.d.) Child Development Monitoring System, which collects population-level data to measure trends and patterns in different areas across children’s developmental stages. Specifically, the Early Development Instrument data collected during Wave 7 (2016–2019) and Wave 8 (2019–2022) and the Middle Years Development Instrument data collected in 2020–2021 and 2021–2022 were used to determine geographical areas in the Lower Mainland (a) where long-term trends in emotional well-being, particularly scales of anxious and fearful behaviour, indicated an increase, and (b) that were below average or where higher percentages of children scored low on the well-being index in the past 2 years. The following methods were used to recruit in the identified neighbourhoods across the Lower Mainland: posters on community bulletin boards after obtaining permission and approval from organizations; emails to district and individual Parent Advisory Committees (both elementary and high school) to request distribution of the recruitment poster, including offers to provide an informational session; in-person meetings to request permission from mental health professionals in private practice and clinics to act as gatekeepers and invite client who may be a good fit for the study to contact me for more information, and to distribute recruitment posters within their professional networks. As described in the Behavioural Research Ethics Board 61 application, interested parents would then be able to contact me at their convenience. Gatekeepers and contacts did not provide me with any names, contact information, or other details of prospective participants. Procedure Although ethical approval was obtained from the university’s Behavioural Research Ethics Board before recruitment began, ethics in research is not a static concept, and I reflected on issues that arose and sought supervision from research supervisors and consultation with critical friends as necessary. The semi-structured interviews were video-recorded and conducted virtually via Zoom, an online videoconferencing service, due to the COVID-19 pandemic. Interested parents contacted me at their convenience via email. I responded with an email outlining the next steps for participation and offered to arrange for a brief phone call (10 to 15 minutes) to screen the individuals for participation in the study. The interested individuals were advised that they might not be selected to participate in the study, depending on the results of the screening questionnaire (see Appendix B). I did not have prior relationships with any interested individuals. During the screening call, I provided a brief overview of the study, including the study purpose and what participant involvement entailed: a questionnaire; an approximately 90- to 120-minute video-recorded virtual interview; possible follow-up questions via telephone, video, or email; and an opportunity to provide feedback on analysis of the data. I administered the screening questionnaire to prospective participants who expressed interest in proceeding. If the prospective participants were eligible to participate in the study based on the results of the screening questionnaire, I sent them the consent form, a list of community and online resources (see Appendix C), and the demographic questionnaire (see Appendix D). Although prospective 62 participants were offered hard-copy informed consent packages, they all requested the documents via email and provided their preferred email address. Participants were offered up to 1 week to consider participating in the study. They were also informed that they could withdraw their consent to participate at any point. Prospective participants who wanted to proceed after reviewing the informed consent form returned the signed copy of the form (see Appendix E) along with the completed demographic questionnaire. I sent a maximum of two follow-up emails to individuals who were eligible to participate and expressed interested in proceeding with the interviews but did not return the informed consent form package or schedule an interview. Interview times were scheduled for a mutually convenient date and time. Participants were sent an email reminder about the interview 2 to 3 days prior to the interview. The email reminder included the Zoom link for the interview, as well as directions to review the informed consent for guidelines on how to protect their personal information on Zoom. Once the participant arrived for the interview online, the Zoom meeting was locked to prevent uninvited guests from joining the meeting and aid with the protection of confidentiality. I reviewed the informed consent and the limits of confidentiality. Participants were reminded that they could withdraw their consent at any time. They were also provided with the opportunity to discuss any questions before proceeding, and to enter a pseudonym to protect their identity while using Zoom. Due to the sensitive nature of the topic, participants could have experienced emotional distress during the interview. Participants were, therefore, reminded of the list of support resources in the community and online. All participants returned the signed consent and demographic forms prior to their interviews. 63 Once informed consent was confirmed and any participant questions were addressed, I turned on the video-recording and transcription feature and began the interview, following the interview guide. Following the interview, participants were asked if they consented to (a) being contacted at a later stage of the research with follow-up questions, if any, and (b) providing feedback on and verification of the data analysis. All participants provided verbal consent to be contact via email for follow-up. I disabled the video-recording and transcription features at the end of the interview. Participants were asked for and confirmed their preferred email address for receiving a $20 e-gift card as a thank-you for their time and participation. Data Collection Both unstructured and semi-structured interviews are congruent with grounded theory (Bluff, 2005; Duffy et al., 2004). In a Straussian approach, semi-structured interviews allow for consistency over concepts, but the interview guide should be adjusted as new concepts arise (Corbin & Strauss, 2015, as cited in Alammar et al., 2019). Adjusting to focus on new issues helps advance the development of theory (Bluff, 2005). Thus, the theory can be generated without a priori hypotheses. Semi-structured interviews were selected as a method of data collection for this study. Using an interview guide (see Appendix A), interviews ranging from 46 to 120 minutes were conducted virtually and video-recorded via Zoom, using the University of British Columbia’s licence. The average interview duration was 69.30 minutes. I transcribed the interviews manually or using the auto-transcribe feature on Zoom. The transcripts were then reviewed manually to correct any errors and ensure the interviews were transcribed verbatim. As more participants were interviewed, the prompts in the interview guide shifted from more open-ended questions focused on gathering a broad picture of the participant’s experience to more directive questions about specific aspects of the caregiver process of seeking help. For 64 example, in the first interview conducted, one prompt used to learn more about the help-seeking process was “What was it like for you to have to find the psychologist?” In contrast, one of the last interviews conducted used the following prompt: “Can you walk me through how you decided which type of service to use?” Another more directive question used in one of the final interviews to gain more data about an emerging theme was “Can you tell me more about how this [the child’s anxiety] has impacted your family?” Follow-up questions after the initial interviews were generated to further facilitate the constant comparison analysis. Two participants did not respond to requests for follow-up, and two participants declined to respond to the follow-up questions. The follow-up questions were aimed at incorporating participants’ feedback on the theory, gathering additional details for the purpose of verify the existing theory and expanding upon categories that emerged after analysis of several interviews (e.g., parents’ coping with stress and emotional experiences of the help-seeking process). To enhance data collection, I used field notes and memos throughout the interviews to document my thoughts, observations, and perceptions of the participants. I also described the participants’ reactions, facial expressions, and gestures. Such observations are meaningful and may influence interpretation of the data (Bluff, 2005). Reflective journaling also took place following interviews and coding sessions to help me be more cognizant of any preconceived ideas I may have had and how they may have affected the interview. This type of data also informed my analysis, as discussed below. 65 Participants Overview Twenty-four caregivers emailed to inquire about participating. Thirteen prospective participants were selected for screening. One was deemed ineligible to participate, as she had not sought out services in the past 6 months. Two were eligible but did not follow up to schedule an interview time. In interviews with three participants, I became aware that their children had been diagnosed (formally and informally) with OCD. As this disorder was previously included with anxiety disorders in the DSM-IV-TR (APA, 2000), and parents had indicated primary concerns of anxiety during the screening, these participants were included in the study. Another participant was a parent of a child hospitalized during a mental health crisis, but the participant reported primary concerns of and seeking treatment for anxiety before the hospitalization and after the child was stabilized. This participant was also included. Ten participants were interviewed. One participant had two children for whom she sought services, resulting in interviews about help-seeking for 11 children. Participants were offered opportunities for follow-up sessions via email or video meeting. During these sessions, parents were asked for additional information and clarification about their experiences, and feedback on the emerging theory. Four participants declined or did not respond to requests for follow-up interviews. Most participants who consented to follow-up questions chose to provide written follow-up, with one participant completing a 43-minute follow-up interview. Many appreciated the opportunity to talk about their experiences during the interviews, with some commenting on the therapeutic value. A number were motivated by advocacy and the potential to effect change by shedding light on the difficulties of seeking mental health services for their children. 66 Despite efforts to obtain a more demographically diverse sample, the participants were a relatively homogenous group (see Table 1). All participants self-identified as biological mothers in heterosexual, dual-parent families, Caucasian or White, and English-speaking at home. All participants had some postsecondary education, and most lived in urban areas. Participant Profiles The participants were a demographically homogenous group with variations in their experiences of help-seeking. Because every participant identified as a biological parent, the terms “parent” and “participant” are used interchangeably. Rich descriptive details provide depth to the findings and were one of the criteria for evaluating the research process (Corbin & Strauss, 2008). This section includes rich descriptions of the participants’ circumstances. Table 2 provides an overview of the parents’ backgrounds and detailed profiles of each parent. To protect the confidentiality of the participants, pseudonyms are used. 67 Table 1 Participant Demographics Demographic variables n % M SD Range Age (years) Caregiver (mother) 10 44.30 4.35 37–51 Participants’ children 11 10.45 2.58 7–15 Ethnicity/race Caucasian/White 10 100 Marital status Married 9 90 Common-law 1 10 Relation to child Biological 10 100 Number of children living in the home Two children 8 80 One child 2 20 Primary language English 10 100 Employment status Full-time 7 50 Part-time 3 30 Self-employed 2 20 Annual household income $75,000–$99,999 3 30 $100,000–$149,999 4 40 $150,000+ 3 30 Highest level of education Some college/university 2 20 Bachelor’s degree 6 60 Master’s degree 1 10 Doctorate or higher 1 10 Geographical location Rural 2 20 Urban 8 80 68 Table 2 Participant Backgrounds Leigh. Leigh reported that she is a married mother of two children. Alexis, her eldest child and the focus of the interview, was 12 years old at the time of the initial interview. Alexis’s younger sibling, Adam, was described by Leigh as being neurodiverse and having complex needs. He was 9 years old at the time of the interview. Alexis was born in British Columbia, and then the family moved to Leigh’s home province, where Adam was born. After a few years, the family returned to the west coast of Canada and settled in a rural area. Although Alexis was described as being clingy since she was an infant, Leigh did not become concerned about Alexis’s anxiety until her daughter experienced physical, verbal, and emotional bullying at the beginning of Grade 6 from what Leigh described as Grade 7 male students in the classroom. Leigh reported there was a temporary classroom teacher for the first 2 months of the school year, and the regular classroom teacher returned in November of that school year. Leigh described Participant pseudonym Marital status Number of children Employee or self-employed Employment status Geographical location Leigh Married 2 Self-employed Full-time Rural Alisha Married 2 Employee Part-time Urban Sarah Married 2 Employee Full-time Urban Erin Common-law 1 Employee Full-time Rural Nicola Married 2 Self-employed Full-time Urban Eleanor Married 1 Employee Full-time Urban Olivia Married 2 Employee Full-time Urban Anna Married 2 Employee Full-time Urban Addison Married 2 Employee Part-time Urban Diane Married 2 Employee Part-time Urban 69 how she perceived that the school did little to address the situation, despite her many efforts to advocate for Alexis. The situation at the school intensified to the point where the family decided to move Alexis to a private school with more mental health supports. Outside of the school environment, Leigh found that her openness and willingness to connect with others and her advocacy skills as a parent contributed to finding support for Alexis. In order to better care for their children, Leigh and her husband both transitioned from full-time employees at their respective workplaces to full-time self-employment. Leigh shared that becoming self-employed in the private sector provided both her and her husband with more flexibility in their schedules and more financial stability. Alisha. Alisha’s daughter, Kara, was the focus of the interview and 9 years old at the time. Alisha is married and has a second child, a boy, who was 8 years old at the time of the interview. Alisha shared that Kara was diagnosed with generalized anxiety disorder at approximately 6 years of age and with OCD at approximately 8 years of age. In retrospect, Alisha saw symptoms of OCD in her daughter during toddlerhood. Although Alisha and her husband managed Kara’s behaviour at home, Alisha noted they had to use different strategies to help Kara than they used with her brother, which helped them, in part, recognize that Kara had some anxious tendencies. The journey to access targeted treatment for anxiety began when Kara was in Grade 1. From Alisha’s recollection, the beginning of Grade 1 was challenging. Kara’s class had a series of substitute teachers during the first several weeks of school, until a consistent teacher was placed in the classroom. Alisha also described some minor bullying incidents on the playground early in the school year. Although Kara was not directly involved, she did witness some of the events. Alisha believed the “rocky start” to the school year contributed to some of the distress and increasingly disruptive behaviours (e.g., running out of the school building) the 70 school reported to her. Seeking treatment required Alisha to be resourceful and unceasingly advocate for help for her daughter. She described how she tried to access many types of mental health support: school counselling, public counselling services, private counselling services, alternative therapy, parenting support, and a pediatrician. Initially denied support from the school, she sought out counselling through public mental health services but faced a wait time of 9 months. As she waited for services, Alisha tried other types of therapy for Kara, which Alisha described as having no lasting impact on Kara’s symptoms. When Kara began receiving counselling services through the public mental health system, Alisha felt her concerns were dismissed by the counsellor. Despite Kara showing increasing distress and struggles in the school environment and difficulties with sleeping, Alisha recalled that the counsellor determined Kara had subclinical levels of anxiety and tried to close the file after three sessions. Alisha described how the counsellor agreed to work with Kara on a weekly basis after the counsellor spoke to the school upon Alisha’s insistence. The sessions and therapeutic approach were not perceived by Alisha as effective. Kara’s behaviours continued to escalate at school until the school counsellor became involved. Alisha recalled that the school counsellor noted some symptoms of OCD. Unable to find trained professional help for OCD for her daughter, Alisha sought out training for herself on evidence-based treatment for OCD until she found a qualified professional in private practice. Sarah. Sarah’s family includes her, her husband, their two school-aged children, and the family dog. The focus of the interview was on Jack, her eldest son, who was 9 years old at the time of the interview. Sarah described herself as completing a second degree in health care after 10 years as a stay-at-home mother. She shared that she has a history of mental health challenges and found psychotherapy to be a positive experience and helpful for managing her symptoms. 71 Jack demonstrated some symptoms of separation anxiety as a young child, which Sarah believed to be developmentally appropriate. His difficulty with emotional regulation became more pronounced in Grade 1 and continued through Grade 4. He initially received support as needed from the school counsellor, but Sarah and her husband decided to reach out for formal, consistent help when they realized they were struggling to support him despite using many interventions and strategies they were familiar with through their own mental health experiences and readings. Sarah recounted that the school counsellor directed Jack to in-person public mental health services. The family began sessions, but in-person sessions were discontinued shortly after they started due to the COVID-19 pandemic. As Jack was not comfortable with virtual sessions, they decided not to continue. Sarah reported that Jack continued to struggle after discontinuing sessions, so she advocated for Jack to return to seeing his counsellor, with whom he had developed a strong relationship. She also found alternate mental health services in the private sector as he waited to meet with his preferred clinician. Sarah’s experiences, worldviews, and training helped her navigate the delays to receiving services. Erin. Erin lives in a rural area with her husband and son, Sam, who was 11 years old at the time of the interview. Erin described having two young adult children who are neurodiverse and have mental health diagnoses, with one having what she described as intense mental health struggles. Sam’s two older siblings live outside of the family home in a different city. In addition to homeschooling Sam, Erin cares for her mother-in-law as well her father-in-law, who has dementia. Erin recalled that Sam was a sensitive and introverted child from infancy. The school environment became increasingly challenging for Sam. In Grade 3 his disruptive classroom behaviour escalated, and he was connected with the school counsellor. Erin reported having high levels of mental health literacy. She shared that she had experience supporting her older children 72 through their mental health struggles and that her work focuses on supporting parents with children with mental health struggles. This experience helped her navigate the school, medical, and mental health systems to advocate for services that were tailored and effective for her son and aligned with her values. Her values included changing Sam’s schooling approach to homeschooling. Nicola. Nicola and her husband live with their two children. At the time of the interview, Daniela was 15 years old and Steve was 13 years old. The couple do not have extended family living locally. Nicola reported that her husband’s family has a history of mental health challenges, including anxiety, OCD, attention-deficit/hyperactivity disorder (ADHD), and hoarding disorder. Both children struggled with anxiety, although Nicola noted it presented differently in each child. They also have what Nicola described as opposite personalities from each other. Starting school was an important event for both children in the journey to seek help. Daniela initially showed symptoms of separation anxiety. Nicola shared that Daniela was also diagnosed with trichotillomania several years later. Steve initially had physiological symptoms that were attributed to anxiety, and then Nicola noticed he had symptoms of OCD. He was also diagnosed with ADHD and a learning disability. Although the anxiety presentation differed for each child, the severity of the symptoms after starting kindergarten alerted Nicola that professional help was needed. Nicola relied on her training and professional experience in the field of child development during the help-seeking process. Her knowledge and awareness of familial mental health history guided her decisions on what type of services to seek and when, even against judgment and doubt from friends and family. This knowledge also helped Nicola advocate for tailored services, ensuring that her children did not “slip through the cracks,” and consider factors that would contribute to the effectiveness of treatment during her decision- 73 making. Nicola’s experience of seeking help for Daniela influenced the help-seeking process for Steve. Eleanor. Eleanor described the family unit, which consists of her, her husband, and their daughter, Lily, as close-knit. Although there is no local extended family, the family has a strong social network and is reportedly connected to their community. Lily, who was 9 years old at the time of the interview, has a family history of mental health challenges on both her maternal and paternal sides of the family. Eleanor values open communication around these topics and reported that she openly discusses struggles with age-appropriate language with Lily, especially because Eleanor has physical health conditions in addition to anxiety. Eleanor described Lily as being very shy as a young child. Eleanor began to notice that anxiety was becoming more of an issue when Lily was a preschooler. Eleanor noted that she and her husband had differing perspectives on how to support Lily. During the first 2 years of school, Lily’s struggle with anxiety became more evident. The process to access and receive help for Lily was relatively straightforward for the family. Initially, Eleanor requested learning and emotional support from the classroom teacher, which helped. Eleanor recounted that she wanted to be proactive, so she increased the level of support by requesting Lily work with the school counsellor as needed for the following school year. This work with the school counsellor led to Lily’s improvement at school, but Eleanor shared that Lily exhibited dysregulation at home. Having a solid understanding of anxiety and self-awareness about her own well-being, Eleanor requested parent support. Again, this process was easy for the family, as they were referred by the school counsellor and found a convenient time for both parents to participate in the online classes, with a relatively minimal wait. 74 Olivia. Olivia, her husband, and two sons moved to the west coast from a different province for her husband’s work. A couple of years after the relocation, her husband experienced psychosis for the first time, was later diagnosed with a mental illness, and is now no longer able to work. Olivia is the sole income provider. At the time of the interview, her eldest son was 15 years old, and her youngest, Jackson, was 13 years old. Olivia reported that Jackson presented with several difficulties from birth including sleeping, eating, and separation. Olivia tried to seek out different types of help over the years: pediatrician, dietician, occupational therapist, and counsellor. In March of Jackson’s Grade 7 year, Olivia became concerned about OCD symptoms that he was experiencing. Due to wait times for mental health services, the situation escalated, and Jackson was eventually hospitalized for a mental health crisis. Once he stabilized, anxiety became the primary concern for Jackson. Olivia had to contend with many barriers and red tape for Jackson to receive ongoing mental health services, including psychiatric care. She described how she sacrificed, needed to be resourceful, and advocated until Jackson received mental health services that fit his needs. She also considered the impact Jackson’s school environment may have had on his mental health and shared that she took a proactive stance, advocating for access to a psychoeducational assessment and applying to a specialized high school program for youth with mental health challenges. In addition to advocating for services for her own child, Olivia also advocated for better mental health services at a societal level. She recalled speaking to several stakeholders and publicly promoting mental health services. Anna. Anna and her husband have two sons: an 11-year-old and Ryan, 7 years old at the time of the interview. Ryan was described as having challenging behaviour since infancy, especially compared to his older brother. Difficulties with separation became more apparent when he began daycare, and Anna recalled that the staff struggled to help Ryan manage 75 transitions on a daily basis. Anna decided to seek help when Ryan was approximately 4.5 years old. The long, confusing, and circuitous journey to receive help began. She described being shuffled through various programs, counsellors, and psychologists, leaving her with negative experiences, a strong sense of being judged about her parenting, and not having her child’s needs met. It was a year and a half before she and her son worked consistently with a mental health provider with whom she felt supported. Anna noted there was a temporary improvement in Ryan’s separation anxiety symptoms followed by increasing difficulties at school. Anna described how she tried to advocate, with help from Ryan’s counsellor, to receive appropriate and effective supports at school. Anna recalled that eventually Ryan was diagnosed with secondary ADHD and began medication to treat the ADHD symptoms. Although Ryan’s functioning improved at home, he still struggled with behaviours at school. At the time of the interview, Anna reported she was still struggling to receive appropriate and effective support at the school. Instead, the school provided a referral to a service that conflicted with the recommendation from the mental health professional working with her and her son. Anna was uncertain about how to proceed and concerned about losing access to the existing school support for Ryan. She shared that she was researching and connecting with other parents to increase her knowledge about access to mental health support in the school system and the Ministry of Education’s policies and procedures for inclusive learning and related funding to help inform her decision about how to proceed. Addison. Addison lives with her husband. Together, they have a 9-year-old daughter and Bentley, a 7-year-old son. Bentley’s personality and behaviour caught Addison’s attention early on. She had knowledge of child development through her work with typically developing children, so she was attuned to what she described as Bentley’s unique behaviours, although she 76 shared that she was unsure of what the behaviours could indicate. Addison reported a family history of anxiety and recalled one of her family members providing her with a resource that she found helpful to recognize anxiety in her son. Addison described how her concerns were dismissed as nothing to worry about each time she sought guidance from her family doctor. She noted that Bentley was experiencing increased anxiety going to daycare and reported an incident where her husband found Bentley alone trying to use the bathroom and crying while the childcare provider was unaware and in a different room. Addison described this event as traumatizing and her breaking point. It was then that she returned to her family doctor, reiterating her concerns and insisting on getting Bentley help until her family doctor referred her to a pediatrician and public mental health services. However, he did not provide her with information about how to contact the mental health agency. Addison recalled how she had to continually advocate for services, learn how to navigate and secure ongoing support at school, and piece together short-term counselling while balancing the financial costs of services. The family also considered an assessment for ASD to get a better understanding of Bentley’s challenges. Addison shared that the heavy financial burden and lengthy wait times dissuaded them from pursuing the assessment. At the study follow-up, Addison had a new family doctor. She reported that upon Bentley’s first visit, the new doctor immediately referred and waitlisted Bentley for a publicly funded ASD assessment. Diane. Diane described her and her husband as only children with very small extended families. Their immediate family consists of a 10-year-old daughter, Nadia, an 8-year-old daughter, and a family cat. Diane shared that she has a doctoral degree and works remotely from home. Nadia’s struggles with separation began at about 12 months of age, according to her mother. When Nadia began kindergarten, Diane recalled that drop-off was difficult for several 77 months. There was some gradual improvement over the next 2 school years, but in Grade 3, Nadia’s tearfulness at separation returned. It was then that Diane first sought out mental health services for Nadia. Diane noted that the anxiety has presented in different ways throughout Nadia’s life. Most recently, Nadia has been struggling with obsession-like worries about getting enough exercise. Recent therapy has not been perceived to be as effective as it was in the past, so Diane was beginning to look for other types of support at the time of the interview. Before making any changes, Diane planned to have a discussion with the current counsellor about the treatment progress and next steps. She shared that she had also sought guidance from a friend who is a child and youth counsellor to help her make an informed decision about different treatment approaches. Data Analysis Overview The interviews and their transcripts were analyzed using the Straussian approach to grounded theory method. Broadly speaking, Corbin and Strauss (2008) described the process of analysis as dynamic. It involves examining a phenomenon, considering important analytic ideas that emerge from the data, and dissecting the data into its various components. These components, or concepts, form the building blocks of the theory (Strauss & Corbin, 1998). Concepts are then grouped into higher level concepts known as categories. The categories are then considered and investigated so that their properties (i.e., characteristic features that define a category) and dimensions (the range along which properties vary) are identified (Strauss & Corbin, 1998). Lastly, the knowledge acquired about the components and their properties and dimensions can be used to recognize and give meaning to the phenomenon. This process of analysis requires researchers to be immersed in the data and to interpret their understanding of a 78 phenomenon, as communicated by the participants. This process includes continually trying and retrying to make meaning until the findings “feel right” (Corbin & Strauss, 2008). The first step of data analysis was to read the interview transcripts in order to immerse myself in the participants’ experience (Corbin & Strauss, 2008). Although the interviews were automatically transcribed, the process of reviewing and correcting transcripts to ensure a verbatim transcription was onerous. Transcripts were deidentified and formatted to have time stamps every minute, and consecutive lines of each speaker were condensed. I reviewed the video recordings and added tags to the transcript to indicate gestures or verbalization contributing meaning to a speaker’s words (e.g., “shaking head and placing it in her hand” to indicate frustration or “sardonic chuckling”). For phrases that were more difficult to discern, I slowed and reviewed the audio repeatedly and reviewed the video to observe the speaker’s mouth while talking. In rare instances, when the phrase could not be understood, “[inaudible]” was used to note the difficulty. However, it did not impact the overall understanding of the paragraph or sentences. Once the cleaning of the transcript was complete, I read the transcript in its entirety while listening to the audio to ensure accuracy. Although this process of cleaning the transcripts was arduous, it was invaluable to immerse myself in the data. It allowed me to document first impressions and ideas, which helped inform the initial coding process. Several analytic strategies, as outlined by Corbin and Strauss (2008), were used throughout the analysis. In addition to the coding paradigm outlined in the axial coding section, I reflected on the content or meaning of a participant’s response as I reviewed and coded the data. Sensitizing (e.g., What are the concerns? Who is involved? With what consequence?), theoretical (How do concepts compare or relate in terms of properties and dimensions?), practical (e.g., 79 How will I go about gathering more data for my emerging theory?), and guiding questions were noted in memos throughout the process (Corbin & Strauss, 2008). Coding The Straussian approach to coding involves three iterative stages: open coding, axial coding, and selective coding. Open Coding. Open coding allows for closer examination of the data, exploring and comparing similarities and differences between data and codes (Thornberg, 2017). Data are broken down by reading and analyzing the data line by line or word by word, and codes are created to label and give meaning to the data (i.e., lower-level concepts; Corbin & Strauss, 2008). As discussed previously, open coding began upon completion of the first interview. I began with line-by-line coding of the first transcript and used a brainstorming approach to identify and label important words or groups of words. This took multiple coding sessions over 3 days. Efforts were made to ensure codes were simple and stayed close to the data (Thornberg, 2017). When possible, I used the participant’s own words (e.g., “tenacious”) to create codes, known as in vivo codes (Bluff, 2005). As a novice, I found open coding was a challenging process, and doubted and questioned my coding process. I used memos to document this process, as well as the ideas I had for labelling the groups of words, for the purpose of discussion with critical friends. I reviewed the literature about the coding process and consulted with other graduate researchers using grounded theory. I was also mindful of my tendency to want to prematurely connect codes under categories based on my knowledge of the literature and clinical training. To stay true to the data, I documented this observation and returned to focusing on generating codes that were specific to the data and not broader themes based on my assumptions. 80 As open coding progressed, codes with similar meaning were grouped together and renamed as subcategories or categories (i.e., higher level concepts) to provide further abstraction. Categories were developed by defining their properties and dimensions (Strauss & Corbin, 1990). As I continued with the open coding process for the first interview, I become more assured about the coding process. This confidence continued as I coded additional interviews and began to better understand the experience and spirit of open coding. The codes and categories arising from the first set of interviews informed the criteria selection for the next set of participants. This theoretical sampling facilitated the comparative analysis of the data and provided a greater depth of understanding and insight into the properties and dimensions of categories, or the conditions under which the categories exist (Birks & Mills, 2011). Axial Coding. Axial coding follows open coding. The data that have been broken down in open coding are brought back into a coherent conceptual framework (Bluff, 2005; Thornberg, 2017). More specifically, axial coding is used to develop individuated categories by connecting subcategories and gaining a comprehensive understanding of the various properties and dimensions of the categories (Birks & Mills, 2011). During axial coding, I refined and differentiated between the concepts and categories identified during open coding. The coding paradigm (Strauss & Corbin, 1990) was used to consider the conditions, actions, and consequences of specific categories, which facilitated the development of subcategories. Categories and subcategories were then linked based on the coding paradigm. I examined the relationship between categories and subcategories and verified the connections between concepts through constant comparison. The different phases of help-seeking began to emerge, and the use of diagrams of the emerging theory facilitated this process. 81 Selective Coding. The last stage of coding is selective coding. In this process of coding, the theory is integrated and refined. A core category to which all categories and subcategories are linked is identified. This core category accounts for variations in the data and forms the backbone of the emerging theory (Bluff, 2005, Birks & Mills, 2011). During selective coding, I again used constant comparison to review the hypothesized theoretical scheme for internal consistency, gaps in logic, and poorly developed categories (Strauss & Corbin, 1990). The theory was trimmed: Codes and categories that lacked relevance to the emerging theory were revised, recoded, or discarded. Negative cases were used to further verify and enhance the theory (Bluff, 2005). Further theoretical sampling was required to achieve theoretical saturation of the core category and validation of the theoretical scheme. I continued axial coding and constant comparison analysis with a higher level of abstraction. The role of context, environments, and actions and interactions across a range of conditions over time was highlighted in the emerging grounded theory of the help-seeking process for parents of children with anxiety. The volume of categories and subcategories that began to emerge during the data analysis was overwhelming. Although I did not have a guiding extant theory when beginning the research, it was useful to have a theoretical framework from which to view the data once analysis was underway, as is consistent with Straussian grounded theory (Rieger, 2019). Through memoing, discussions with a critical friend (doctoral-level research assistant) and the ongoing and final phases of the literature review, I identified Bronfenbrenner’s process-person-context-time model (PPCT; Bronfenbrenner & Morris, 1998, 2006) as a comprehensive framework from which to understand the complex interactions between factors, environments, and contexts involved in help-seeking. The PPCT facilitated selective coding and helped relate the emerging findings by linking the categories to the core 82 category more concisely and integrating them into a cohesive theory. The PPCT is summarized below. By this later stage of selective coding, all data were accounted for by the emergent theory and theoretical saturation had been reached. As a final step of verification, I shared a summary of the generated theory with the participants for comments and feedback. I re-examined the theory with the comments and feedback in mind before finalizing it. The substantive theory that was generated is discussed in detail in Chapter 4. Bronfenbrenner’s Process-Person-Context-Time Model. Urie Bronfenbrenner began developing his ecological model of human development in the 1970s (Bronfenbrenner, 1977). His theory of human development has evolved through three phases, with the third phase highlighting biopsychological and environmental factors (Eriksson et al., 2018). The PPCT was developed in the last phase of the evolution of his theory (Bronfenbrenner & Morris, 1998, 2006). Each construct of the PPCT simultaneously and reciprocally interacts to impact human development. In the PPCT the construct of “proximal processes” is emphasized. These processes involve reciprocal interactions between the individual, other persons, objects, and symbols in the individual’s immediate environment and can produce two types of developmental outcomes: competence or dysfunction (Bronfenbrenner & Evans, 2000). Personal characteristics of the individual include biological, physical, and psychological attributes, such as age, gender, and temperament. Personal characteristics can be divided into disposition, resource, and demand characteristics. These characteristics influence the initiation and trajectory of proximal processes (Bronfenbrenner & Morris, 2006). Context was focused on extensively in the earlier phases of the theory (Rosa & Tudge, 2013). In PPCT, context refers to four nested structures of environment, known as “systems”: the microsystem, mesosystem, exosystem, and macrosystem 83 (Bronfenbrenner, 2005; Xia et al., 2020). Three levels of time are included in this construct of PPCT (Bronfenbrenner & Morris, 1998, 2006). Microtime refers to the duration of the proximal process. Mesotime encompasses how often the proximal processes occur over days or weeks. Macrotime focuses on changes in society within or across generations. This final iteration of Bronfenbrenner’s bioecological model of development offers a holistic framework from which to view public mental health research (Vaezghasemi et al., 2023, Eriksson et al., 2018). Memos Memos are written records of the researcher’s thought processes and conceptualization of the data in narrative form (Bluff, 2005; Lempert, 2007) and are vital in the analytic process (Tie et al., 2019). They may include code names, constant comparisons of data, reflections on the questions asked of the data, and theoretical comparisons (Strauss & Corbin, 1990). My memos moved from more exploratory to more focused and summative as the analysis progressed (Corbin & Strauss, 2008). They also helped me with my use of the literature review, as I noted relevant theories or concepts to consider in the constant comparison. Diagrams were used to visually represent the relationships between concepts and highlight gaps in the theory. Methodological notes were also used to explain my analytic process and help identify follow-up questions for participants during the analysis. Memos and methodological notes were used to aid in the development of the emerging theory. The information from the memos was used to detail how the concepts are related and fit together (Corbin & Strauss, 2008). Constant Comparative Analysis Constant comparative analysis is a crucial component of grounded theory. Not only are incidents and units of data compared to each other for categorization, theoretical comparisons are made to deepen the analysis. When comparisons are made based on properties (e.g., size or 84 shape) and dimensions (e.g., frequency of occurrence), similarities and differences are considered to classify the data into a particular category. When a researcher has difficulty making meaning from an incident, and its properties and dimensions are not evident, theoretical comparisons may be useful. In theoretical comparisons, incidents are thoroughly examined by making comparisons based on what is known in order to understand what is not known (Strauss & Corbin, 1998). This comparison also facilitates theoretical sampling. I used two techniques for comparing concepts: the flip-flop technique and systematic comparison (Strauss & Corbin, 1998). The flip-flop technique of theoretical comparison requires the researcher to view the data from the opposite perspective to identify meaningful properties (Strauss & Corbin, 1998). For example, in this study, satisfaction with the service provider was explored in terms of what participants found effective, as well as ways in which they were dissatisfied with the service provider. Systematic comparison draws upon the researcher’s experiences or from the literature (Strauss & Corbin, 1998). It helps the researcher become more sensitized to the properties and dimensions in the data. I used these types of questioning and reflection as tools to better understand the data. Remaining open and sensitive to the possible properties and dimensions that may relate to a particular phenomenon is important in constant comparative analysis. In the process of creating the category of mental health literacy, a review of the definition and literature helped identify, in the data, the types of knowledge and beliefs participants had about mental health and help. This identification, in turn, sensitized me to how the knowledge and beliefs were gained and formed, which, through further comparative analysis, led me to create and select the core category of being an advocate. 85 Saturation Deciding on the final number of participants was primarily guided by theoretical sampling, with the goal of gathering data until data saturation was reached. Saturation within grounded theory refers to theoretical saturation, where concepts have been fully developed and explained, and relationships between concepts are well detailed and validated (Corbin & Strauss, 2008). The anticipated number of participants for theoretical saturation in this study was 20 on the basis of the following: Thomson’s (2010) finding that the average number of interviews in 100 grounded theory studies across disciplines was 25, and grounded theory studies exploring help-seeking in various populations with sample sizes ranging from 7–30 (see Ben-David et al., 2019; Johnson & Menna, 2017; Pishva, 2017; Timlin-Scalera et al., 2003). The concept of saturation is often considered an indicator of the quality of qualitative research, but definitive rules for how to determine saturation are lacking, as are guidelines for estimating sample size for purposive samples (Bowen, 2008; Guest et al., 2006). The following evidence highlights the lack of coherent guidelines for estimating sample sizes to reach saturation. When considering the role of saturation on sample size, Mason (2010) used content analysis to explore 174 PhD studies using grounded theory across disciplines, and restricted data collection methods to semi-structured or unstructured interviews. Only studies using one interview per participant were included. Results showed a mean of 32 participants or interviews, with a range from four to 87 participants or interviews and a standard deviation of 16.6. Morse (2000) suggested 20–30 participants for grounded theory, with two to three interviews per participant. There is also evidence to suggest that as few as six interviews may be sufficient to develop useful themes and meaningful interpretations in studies with a high level of homogeneity among participants (Guest et al., 2006). 86 In grounded theory, there is discussion in the literature that the concept of theoretical saturation for robust research faces many practical challenges, particularly for PhD students. Strauss and Corbin (1998) acknowledged that there may be times when researchers must accept that they are not able to develop a theory as fully as wanted. Mason (2010) also noted that theoretical saturation may not be perfectly achievable, particularly in the context of doctoral research and the constraints graduate students face. Increasing the sample size may not always be necessary to reach saturation (Bowen, 2008). Rather, adequacy and appropriateness of the sample for the research topic may be more beneficial for efficient and effective saturation. Many scholars (Aldiabat & Le Navenec, 2018; Bowen, 2008; O’Reilly & Parker, 2013) have argued that rigour and trustworthiness of the research can be demonstrated when researchers are transparent, explain what saturation means within the context of their study, and outline how it was achieved, including limitations of the study. As previously indicated, the sample in the current study was highly homogenous in terms of demographics. However, the experiences of the participants were heterogeneous in several ways, leading to a diversity of data that facilitated saturation. Families’ experiences varied in the level of health care accessed (e.g., primary, secondary, tertiary), the types of mental health services accessed and received (psychiatric, individual or group psychotherapy, school-based counselling, parent-support services, or a combination), the settings in which they received mental health services, the types of therapies with which they engaged, the number of contact points with mental health services families had by the time of the interview (ranging from two to 13), and their level of satisfaction with services. 87 Parents’ level of mental health literacy also varied. For example, some parents were very knowledgeable about childhood anxiety and were able to (a) easily recognize their child’s symptoms of anxiety as outside of typical development and (b) identify the symptoms as anxiety earlier in their child’s life. Others had little knowledge of or familiarity with anxiety and had more difficulty conceptualizing the problematic behaviours their children were displaying early on. Parents’ level of knowledge about the various systems they encountered during the help-seeking process (e.g., school, mental health care, health care) was also diverse. Those who were more knowledgeable of the systems, including how to navigate them, were better able to ask for specific professional mental health services. These examples illustrate the range of participants’ experiences, which allowed for constant comparative analysis of the concepts and core categories that have led to the substantive theory detailed in Chapter 4. Having opportunities to follow up with participants and elicit their feedback further provided me with rich, detailed, nuanced data to test and validate the categories, the relationship between the categories, and the emerging theory. Based on the criteria of grounded theory, the emerging theory, the variability in sample size recommendations in the literature to reach saturation, and consultation with my co-supervisors, the decision was made to end data collection after 10 participants (11 children). This decision was also supported by the literature on sample size in grounded theory studies. Ensuring Rigour Criteria for Evaluating Grounded Theory Evaluating research is an important part of the scientific method. The concept of evaluating qualitative research has been discussed in the literature, as has applying the quantitative ideas of rigour to qualitative research (see Corbin & Strauss, 1990; Davies & Dodds, 88 2002). In grounded theory, there are specific procedures for data collection and analysis. The application of these procedures and practices is not meant to be rigid and strict, but rather flexible to allow for the discovery of theory from the data. The term “rigour” refers broadly to the reliability and validity of the research (Davies & Dodds, 2002). Cooney (2011) argued that evaluating both the research process and the resulting product (i.e., theory) is vital to ensuring rigour. Rigour and trustworthiness of the research can be demonstrated when researchers are transparent. Corbin and Strauss (1990) outlined criteria to highlight the information needed to evaluate the adequacy of the grounded theory research process, as well as the grounded theory. In line with transparency to promote the evaluation of rigour, Corbin and Strauss (1990) encouraged including discussion of these criteria in research writings. The criteria for both process and product were considered throughout the research. Previous sections of this chapter outlined considerations made and strategies used during the research process, including the rationale for initial and theoretical sampling, constant comparative analysis, and use of literature reviews in category development and identification, including the core category. The research process was further documented in the audit trail. An audit trail is a systematic record of the research process, including the theoretical, methodological, and analytical decisions made by the researcher. It outlines the steps taken and the rationale for the researcher’s decisions in order to demonstrate to the reader that the theory is grounded in the data (Bowen, 2009). In addition to functioning as the methodological link between data and theory (Lempert, 2007), memos and methodological notes provide a record of the analysis process (Bluff, 2005). These documents, in addition to transcripts and audio recordings of interviews, field notes, and reflective journaling, contributed to the audit trail. I 89 also engaged critical friends (e.g., graduate student research assistants) and supervisors in discussion to critically review the audit trail. The role of the critical friend is discussed below. Practices and Strategies for Ensuring Rigour Theoretical Sensitivity and Reflexivity. Theoretical sensitivity refers to how the researcher’s personal experiences, education, training, and understanding of the world influences how the researcher makes meaning of what participants share (Strauss & Corbin, 1990). Theoretical sensitivity focuses on how the researcher conceptualizes and interprets data, makes conceptual links, and identifies core categories to generate a theory that best reflects the participants’ experiences with the phenomenon rather than what effect the researcher has on the research process (Hall & Callery, 2001). It is an important aspect of constant comparative analysis. Increasing sensitivity to the data and the emerging theory fosters a robust analytic process because multiple perspectives and comparisons are considered and examined throughout the generation of the theory. Reflexivity, as described earlier in this chapter, also contributes to ensuring the trustworthiness and utility of the theory (Hall & Callery, 2001; Palmquist et al., 2017). Reflexivity, along with theoretical sensitivity, was incorporated throughout the research process through the use of critical friends, memos, methodological notes, and reflective journalling. As I built awareness of the potential influences that I had through developing the interview questions and collecting and analyzing the data, I raised these concerns with and sought feedback from critical friends. Some of these concerns are detailed below to increase transparency of the research process in this study. I also had to consider my personal characteristics, the balance of my role as researcher, my limited experience with conducting 90 semi-structured research interviews, my training in counselling psychology, and my theoretical orientation to clinical practice. Corbin and Strauss (2008) discussed being able to “step into the shoes of participants” to accurately capture the participants’ experiences and perspectives and draw from the richness of the data. Given that I used semi-structured interviews to understand parents’ experiences, from their perspective, I was cognizant of my role as a researcher and not that of a counsellor. Although I was in the role of researcher, I drew upon my training in counselling psychology and used an empathic approach to interviewing, with genuine care and interest in participants’ experiences. This training also helped me with the practice of reflexivity, as critical reflection is an important aspect of providing effective counselling. Another consideration was my theoretical orientation to clinical practice, CBT. I was mindful of how this may have impacted the interactions with participating during interviews and the resulting analysis. In particular, I was cognizant of my level of directiveness during the semi-structured interviews and made efforts to ensure participants had the freedom to share what they felt was relevant to the research question, as well as offered participants opportunities to share additional information throughout the interview. These efforts were made to ensure that I was not limiting the data from which to create the theory. When reviewing the transcripts, I made notes of how to adjust my interviewing style for future interviews. De Tona (2006, as cited in Berger, 2015) suggested that participants are more likely to share their experiences with a researcher they perceive as being aligned with their cause. My role as a service provider, my clinical training, and my interest in the research topic may have helped parents feel more comfortable disclosing information and affected what they chose to share, as illustrated by what participant Erin said to me: “Thank you for your work and energy and 91 interest…. It’s so refreshing and important. I think for people like me, going, like, “Yes, there’s, there’s so many people out there working hard” … [is] so inspiring and hopeful.” Several participants expressed that they were motivated to participate because they hoped that sharing their experiences might effect change. As a clinician and graduate-student researcher, I am well versed on the clinical presentation and etiology of childhood anxiety and anxiety disorders. I also have connections with other researchers, clinicians, and organizations within the field of child anxiety that provide many opportunities to receive training in evidence-based treatment. Because of my area of practice, such information is easily accessible to me, and I am knowledgeable of how to access both information and services. I used reflective journaling to ensure that I was able bracket my experience and remain open to participants’ process. The gaps in the literature and the discrepancy between service use and service need have driven my interest in this topic and shaped how I understood the process that parents engage in to recognize, seek help, and access services for their children. As discussed in the section about constant comparison analysis, and as is consistent with the Straussian approach to grounded theory, I continued to consult the literature as the analysis progressed to further sensitize myself to different ways of viewing the data and to prevent myself from viewing and interpreting the data on the basis of my pre-existing knowledge and assumptions. As the data analysis progressed, literature reviews were also conducted to formulate and test hypotheses about how categories may be related, and to develop theoretical density of the categories, including the core category. Triangulation. Triangulation is a strategy where different perspectives (e.g., multiple sources of data, theoretical frameworks, or researchers) are used to explore the same phenomenon. If these various perspectives lead to similar findings, the validity or credibility of 92 the findings is enhanced (Payne, 2015). There are different types of triangulation (see Carter et al., 2014). Triangulation was utilized in several ways in this study. The use of multiple methods of data collection is known as method triangulation (Carter et al., 2014). Interviews (as well as the video recordings and transcripts of the interviews), observations, and field notes were used in this study to explore the help-seeking process. As previously described, I also offered participants the opportunity to provide feedback on my analysis of their individual interview and to check their understanding as the theory developed. This respondent validation, or member checking, is a form of triangulation used to confirm the quality of analysis and contribute to the credibility of the findings (Payne, 2015). It helps strengthen the authenticity of the data and allows participants to share their reflections on the emerging theory. Testing my hypotheses about concepts emerging from the data and their relationships with one another is a crucial part of the grounded theory approach (Corbin & Strauss, 1990). Member checking is particularly important, given that the meaning that the participants make from their experience is prioritized in grounded theory. As I took a critical realist position to guide my methodological framework, the use of this type of triangulation is consistent with the philosophical underpinnings of my proposed research. Investigator triangulation involves two or more researchers examining the phenomenon being studied (Carter et al., 2014). A critical friend works alongside the researcher to both support and challenge with the shared aim of producing successful work. The role of a critical friend is to provide a different perspective from which to view data, voice critiques, and ask thought-provoking questions (Noor & Shafee, 2021). This critical friend helps reduce researcher bias, ensure that the analysis is inductive rather than theory-driven, and enhance theoretical sensitivity and reflexivity as data are collected and analyzed (Corbin & Strauss, 1990). 93 The critical friends in this study were doctoral-level research assistants with experience in qualitative research methods. Research Assistant 1 (RA1) has a school psychology background with experience as a mental health service provider to adolescents. Research Assistant 2 (RA2) has a counselling psychology background with clinical experience working with adults and trauma. Both had enough familiarity with anxiety and help-seeking to understand the context of the study, but their experience and training differed so that they were able to question my line of thinking and audit trail, pose alternate hypotheses, and explore alternate conceptual linkages throughout the analysis. As broad examples, discussion with RA1 helped me consider in more depth how the school context may have shaped the process for parents. This critical friend also served as a second coder for intercoder agreement, which is detailed below. RA2 directed me to alternate theories, which helped me consider the cultural context in additional ways and view the data from a social justice lens during the selective coding phase. Intercoder Agreement. A negotiated agreement approach was used to assess intercoder agreement. In this approach, two or more researchers code a transcript, compare codes, and discuss disagreements to resolve as many discrepancies as possible (Campbell et al., 2013). I developed the first iteration of the codebook using NVivo software before discussing and explaining the coding process to RA1. RA1 was then provided with a copy of an NVivo file to independently code a transcript selected at random. After completing the analysis of the transcript, we met to compare codes, discuss discrepancies and questions RA1 had about the coding process, and resolve as many differences as possible in the coding. Intercoder reliability was not calculated at this stage (Díaz et al., 2023). This process was repeated with three transcripts, initially adding, then merging, dropping, and refining codes and categories with each round and phase of coding. A proportion agreement method was used to calculate intercoder 94 agreement (Campbell et al., 2013). Once acceptable levels of intercoder agreement were achieved, the updated codebook was used to code the transcripts again, as recommended by Campbell et al. (2013). Summary Grounded theory is a methodology that aligns with the purpose and research question of the current study. In this chapter, the Straussian approach to grounded theory, the procedures for recruitment, and data collection were detailed. A description of the iterative data analysis process and the criteria for evaluating the research process to enhance rigour was also provided. In the next chapter, the findings of the study are elaborated upon and explained. 95 Chapter 4: Results Overview The purpose of this study was to develop a substantive grounded theory to explain parents’ process of help-seeking for their child struggling with anxiety. The initial research question guiding the study was as follows: What is the process parents engage in when seeking psychological treatment for their children struggling with anxiety? As discussed in Chapter 3, the research question helped focus and define the boundaries of the research. The research question also served as a guide when coding to create the theory. The research question did not change significantly throughout the research process, with only a minor adjustment to the question. The data revealed that parents accessed a range of treatment services. Therefore, the term “professional mental health services” was used in place of “psychological treatment” in the research question. The slight modification of the research question is consistent with the Straussian approach to grounded theory (Alammar et al., 2019). This chapter begins with an overview of the grounded theory that was developed in this study. Each primary category is then detailed, including the context, actions, and consequences influencing each category. Overview of the Grounded Theory Using the Straussian approach to the grounded theory methodology, six categories emerged from the data. A core category, being an advocate, was identified. The data also revealed five categories that corresponded with the phases of the help-seeking process: (a) recognizing anxiety as problematic, (b) deciding to seek professional mental health services, (c) initiating professional mental health services, (d) receiving professional mental health services, 96 and (e) if necessary, reinitiating or being redirected to other professional mental health services. The five categories and the associated subcategories for each category are shown in Table 3. Table 3 Overview of Primary Categories and Subcategories Primary categories Subcategory Recognizing anxiety as problematic Noticing initial flags (Phase 1) Observing symptoms of anxiety Recognizing functional impairment Recognizing impact on family Deciding to seek professional mental health Shift in balance services (Phase 2) Deterrents to seeking help Considering mental health service options Initiating professional mental health services Service availability (Phase 3) Practical considerations Clinician selection Considering the service setting Receiving professional mental health services Child’s experience of service (Phase 4) Therapeutic process Assessing goodness of fit Perceived level of effectiveness Reinitiating or being redirected to other mental health services (Phase 5) Engaging with multiple points of mental health services contact Experiencing unmet needs Encountering systemic barriers 97 The results indicate that the help-seeking of parents of children with anxiety is a complex, dynamic process, in which parents play a critical role. Movement through the phases of help-seeking is nonlinear and results from interactions of a variety of factors across multiple environments and contexts. Parents take an active role to facilitate the movement between phases and ensure access to services. They seek information from a variety of sources at each help-seeking phase to gain knowledge about child anxiety, available services, and navigation of the disjointed mental health system. Though some parents move through each phase sequentially, others may bypass phases. Families may access a number of services at a given point in time, and the trajectory of each service may vary. The proposed theory is illustrated in Figure 1. The Core Category of Being an Advocate Overview The core category of being an advocate emerged from the data, with one associated subcategory, enhancing mental health literacy. The core category provides a coherent explanation of how parents move through the phases of help-seeking and how they cope with and address the challenges they face when seeking mental health services and navigating the systems through which mental health services may be offered. Being an advocate provides the most robust account for the linkages between categories. There were several levels of contextual factors leading parents to advocate. At the child level, the severity of the child’s anxiety and resulting impact on the family were closely connected to being an advocate. At the parent level, personality characteristics, values, education, previous experience with mental health or mental health services, and the ability to cope with stress, including available supports, influenced parents’ ability and confidence to advocate. 98 Figure 1 Overview of the Model of the Help-Seeking Process for Parents of Children with Anxiety Note. MH = mental health. Help-Seeking Process Phase 1: Recognizing Anxiety as Problematic Phase 2: Deciding to Seek Professional MH Services Phase 3: Initiating Professional MH Services Phase 4: Receiving Professional MH Services Phase 5: Re-initiating or Being Redirected to Professional MH Services Precipitating Event Being an Advocate Enhancing MH Literacy Environmental and contextual factors Environmental and contextual factors 99 For example, parents who had confidence in their knowledge and decisions, felt strongly about mental health, and were described by others as tenacious, determined, or persistent were more likely to continue reaching out to a range of service providers until their child received appropriate services. This point is highlighted by Eleanor: I’m also a kind of person where I don’t wither if I get a “no.” I will fight you for a “yes” if I really think this is where I should get it. And, and that is just who you are, right? You either kind of operate that way or you don’t…. It has its negatives for me, but in this moment, it’s a positive. The family context also influenced the level of advocacy in which parents engaged. Family supports (e.g., childcare, local extended family, parents’ social supports), family constellation, dynamics, parents’ education, professions and employment type, and family history of mental health concerns all influenced their ability to be an advocate. At the school and community level, factors such as collaboration and communication with the school staff, classroom milieu, and staff experience and familiarity with mental health helped or hindered the advocacy process for parents. Contextual factors at the societal level included the COVID-19 pandemic, systemic barriers to mental health and health services, and stigma. These conditions are discussed further in each phase of the help-seeking model. The advocacy work that parents engaged in generally led to better access to services or resources, a better environment fit for the child, or more tailored or effective services for their child. For example, Alisha spoke about how her advocacy prevented her daughter from being misdiagnosed with a behavioural disorder. Eleanor noted her belief that her situation would have slipped “under the radar” had she not repeatedly requested services. Although there was a benefit to accessing services, advocacy work was emotionally challenging for many parents. Many 100 shared that they felt overwhelmed, discouraged, and drained. Parents sought out the informal help of friends, relied on previously learned coping strategies, requested parent support from various agencies, or sought out their own counselling to cope with the stress of help-seeking for their child. To illustrate the challenges, Leigh described “fighting the system” and feeling the “onus” was constantly on her to find and arrange support without guidance. She also believed that her advocacy caused her to be viewed as a “pain in the butt” by school staff and worried it would have a negative social impact on her children. Parents had to be proactive, resourceful, and effective problem-solvers when faced with barriers to services, all while managing their own emotional experiences. They were relentless in their pursuit to secure professional mental health services for their child. Parents engaged in different types of advocacy throughout the help-seeking process. As described above, parents primarily focused on natural advocacy to obtain services to meet their child’s mental health needs. This advocacy included learning and deciding how to support their child at home, learning about the various systems offering mental health support, and being resourceful when faced with potential barriers. When their concerns about their child were dismissed by professionals, they continued to seek help and requested or insisted on academic or behavioural school supports. Some parents had to ensure that mental health services outside of the school system were obtained when they needed to meet school designation criteria and when the child’s services within the public sector were terminated due to bureaucratic policies. When parents had concerns about the effectiveness or fit of services being received, some voiced their concerns to the clinician or organization providing services, whereas others requested alternate services. One outstanding example of this advocacy work is when Alisha took the lead in treatment after multiple unsuccessful attempts to secure specialized services: 101 I did tons of reading and online resources and, you know, basically figured out how to do ERP [exposure and response prevention].… The IOCDF [International OCD Foundation] has a conference, I took their conference…. Honestly, if you can’t get help, you might as well just figure it out…. We just did something every day for 4 months straight, so from, like, July ’til about October of 2020…. That’s when we sort of started to try to figure out this ERP. I did a CYBOCS [Children’s Yale-Brown Obsessive Compulsive Scale] just like a checklist…. At the bottom it says, like, you know, this is to be scored by a professional. So I didn’t score, I just kept it for my own self and sent a copy to her pediatrician. Not only did Alisha train herself to deliver evidence-based treatment for OCD when no one in her community was able to do so, she also learned to use a measure to help identify the severity of symptoms and track her daughter’s progress over time. Some parents also engaged in self-advocacy, requesting services for themselves when they felt unable to help their child or recognized a decline in their own mental health. Typically, parents with previous mental health services experience and those who prioritized mental health and whose parenting philosophy highlighted parent-child connection were more likely to seek out support for themselves. Parents advocated for their parent peers in various ways. Parents with higher levels of mental health literacy and confidence in their help-seeking skills were more likely to verbally share information, suggest resources, and encourage other parents of children with similar struggles to seek help before reaching a crisis. The sharing of information typically occurred in conversation with other parents. Two parents shared information more formally with other 102 parents through their work. Others contributed to the sharing of information by posting feedback or input on parent group pages on social media. Service advocacy occurred when families tried to piece together services within and between the health, mental health, and school systems. Some parents found themselves in a case-manager-type role, attempting to coordinate and integrate services. For some, this involved collaborating with and educating school staff and other important adults in the child’s life. Anna engaged in service advocacy when she worked with her son’s counsellor in the community to arrange effective support services at school. She attempted to coordinate and encourage the school-based team to implement strategies found to be effective at home. Program and cause advocacy were less commonly described by participants. Program advocacy was illustrated by two examples. One family donated funds to the public mental health service program they were accessing. Another participant helped organize an event in the community with the goal of improving the referral process for families. The event focused on informing service providers about agencies providing similar and complementary services and facilitated connections between providers and agencies in the field. Parents engaged in cause advocacy by joining committees within a specific system (e.g., parent education or advisory committees) to provide more direct input to better meet families’ needs. Some parents also contacted provincial and federal levels of government officials to formally and informally voice concerns, offer recommendations for change, and hold the government accountable to its strategic and financial plans for mental health. Typically, participants engaging in these types of advocacy were confident in their knowledge and skills. 103 Enhancing Mental Health Literacy An inherent part of being an advocate is enhancing mental health literacy. Parents took steps to gain knowledge about anxiety, how to support children with anxiety, and the various systems that offer professional mental health support and how they operate. This learning about systems included what type of help to seek and where, as well as how best to obtain it. Increasing knowledge about mental health did not occur exclusively during a particular phase of help-seeking. Rather, enhancing mental health literacy occurred through the entire help-seeking process and facilitated parental advocacy. This section details enhancing mental health literacy, a subcategory of being an advocate. Participants’ level of mental health literacy varied at the outset of the help-seeking process. Those with higher levels of mental health literacy at the beginning of the help-seeking process had education or professional training in child development or the health care field, a family history of mental health challenges, or personal experience with seeking and engaging in mental health support. Mental health literacy benefitted parents in several ways. They were more likely to reach out to multiple information sources and know where to seek out more information, who to ask for help, and some of the barriers to anticipate. These parents discussed experiencing less stigma and tended to be more open to discussing mental health topics and experiences with close others, as well as with their children. This openness often led to feeling supported and receiving information and resources. Higher levels of mental health literacy also helped some parents implement self-help resources at home to manage their child’s anxiety. Parents continually sought out information to inform themselves about an array of topics throughout each phase of help-seeking. Topics included anxiety, anxiety management, available resources, therapeutic approaches, feedback on particular clinicians, and how the various systems 104 operate (e.g., school, mental health, and health care systems). Seeking out and gathering information enhanced various components of mental health literacy. As mental health literacy increased, parents were better able to advocate for their children. Leigh referenced the need to obtain a high level of knowledge about the health system to advocate for her child: “I can’t tell you how many times people have said, ‘Are you a medical background?’ Now, I’m like an English and history major…. I had to learn a lot about the medical system.” When information was not readily available or easily accessible, parents took great pains to find the necessary information or resources, as illustrated by Olivia’s comment: “Why doesn’t the FBI [Federal Bureau of Investigation] hire [laughing] mothers, right? Because we will find you the information. We’ll figure it out, because we’re so used to it…. That’s what we do.” Parents tried to access a variety of information sources. They often relied on other parents with lived experience for advice and information. For example, several parents reached out to parent groups on social media platforms to learn about how to secure supports for students with extra needs at school. Information was shared on these platforms about what steps others took and found successful or ineffective, administrative details such as research into the Ministry of Education Special Education designation categories, how to obtain a designation, and funding sources and how to apply for funding. Another form of connecting with other parents with lived experience was through word of mouth. Parents asked around for recommendations or feedback on clinicians or services. Friends with children experiencing similar struggles was another resource parents relied on. Being able to speak to a trusted person about shared experiences and receiving solicited advice was a valuable aspect of parents’ coping. Parents also reached out to other knowledgeable individuals in their children’s lives, such as the child’s school, daycare, or after-school care. Sometimes parents approached these knowledgeable individuals to discuss the 105 parents’ concerns about their child or to inquire about available resources or services. Other times, the school reached out to suggest avenues to pursue or offered school-based services. For more serious concerns or specific questions, advice or guidance from a trained professional was sought. These professionals included primary health care providers, publicly available peer parent-support programs, or family or friends with training and expertise in a relevant area, such as education, child development, or child psychology. Parents also searched for educational information online (e.g., reading material, webinars, videos), via books, and by attending conferences. The information sources accessed were not specific to any particular phase of help-seeking. The context of the caregiver was particularly relevant throughout the help-seeking process. Contextual factors, such as a parent’s educational and professional background, character traits, personal experience with mental health services, and demographic factors, all played a role in the help-seeking process. Broader contextual factors, such as family history of mental health challenges, social and community network, and geographical area, also impacted a parent’s level of mental health literacy. Mental health literacy is not a static concept. Although parents had varying levels of mental health literacy, they each engaged in actions to increase their knowledge on an array of topics. This increase in mental health literacy facilitated each parent’s journey of advocacy to ensure their child received appropriate and effective mental health services. Parents may not have always intentionally sought out information to increase their knowledge of mental health topics, but discussing and sharing their concerns with others, whether professionals or social supports, facilitated the enhancement of their mental health literacy. The next section describes 106 each phase of the help-seeking model and further elucidates how being an advocate and enhancing mental health literacy influenced parents’ movement through the help-seeking model. Phase 1: Recognizing Anxiety as Problematic In this study, parents described a recognition that their child’s anxiety was causing difficulty in the child’s and family’s life. This recognition preceded decisions and efforts to seek professional mental health services. Thus, recognizing anxiety as problematic emerged as the first phase of the help-seeking process. Four subcategories became apparent in the analysis: noticing initial flags, observing symptoms of anxiety, recognizing functional impairment, and recognizing impact on family. In the first phase of the help-seeking model, the parent, family, and school and community contexts play a large role in the recognition of anxiety being a problem. As part of the recognition process, parents seek or receive information or guidance from knowledgeable others. Although parents may recognize signs and symptoms of anxiety in their child, and notice difficulties in areas of functioning, another adult in the child’s life, such as school staff, coaches, or other professionals from whom parents are seeking guidance, may provide information or recommendations that expedite the process of recognizing anxiety as problematic. Guidance from these professionals may be solicited or unsolicited. The family’s mental health history, child’s symptoms over time, parent’s level of mental health literacy or education in a related field, life stressors, stigma, and access to resources and social connections influence problem recognition. The school staff and resources are also influential in this phase. Noticing Initial Flags All parents described behaviours or personality traits early in the child’s life that were of note to them, sometimes from infancy. The noted behaviours and temperaments ranged. Some 107 children were described as “sensitive,” slow to warm, “rule oriented,” or “shy,” whereas others were characterized as “bright,” “defiant,” “active,” or “social.” Parents recalled their children “exploded” or had “meltdowns” or “overreactions” to seemingly small incidents, had challenges in social situations, or had difficulties sleeping and eating. As the children grew older, these difficulties persisted. Parents may have been aware of particular behaviours, but often felt unable to discern if the behaviour was developmentally appropriate. Having a teacher or coach provide feedback about the child’s functioning in a different environment, or frame the behaviour as anxiety, helped provide parents with a different perspective on the behaviours. For those with a family history of mental health challenges, similarities between the child and family members with mental health changes were observed and noted. In retrospect, these behaviours and personality traits were identified as initial flags of concern or query. Observing Symptoms of Anxiety Parents shared how the anxiety presented in their child, and were able to identify specific cognitive, physiological, behavioural, and emotional symptoms. These symptoms alerted parents to their child’s increasing difficulty. How easily parents were able to identify their child’s symptoms as those of anxiety depended on the parent’s level of mental health literacy and their experience with mental health concerns. Although all parents noted their child’s difficulties, not all parents independently recognized the behaviours, cognitions, and emotional distress as symptoms of anxiety. Parents facilitated the recognition of anxiety by enhancing their mental health literacy. They sought information through social connections, knowledgeable others, trained professionals, reading material, or online content. Other times, information was shared with parents when they discussed their concerns with friends or family in the context of socializing or needing emotional support. 108 Recognizing Functional Impairment Recognizing symptoms of anxiety did not immediately lead to seeking professional services. During the interviews, parents shared the indicators that helped them realize the anxiety was becoming more problematic. Parents spoke of the decline in their child’s daily functioning and described increasing difficulty with transitions, social situations, tolerating uncertainty, trying new things, and sleeping. Some also noted a loss of enjoyment in activities that were previously enjoyed by the child, and an increase in the child verbalizing negative beliefs about themselves or their abilities. Parents first made efforts to mitigate the effects of anxiety with informal help-seeking. They sought supports from the classroom teacher or school administrative staff, sought information and self-help material to learn how to support their child at home, and began teaching their children skills and strategies the parents learned from their own experiences or therapy. Accommodations to reduce their child’s emotional distress were another way parents tried to help their child. Accommodations ranged from changing employment or modifying parents’ schedules, seeking alternative schooling options, reducing the child’s responsibilities or expectations, and providing reassurance, whether by being in close physical proximity or repeatedly responding to reassurance-seeking behaviours. If families were able to manage the child’s level of anxiety with their knowledge and the resources available to them, they typically did not decide to seek professional help. When efforts to help the child cope were not sufficient to manage the anxiety, or if efforts to manage the anxiety were not sustainable, parents recognized that the anxiety was more problematic than they were equipped to handle, and further support was needed. Eleanor illustrated this balance between the level of support provided and the severity of the anxiety when discussing her daughter’s worries about substitute teachers: 109 I really had to sort of say to her every day, “In the school, we don’t put bad people in front of you. Bad people don’t get to be teachers.” … I really had to walk her down, “they [teachers] go to school, the police look at them.” … I really had to do the whole thing and for her to go, “Okay.” But I was doing it almost every day, right? So, things just sort of started … adding up for me. And it was so quick and so sudden for me. I was like, this isn’t just being challenged…. That began the conversation for me with her teachers of “I don’t think this is just perfectionism or being shy. I actually think she’s got some anxiety here.” … Then the Grade 1 teacher going, like, “Yeah, I agree.” … The teacher at that time was enough support for her…. You learn at some point in time that the, the normal people where this isn’t their expertise, including you, you have a certain amount of cope [support and skills] you can give a kid. And I think that cope, for her teachers and our after-school caregivers and I, ran out in Grade 1. Recognizing Impact on Family Parents were also aware of the negative impact the child’s anxiety was increasingly having on the family, including financial and emotional strain on the parents, an increase in stress for the parents and their relationship with each other, a decrease in parents’ overall well-being, and an increase in family discord. Siblings were also impacted by the increase in family stress and learned maladaptive behaviour from their sibling with anxiety. Parents recognized that the anxiety often required a great deal of their attention and effort, leaving them less attentive than they would like to their other child or children. When the anxiety was perceived as interfering with their child’s daily life, as well as the lives of family members, parents began moving to the next phase of help-seeking. 110 Phase 2: Deciding to Seek Professional Mental Health Services Whereas the previous phase focused on problem recognition and symptom management with informal help, the next phase of the help-seeking process centres on the decision to seek professional mental health services. Sarah discussed her experience of the transition from Phase 1 to Phase 2 of the help-seeking process: I think that was the big sort of “aha” around this is beyond just normal kid behaviour…. We were struggling a little bit. Like, okay well, we’re trying all the things that we know, and I was getting out of my parenting scope…. Knowing that, I think part of it too is knowing my own, my own reactions. And my own mental health was like “I’m starting to get triggered by this. I’m starting to get angry myself, and I’m noticing that, you know, the strategies that I have aren’t working for me based on, you know, the intensity of what’s going on here. I need, I need some help with this.” So, I think that recognition of just, like, I was a little bit in, in too deep, I guess. There are three associated subcategories: shift in balance, deterrents to seeking help, and considering mental health service options. Shift in Balance In the previous phase, parents were able to balance the impact of the anxiety on the child and the family with supports and strategies to manage anxiety. Ultimately, there was a precipitating event—such as starting school, changes in the family, being bullied, or a traumatic event—that led to a shift in balance, where the severity of symptoms increased to a degree that was no longer manageable with the strategies and supports being used. For Nicola’s daughter, Daniela, beginning kindergarten was the precipitating event: 111 When my daughter started school she would cry, and she would cry walking from our house all the way up until school and she would cry when she was at school. And this went on and on and on…. After a month of just tears, she says to me, “Mom, life is just too hard. I can’t take it anymore. I just want to die.” And I just thought, “I have a 5-year-old telling me that they want to die ’cause school is too hard, and it’s kindergarten.” And that to me was the major red flag. I was like “Okay, we need some serious help here.” And so that’s what started the journey for her. Leigh also identified a specific event that resulted in an increase in her child’s anxiety symptoms: It was always there, it’s not like it just appeared, the anxiety…. [But] it exploded with the bullying. Before that it was like, “Is she shy? Is she nervous?” … I can definitely see she’s always had anxiety. But good God! Parents had different thresholds at which the severity of the anxiety outweighed the supports in place to manage it. Again, parent contextual factors and mental health literacy played an important role in the decision to seek help. Parents’ emotional experiences and their ability to cope also impacted the decision to seek help. Some coped by reaching out to their social networks and supports, connecting with others with similar experiences, and seeking their own counselling, whereas others used denial or ignored their own well-being out of necessity to focus on their child’s needs. Other sought guidance from trained professionals, such as primary care providers or child educators. Professionals with more training and expertise in mental health were better able to recommend services or direct parents to seek help. The duration of symptoms also factored into the shift in balance and parents’ decision to seek help. 112 The school context was also influential at this phase. The school environment, rapport between parent and school, level of mental health literacy among the school staff, how resourced the school was, and the school’s willingness to collaborate with parents impacted how well the child was supported. This context was important because parents had to rely on school staff to understand and manage problematic behaviour effectively in the school setting. Parents’ experiences with eliciting support from the school varied, with a number of parents feeling frustrated, disappointed, and dissatisfied with the interactions and supports, or lack of supports, their child received. When low-barrier services (e.g., school counsellor) were offered to parents, the decision to accept services was easy and parents moved quickly from Phase 1 (recognizing anxiety as problematic) to Phase 3 (initiating professional mental health services). Other times, families tried to manage on their own until they reached a crisis point. Parent cognitions and knowledge about the trajectory of anxiety were particularly important and highlight the role of mental health literacy at this stage. Diane elaborated that with her daughter’s most recent presentation of anxiety, she waited several months to reach out to a counsellor because she hoped the anxiety would resolve on its own. Upon reflection, Sarah echoed the sentiment. Although she was not concerned about stigma, she also delayed seeking help initially because of concerns about “fitting in” sessions into the family’s schedule and not having enough time, despite not being overscheduled. She also acknowledged thoughts that the problem was “not that bad” and “let’s see how it goes” contributed to her decision to delay initiating mental health services in the public sector after being referred by the school counsellor. These examples illustrate that parents consider how problematic the anxiety is when deciding whether to seek services. The severity of the anxiety must be disruptive enough to the child and family for parents to take further action to 113 seek help, unless low-barrier services are offered. These examples also emphasize the role of mental health literacy in parents’ advocacy for services. Deterrents to Seeking Help The decision to seek professional mental health services was not always a long process. For some parents, the decision was prolonged and they faced deterrents to seeking help. Parents sought information to help them with the decision to seek help. When it was difficult to obtain information, parents managed the situation on their own or continued with the current services until the information could be obtained. Some parents described getting or hearing about others getting the “runaround,” where inaccurate information was given to parents or referrals were made to resources for which families were ineligible. This runaround resulted in parents being sent from place to place without acquiring the needed or desired information or service. Other parents spoke of difficulties getting information and receiving poor guidance or conflicting information from trained professionals. Trained individuals dismissed parents’ concerns and requests for guidance about appropriate services to access, or trained professionals recommended services that contradicted another professional’s recommendation. Stigma was another deterrent to seeking help, although parents recognized that they may not experience stigma for asking for help to the same extent as others would. For instance, none of the parents had concerns that the Ministry of Children and Family Development would remove their children from their home, but they were aware that this fear could discourage others from seeking help. Parents discussed worries about being judged by others and described how it was difficult to admit the level of their struggles with parenting. Mental health literacy and social support helped diminish the effects of stigma. 114 Considering Mental Health Service Options The precipitating event may lead parents to decide to access professional mental health services, but they must also consider what type of mental health service to access. Parents considered and weighed many factors against the backdrop of the family’s context, child’s school context, and the parents’ own characteristics. There was an interplay between these factors and the actions parents took to gather information and arrange supports. For example, Anna initially contacted her Employee and Family Assistance Program provider to explore what options were available for children. When she learned there were no appropriate services for children, she had to consider what other types of services she could access and where. The types of mental health services considered by parents were psychiatry, counselling or psychological services, alternative therapies, or a combination of these services. Parents considered several factors and took many actions when deciding which type of service to pursue. When considering psychiatric services, parents voiced initial concerns about their child being prescribed medication. Hearing of others’ positive experiences of working with a psychiatrist encouraged parents’ openness to this treatment option. Nicola elaborated that connecting with another parent who shared her experience of working with a psychiatrist helped inform Nicola about the scope of psychiatric services. Enhancing her mental health literacy by becoming informed about what psychiatric services may entail provided her with the confidence to pursue both psychiatric and counselling services. Erin also referenced the mental health literacy she had gained through her professional experience and previous experience supporting a child with mental health challenges as informing her decision to seek school counselling: “Again, knowing a little bit about supporting families, having this 10-year gap between my oldest and my youngest, you know, I was experienced to know what was needed.” Similarly, 115 Sarah talked indirectly about her mental health literacy when she discussed her own prior experiences of counselling and how they shaped her positive beliefs about the value of counselling for children. Parents were more likely to move to the next phase of the help-seeking process if they had higher levels of mental health literacy, were able to enhance their level of mental health literacy by seeking out or having access to reliable and trusted information providers, and had the skills and confidence to advocate and the resources to manage their own parenting and personal stress. The parents who had difficulty accessing reliable information or faced many deterrents to seeking help typically remained in Phase 2 until they were able to obtain the information or guidance needed to initiate professional mental health services. In this study, all parents who reached Phase 2 persisted in their attempts to enhance their mental health literacy about where and how to seek professional services and moved on to another phase in the help-seeking process. Phase 3: Initiating Professional Mental Health Services The phase of initiating professional mental health services tended to be more practical in nature. The initiation of services was greatly impacted by the parent, family, school, and community context. The availability and quality of services varied between communities, and families in rural areas faced additional challenges compared to those living in urban centres. These aspects are captured in the service availability subcategory. Families considered many practical factors, including scheduling, location, and financial resources when deciding where to access services, which is reflected in the practical considerations subcategory. Another subcategory revealed during the analysis is clinician selection. The degree to which parents considered factors related to clinician selection varied, depending on the parents’ mental health 116 literacy regarding the therapeutic process, as well as practical factors. The last subcategory in this phase of the help-seeking process is considering the service setting. Advocacy and resourcefulness helped parents navigate the systems and overcome some of the challenges they faced when trying to access services, but all parents experienced a delay between initiating and receiving services. Parents’ ability to cope with the emotional impact of seeking help for their child also influenced the steps they took to advocate for the prompt receipt of services. Nicola’s experience with her family doctor illustrates how various direct and indirect contextual systems influence the advocacy process for initiating services. Having a background in child development, Nicola was aware of the wait times as well as the need to access supports as quickly as possible. Based on several factors, she made an informed decision to use both psychological and psychiatric services. She noted how her confidence in her knowledge and research of mental health and treatments, financial stability, and flexible work schedule, as well as the expertise of her primary health care provider, facilitated her ability to advocate and initiate timely services: He [family doctor] said, “Are you willing to drive to [location]? He specializes in children and teens.” I was like, I’ll drive anywhere. This is a psychiatrist that specializes in children, like yes! And the waitlist is long, like to see a psychiatrist. Oh my goodness! And again, it’s like, you know, like we’re living every, every day where she [daughter] is bawling her eyes out and she’s telling me that she wants to die. And then I’m being told I have to wait 6–8 months. Like, kindergarten is going to be over! The same contextual systems influenced Addison’s experience differently. Similar to Nicola, she had experience in the field of child development; however, she was unsure of what type of help to seek. She did not have the financial resources to access services privately, and her 117 family doctor did not immediately recognize the mental health concerns. Addison visited her family doctor several times, seeking guidance about her son’s behaviours. She was discouraged by her family doctor from looking further into her concerns and was reassured that things were “fine,” and her child was “just being a boy.” She had to be more persistent in her advocacy. She continued to request help from her family doctor, recognizing the need for help but having limited knowledge of sources of help: And I went back to my GP [general practitioner], and I was in tears describing the anxiety and the behaviours that I was witnessing and my son. And I was just in tears. And my doctor’s like, “I didn’t realize it was this bad. I will refer you to a pediatrician. It might take a while.” And then he said, “In the meantime, reach out to [name of public mental health services].” But then he didn’t know how to reach out to [name of service]. So then I asked his [child’s] preschool: “Do you know how to reach out to [name of service]?” And they said, “Oh, yeah, yeah, call this number and they can tell you.” As highlighted throughout this section, initiating services did not immediately lead to receiving services, and families may have initiated more than one service at a time. Service Availability All parents described delays in accessing services due to wait times. This delay was consistent across all settings in which services were provided. Wait times ranged from several months to a year, often at a time when the child and family were struggling most with the anxiety. Olivia recalled initiating services when her son began experiencing visual and auditory hallucinations and being given an estimated wait time of 5 months to meet with a child psychiatrist: “Oh it’s ridiculous! My child is not well. Your option is to wait or go to emerge 118 [hospital emergency department]. That’s true of anybody.” Nicola reflected on her experience of initiating services by trying to access psychotherapy in the public mental health sector: When you apply, or when you look for help, the level of seriousness that you’re dealing with has to be high enough for them to say, “Yes, we will accept you.” But then you need to wait [laughing]. But then you’re on a waitlist, and I was told it could be up to 6 months. So, when you’re high enough [in terms of case severity] to be accepted, you can’t wait 6 months. Like, we need help for this now! Wait times were particularly challenging for families wanting to initiate more specialized services. They voiced concerns about the lack of pediatricians and child psychiatrists, as well as the lack of clinicians trained in specialized therapies or effective therapies for treating specific disorders. Alisha highlighted the lack of specialized services for children in her area: “There was nobody in our local area that worked with OCD and with kids her [daughter’s] age.” Families in rural areas experienced this lack more often than those in major urban centres. At the follow-up interview, Leigh shared that her daughter was still waiting to connect with a child psychiatrist. It had been 4 years since she made the referral request. Families in rural areas or smaller urban areas also commented on the limited resources, lack of centralized services, and challenges finding a clinician with whom they did not have an existing personal relationship. Lastly, parents also acknowledged the impact of the COVID-19 pandemic in delaying access to services even further. Parents who had experience initiating services both before and after the start of the pandemic noted an increase in wait times, with estimates of a year or longer. To advocate for timely services for their children, parents resorted to several strategies. To bypass wait times in the public mental health sector, parents redirected their efforts to seeking services in the private sector. This option was only available to parents with the financial 119 resources to do so. Parents were resourceful and made other efforts to decrease wait times, including asking to be placed on a cancellation list, consenting to student practitioners with shorter wait times, and travelling outside of their neighbourhoods or communities to access services. When initiating mental health services in the public sector, some parents were offered a parent-support service while the child was waitlisted for individual services. This service combined materials on strategies and skills for parents to review with phone-based coaching. Parents generally found aspects of these sessions helpful but not sufficient to target their specific concerns. All parents receiving this parent-support service also waited for their children to received individual sessions. Practical Considerations When initiating mental health services, parents had to consider practical matters such as logistics, scheduling, and finances. Office location, frequency of appointments, and coordination of both the parent’s schedule and the child’s schedule to attend appointments were all weighed. For some children, leaving school during class time was very distressing, further limiting parents’ options for appointments. Providers did not have the flexibility to accommodate all families’ schedules. As a result, parents working full-time with set schedules had to take time off work. If parents decided to access private mental health services, they also had to consider the financial cost. This included considerations of whether they had paid time off to attend appointments, the cost of private services, and any funding or extended health benefits available to them. Parents who did not have the financial resources for private services waited to access public mental health services or accessed mental health services through the health care system (e.g., through their family doctor). How parents weighted these factors depended on their beliefs 120 about help-seeking, their values and priorities, and how quickly they wanted to begin receiving services. Clinician Selection Not all parents selected the clinician their child worked with. This lack of choice was often due to the availability of services or the intake process at a particular organization or clinic. Parents with a choice of clinician and with more knowledge about mental health treatment were more likely to consider several factors about their clinician. These factors included the clinician’s experience and qualifications, the convenience and timeliness of beginning sessions, how well the clinician’s therapeutic approach to treatment aligned with the parent’s views of anxiety and treatment, and how well the clinician would be able to build rapport with the child. A recommendation from a trusted person also influenced parents’ selection of clinicians. Considering the Service Setting The types of setting in which parents initiated professional mental health services included acute care, primary health care, secondary health care, school, and public or private mental health care. The decision to access services in a particular setting depended on the availability of services, practical considerations described above, and the severity of the child’s anxiety. Notably, parents may have had to make multiple attempts to initiate services. These attempts may have occurred in more than one setting because parents chose to pursue a multidisciplinary approach, they were unsuccessful in their initial attempts to obtain services, or they were unwilling to wait lengthy periods of time to receive services. Alisha’s experience of this phase of help-seeking exemplifies how circuitous initiating services can be. She initially sought out services in the school setting, requesting that her daughter, Kara, meet with the school counsellor. The school declined her request, deeming Kara’s symptoms as not significant enough 121 to warrant the school counsellor’s services. Alisha then completed the intake process for public mental health services, which recommended she seek a referral to a pediatrician while being placed on the waitlist. Alisha then initiated services with the pediatrician, a secondary health care provider, by booking an appointment with her primary health care provider to request a referral. After three attempts at initiating services and being held in a “waiting pattern,” Alisha initiated an alternative therapy in the private sector at the recommendation of a school staff member. There was no wait for this service, so she was finally able to receive services, although not in the therapeutic approach she preferred. Phase 4: Receiving Professional Mental Health Services The fourth phase of the help-seeking process that emerged was receiving professional mental health services. Four subcategories were identified in this phase: child’s experience of service, therapeutic process, assessing goodness of fit, and perceived level of effectiveness. Child’s Experience of Service Parents shared their child’s experience of receiving mental health services. Some children enjoyed the sessions and the office space. Some made a particularly strong connection with their counsellor or, on the contrary, did not connect well. Some found the process of talking about their difficulties very challenging and uncomfortable, and some found attending sessions during school time very disruptive and anxiety provoking. Some children, primarily those who had previous experience with mental health services, refused to attend sessions. Parents also described mixed engagement from their child, who sometimes actively participated and at other times refused to participate. 122 Therapeutic Process Parents described the therapeutic process. It typically began with a diagnosis, whether formal, informal, or a self-diagnosis. Most parents self-diagnosed their child or received confirmation from a mental health professional about the presence of symptoms of anxiety. A diagnosis was especially important for families arranging formal support at school. For the few who were provided with a diagnosis by a mental health professional, there was often a diagnosis of a comorbid disorder or multimorbid disorders, such as another anxiety disorder, OCD, ADHD, a learning disability, or depression. These diagnoses were typically made after the initial anxiety diagnosis. Three parents were considering or waitlisted for an assessment for ASD. Parents accessing public mental health services described the intake process. They arrived in-person early on the specified day and waited to complete the intake interview to determine if they were eligible for services. For some, this meant arranging time off from work. Those accessing private counselling services described an initial screening, usually via phone, before meeting for a session with the counsellor. The intake process for counselling services was usually straightforward. For those accessing psychiatric services, the intake involved booking with a primary care provider. All parents opting for this type of mental health service had family doctors or nurse practitioners to whom they were already connected. A range of therapeutic approaches were offered to treat the child’s anxiety. Many of the counsellors used play-based therapy. Other approaches included emotion-focused family therapy, CBT, behavioural therapy, acceptance and commitment theory, dyadic therapy, equine therapy, neuro-movement therapy, and medication. Some therapies were delivered individually to the child, with little involvement from parents. Others incorporated parent sessions. Some families were offered the option of group therapy for anxiety, for either the child or the family. 123 These groups were CBT-based. Public mental health services were short-term, with families receiving a maximum of 10–12 sessions, depending on the organization. The societal context influenced the therapeutic process. The pandemic disrupted the therapeutic process for all families. Services were paused before resuming virtually. Not all families returned to sessions with the onset of virtual counselling, opting instead to “take a break” from counselling. The virtual format was difficult, especially for those engaged in play-based therapy or equine therapy. For children who struggled to attend in-person sessions due to symptoms of anxiety, the virtual format was welcomed. In the therapeutic process, providers could refer families to more specialized services, parent-support services, or a different modality of treatment (e.g., group or individual therapy). A referral could be made for concurrent treatment or result from the termination of services. The discharge or termination process varied widely for families. A lack of continuity of services was especially emphasized by parents accessing services in the public mental health system. Parents recounted how sessions were terminated not because treatment goals were met or anxiety symptoms decreased, but due to administrative policies, clinician’s personal reasons, or clinician’s lack of expertise. Not all families were referred to other services to after reaching their session limit in the public sector. Parents shared that these types of terminations felt abrupt and left them feeling unsupported. Other families terminated services by not returning for sessions. Some families did not terminate but decreased the frequency of sessions to an as-needed basis. In responding to reduce the gaps in service provision, parents highlighted being an advocate. When Alisha believed that the counsellor was prematurely terminating services, she successfully advocated for the continuation of services: 124 At first, she was going to close the file after at three sessions. Nine months’ wait, yeah, and then it was like three sessions.… But particularly, like, school is really struggling with her so, or she’s struggling at school. And so, I said, “You know, maybe before you close the file, you could at least just touch base with the people at school, because that’s kind of what brought us here” [laughing]. And so she met with the people at school, and then all of a sudden she’s like, “Okay, I’m going to book you in for weekly sessions for the next, you know, 8 weeks.” … So obviously whatever the school people said changed her view a little bit. In contrast, Anna described having less knowledge of how to enhance effective help-seeking: “Do I just have to take what they give me? Am I, am I allowed to say ‘No, I don’t want that’? Am I allowed? Right, I don’t know what the rules are on that.” When a counsellor terminated services due to personal reasons shortly after sessions began, Anna’s son, Ryan, was placed back on the waitlist and they faced another delay. They waited a year from the time she initially sought services at a public mental health agency to the time she was able to consistently work with a clinician at the public mental health agency. Anna’s level of mental health literacy, particularly the effective help-seeking component, influenced her ability to advocate for timely services. Assessing Goodness of Fit The experience of receiving services was influenced by goodness of fit. Parents spoke about the fit of services for the child and family. Families wanted services that were targeted at their identified concerns and specific challenges. Parents also valued the relational fit between the provider and the child, emphasizing the importance of the therapeutic relationship. The fit of the provider’s style and therapeutic approach with the child and parent, as well as the provider’s 125 experience and expertise with the child’s specific constellation of symptoms was also discussed. Parents’ level of mental health literacy informed their sense of goodness of fit, as some parents valued evidence-based therapies and researched therapeutic approaches that would align with their child’s needs and their parenting philosophies. Parents acknowledged and appreciated when providers tailored services to their child, whether it be adjusting session content or delivery style to the child’s developmental level, interests, or personality. A goodness of fit was not always achieved, particularly when parents had less autonomy over clinician selection. When the goodness of fit was viewed as unsatisfactory, parents had to weigh their options and decide whether to advocate to improve the goodness of fit. This decision involved balancing financial resources and time. Olivia spoke about the financial burden of finding someone located close to her area, knowledgeable about working with children, and with some level of expertise in dealing with anxiety and the “trauma of what he went through,” referring to her son’s hospitalization. She was willing to make the financial sacrifice. The financial burden was also of concern for Nicola: “We had used up our $500 health benefits at this point. And to go shopping [for a new service provider] at that point, to be trying to find a better fit, I mean, how much money were we going to be spending on this?” At this stage, she shifted to solely working with the psychiatrist, as she felt well supported, the behavioural approach was working well for her daughter, and the service was covered under universal health care. Parents also considered how effective the current services were when deciding if and how to advocate for a better fit. Perceived Level of Effectiveness Throughout the therapeutic process, parents assessed how effective they perceived the mental health services to be. Several factors influenced parents’ perceptions, including changes 126 in anxiety symptoms and family functioning. As expected, when symptoms and functioning improved, services were perceived as effective. Parents noted indicators of improvement such as an increase in children’s coping skills and use, quicker self-regulation, more verbal communication of needs and feelings, and less avoidance of anxiety-provoking situations. They also noted less family conflict, other family members’ use of coping skills, and more parenting consistency between parents. Some families noted that their child’s symptoms did not improve or worsened while receiving services. Alisha reflected on Kara engaging in equine therapy for 3 months and recognized that although Kara enjoyed being with the horses and “felt good” after sessions, there was no lasting impact on Kara’s symptoms. Changes in various contextual systems were attributed, in part, to worsening of symptoms or decrease in functioning. Examples of contextual changes included the child transitioning to a new grade or teacher at school, parent health issues arising, or changes in parent’s career or work schedule. Some parents were uncertain about how beneficial mental health services were for their child, as they noticed mild or minimal change while the child attended sessions. Parents’ perceptions of the provider also influenced their perceptions of the effectiveness of the mental health services. Generally, providers who offered parents psychoeducation about anxiety and its treatment, provided parent support, or engaged parents in their child’s therapy were viewed as more experienced and knowledgeable. Providers who collaborated with other support people in the child’s life (e.g., school team), made clinical decisions that resulted in the child’s improvement, and provided rationales for their decisions or recommendations were perceived as more effective. Parents felt less confident in providers and viewed them as less effective if parents disagreed with the provider’s clinical judgement, treatment plan, or assessment, or felt judged by the provider. Providers were also deemed to be less effective if 127 there was poor goodness of fit, a lack of coordination between providers, or providers offered incorrect or conflicting information or information that was not relevant to the family’s situation. When receiving professional mental health services, parents further considered goodness of fit, the child’s experiences of the service, the mode and therapeutic approach, and the perceived effectiveness of the service. Life circumstances in the parent, family, and school context impacted child’s progress in therapy. How well the provider was able to help the child increase their anxiety management skills, and improve functioning within the family under these conditions impacted movement to the next phase of help-seeking. Phase 5: Reinitiating or Being Redirected to Other Professional Mental Health Services The help-seeking process continued for families after families reinitiated services of their own volition for a variety of reasons or were redirected to other professional mental health services. This process was often onerous, as parents had to return to earlier phases of the help-seeking process after investing time, effort, and finances into a service. Often they faced the same barriers they encountered previously, which they would have to overcome again. Alisha likened getting caught in this loop of help-seeking to being “stuck in a hamster wheel.” The context for this phase of help-seeking included parents’ mental health literacy informing their decision on which supports to access and when, their ability to increase their level of mental health literacy in order to advocate for appropriate and timely services, the availability and quality of service and supports in the family’s community, the level of mental health literacy at the school level, and structural issues in health, mental health, and school policies. The actions that parents took varied, depending on reciprocal interactions between their contexts, service providers, information sources, and the severity of their child’s condition. 128 Engaging With Multiple Points of Mental Health Services Contact It became evident that all families sought out and received services multiple times. The points of contact with mental health services ranged from two to 14 for each family, with not all contact leading to the receipt of services. Parents highlighted the “convoluted” process for help-seeking, at times reaching out to multiple services simultaneously to determine which service they could access most quickly. Many factors, including earlier phases of help-seeking, influenced how many points of contact a family had with mental health services. Sarah described her family’s experience: We started to do things like introduce meditation techniques, and he [child] was talking to the school counsellor, not on a really regular basis but sort of as needed…. She noticed that this [anxiety] is a continuing issue so she referred us to, like, a community service that was available for, for counselling. We didn’t take it right away. But then we, you know, after some time we’re like, “Okay well, the things that we’re doing aren’t enough for, aren’t working, and we could use a little bit of support.” So, we sought that out…. And then we had COVID. And he [child] didn’t want to do video chat with the counsellor so we said, “Okay, well, I guess we’ll just deal with this for now.” And it [child’s anxiety] just, it didn’t get better…. So we’re still waiting to see that counsellor again. But in the meantime, we’ve sought out a private counsellor that he’s been seeing every, like, every 2–3 weeks, maybe even 3–4 at some times. And he’s really enjoying it. I think it just helps him to have some like normalization of, like, talking about emotions and sort of breaking down thoughts and behaviours, and how they’re, you know, one leads to the other and you can stop it at this point with these strategies and, and that type of thing. 129 Sarah’s example illustrates the escalation of services from implementing self-help strategies at home, receiving infrequent counselling support at school, to receiving more intensive counselling services in the community. When faced with a disruption in services, Sarah’s family continued to cycle between help-seeking phases until the level and fit of service met the family’s and child’s needs in a timely manner. Sarah’s example also refers to the next subcategory. Experiencing Unmet Needs Ineffectiveness of Current Services. As discussed in the section on Phase 4 (receiving services), perceived effectiveness of services depended on a variety of factors. Lack of or minimal improvement in symptoms, poor fit, change in symptom presentation, and lack of provider experience or training prompted parents to move back to previous phases of the help-seeking process. When a service provider’s treatment approach was perceived by parents as not appropriate for the presenting problem, parents decided to seek other professional mental health services and began the help-seeking process from Phase 2. If anxiety symptoms reemerged or presented differently after a period of being well managed, parents returned to Phase 2 and promptly moved to Phase 3 if they wanted to reinitiate services with a provider they had used previously. This re-initiation was likely to happen if the child had a strong therapeutic relationship with the provider. If parents were unsuccessful at reinitiating services, they returned to Phase 2 and had to reconsider the service options available to them. Regardless of the reason for rereferral or re-initiation of services, parents often faced more wait times. When there was a lack of improvement in the child’s symptoms, mental health providers referred families to specialized services, such as a psychiatrist. The specialized service could be accessed 130 concurrently or the child could be discharged from their current service to transition to the new service. Parents could also initiate this process, again cycling back to Phase 2 of the help-seeking process. When the specialized service was offered within the same agency, parents bypassed Phase 3 due to a streamlined process for existing, active clients. However, they still faced a wait for the specialized services. Diane described her experience of needing to return to previous phases of help-seeking: I don’t know if it’s a function of being over Zoom, or ’cause it’s been over Zoom since the last lockdown, … or just this counsellor’s approach, but nothing is helping. So I’m just starting to look for … other support…. I think I’ll try maybe a couple of in-person sessions for, for my daughter and see if getting back in the clinic face-to-face with the counsellor will help. If it doesn’t, then I’m going to look at this other counsellor. Being an advocate was very relevant when needing to seek out other services due to the perceived ineffectiveness of current services. Alisha recognized the need to change the treatment plan for her child, but redirecting to other services was challenging for her: When I said, “I think we’re dealing with OCD, and I think we need to shift and we need to be doing exposure and response prevention,” she [the counsellor in the public sector] said, “Oh no, I don’t think so.” And, you know, she wanted to just close the file. So, I said, “Well, could you just leave it open ’til we find somebody? You know, ’cause we have no one.” And she agreed to, and then so I looked around…. There was nobody in our local area that worked with OCD and with kids her age…. [I] went back to the school counsellor, so I was like, “I know this is maybe, like, you might not agree, but … school’s out, you’re not coming back into this position in the fall at the school, you know, I know you have a private practice, like, could we see you in the summer? ’Cause at least 131 you know her, you know a little bit about this.” ’Cause I kind of trusted her from what she told, how she’d identified it [OCD] in the first place. So she did agree to see us just for, you know, the summertime. Alisha successfully advocated for effective support for Kara while cycling back to previous phases of help-seeking. She was required to be creative and resourceful when considering which mental health services to switch to, and she had to skillfully coordinate services to prevent gaps in support. Dealing With Bureaucracy. Parents faced bureaucratic barriers resulting in a redirection of services. Families maxed out their extended health benefits or session limits, experienced clinician turnover in the public sector, or had to return to waitlists if they wanted to reinitiate services after a break in services. When session limits were reached, parents were sometimes redirected to other public mental health services. Other times, services were terminated without any offers to support the transition. Again, parents were left to navigate the next steps on their own and restart the help-seeking process. Encountering Systemic Barriers The experience of seeking help and getting “stuck in a hamster wheel” helped parents gain an intimate knowledge of the mental health, health care, and school systems. Through their experiences and knowledge, parents identified many systemic barriers. All parents acknowledged their privilege and its effect on seeking services. Many parents expressed how lucky they felt to have privilege, which included their skill set to communicate and navigate services as White, English-speaking individuals, their education, their access to a consistent primary care provider, their financial stability, their learning from past experiences, and acknowledgement that their situation could be worse. They spoke of the empathy they felt 132 for those who did not have the resources, education, and experience they had to be able to navigate the process. Along with recognizing and feeling grateful for their privilege, parents recognized discrimination against groups of colour, including Indigenous people, new immigrants, and refugees. Some parents also noted the disparity between genders, with the burden or responsibility for children with mental health concerns being placed on female caregivers in Canadian culture. Conceptualizing mental health within the medical model was another concern parents raised. At the same time, parents noted how mental health was not given the same attention and resources as physical health within the medical model. Alisha spoke to this: It does bug me that we have to pay. We live in Canada, and … a person has … a health condition, and … the evidence-based treatment is medication and ERP [exposure and response prevention]. And, you know, both of those things are not covered…. We do have extended health [benefits], but they’re not publicly available to everybody. Another related systemic issue is the lack of information provided to families about mental health. Unless parents had knowledge from previous experience or education and training in a related field, they usually had low levels of mental health literacy. Eleanor referenced the resources she received from the Ministry of Health as a new mother that outlined physical developmental milestones for children. She noted that no such handbook was available for mental health, leaving parents uninformed about what is developmentally appropriate behaviour in regard to mental health. Parents identified a need for personalized guidance to navigate the “disjointed” mental health system. This guidance would include best practices for anxiety using a family-centred approach, and how to most effectively manage “red tape.” Parents had to independently seek 133 information about the conditions or requirements to receive mental health supports in various settings, including cross-boundary services for those living in areas with limited resources. They also had to acquaint themselves with procedural issues to introduce and maintain supports or obtain funding in a school setting. Not only was the help-seeking process difficult and serpentine but gathering information to navigate the help-seeking process was also laborious, further straining parents. Parents also believed that personalized guidance could help to decrease the sense of being “stuck in the hamster wheel” because more appropriate services would be initiated from the outset of the help-seeking process. Summary Enhancing parental mental health literacy facilitated parents’ advocacy, which helped explain the movement through the phases of help-seeking. Parents face many hurdles when seeking help for their child with anxiety. These hurdles were often influenced by various contextual factors, which helped or hindered the process. In addition to trying to conceptualize their child’s emotional and behavioural difficulties, support their child, manage the impact of anxiety on the family, face the financial burden of accessing services and supports, and navigate the various systems in place to provide professional mental health services, parents had to also address and cope with their own emotions and experiences of seeking help. The help-seeking process for parents of children with anxiety is not easy, even when the steps are straightforward or smooth, and parents are required to repeatedly demonstrate their resilience. 134 Chapter 5: Discussion Overview The current study sought to answer the following research question: What is the process parents engage in when seeking professional mental health services for their children struggling with anxiety? Using a Straussian approach to grounded theory, this study generated a theory of the help-seeking process for parents of children with anxiety. Parents seeking professional mental health services for their children with anxiety engaged in a process involving five phases of help-seeking: (a) recognizing anxiety as problematic, (b) deciding to seek professional mental health services, (c) initiating professional mental health services, (d) receiving professional mental health services, and (e) reinitiating or being redirected to other professional mental health services. The process was circuitous and often overwhelming. Being an advocate emerged as the core category, with enhancing mental health literacy as the associated subcategory. Being an advocate was central to parents’ movement through the five phases and managing the barriers that parents almost inevitably faced. There are many contextual factors that are intricately and reciprocally connected with the actions and efforts parents make as they progress along their journey to access and receive timely professional mental health services. In this chapter, the grounded theory is first situated within existing theoretical frameworks and then discussed in relation to the extant literature. This is followed by a discussion of the implications for practice and policy. Limitations and strengths of the study, as well as future directions, are considered. Situating the Grounded Theory The final literature review facilitated my ability to situate the grounded theory within extant theories or frameworks (Thornberg & Dunne, 2019). Concepts from two established 135 models were used to enhance theoretical sensitivity and validate the findings. The process of help-seeking can be view through the lens of the PPCT (Bronfenbrenner & Morris, 1998, 2006) and the transtheoretical model of change (TTM; J. O. Prochaska, 2008; J. O. Prochaska & DiClemente, 1983). In the section below, I situate the grounded theory within these extant frameworks as well as the extant literature. In Relation to Theoretical Frameworks Transtheoretical Model of Change. The TTM is predicated on the assumptions that behaviour change takes time and that the change process is continuous and cyclical (J. O. Prochaska, 2008). The model focuses on six stages of change, 10 processes of change used to progress or regress through the stages, decisional balance, self-efficacy, and temptation (J. O. Prochaska & Prochaska, 2011). The stages of change are central to the model and consist of the following: precontemplation, contemplation, preparation, action, maintenance, and termination (J. O. Prochaska, 2008; J. O. Prochaska & Prochaska, 2011). In the precontemplation stage, the individual has no intention to modify or change behaviour in the next 6 months. Individuals who intend to change their behaviour within the next 6 months have reached the contemplation stage. The preparation stage is characterized by people who intend on taking action in the immediate future. For individuals to reach the action stage, they must have made specific and observable changes to their behaviours and those behaviours must have resulted in objective benefits to their health. In the maintenance stage, individuals have been able to sustain the behavioural changes for 6 months or more and are working to prevent relapse. Termination is the final stage, in which individuals are confident in their ability to maintain behavioural changes and experience no temptation to return to their previous behaviours or habits. Reaching the termination stage may not be realistic, and a lifetime of maintenance may be a more realistic goal 136 (J. O. Prochaska & Prochaska, 2011). The stages of preparation and action are the most malleable and where movement between stages is most likely. The earlier stages and later stages tend to be more stable (J. O. Prochaska, 2008). The Grounded Theory Through a Process-Person-Context-Time Model and Transtheoretical Model of Change Lens. In the help-seeking process, recognizing anxiety as problematic can be viewed as involving proximal processes relating to anxiety that led to “dysfunction.” The child’s characteristics, the environments and situations to which the child is exposed, and the child’s interactions with peers and important adults in those environments reciprocally interact. Each child, with biological and psychological predispositions, is faced with situations and environments that are anxiety-provoking and responds to and engages in those environments and situations by fighting, fleeing, or freezing in their own unique way. Their parents and other caregivers, such as school teachers and staff, respond to the child’s behaviour and emotions in a variety of ways on the basis of the interaction between their own characteristics, predispositions, actions, and reactions; others in their lives; and objects and symbols in their own environment. In the help-seeking process, how these constellations of factors interact determines how and when parents recognize the “dysfunction” in the child’s behaviour. The mesosystem involves the child’s home and school environments. In terms of the TTM, parents cycle between the precontemplation, contemplation, and preparation stages, vacillating between levels of awareness of how problematic they find their child’s symptoms of anxiety and intensity of action to address their concerns. In deciding to seek professional mental health services, additional contextual systems are brought to the forefront. Parents’ social and work environments influence with whom and what parents reciprocally interact. Additional other persons and objects may be brought into the 137 child’s microsystem in the form of informal supports. The “dysfunction” has reached a level that requires parents to seek people, objects, and symbols from wider contexts. This development corresponds with parents’ movement between the preparation and contemplation stages of change in the TTM, as they try to establish a balance between implemented supports, deterrents to seeking help, and the severity of the child’s symptoms. The precipitating event and resulting shift in balance moves parents to initiating professional mental health services. The context expands to include community and sociocultural environments. Other people, such as trained professionals from the community, are sought to engage with the child and family. These other people can then further impact the reciprocal interactions between the child, parent, and their respective microsystems, as the proximal process continues to evolve over time. In this phase of help-seeking, the TTM suggests that parents cycle between the action and preparation stages of change as they take action and seek help to modify the anxious behaviour. They may also return to developing their plan of action depending on the barriers they face while help-seeking. From a PPCT model lens, receiving professional mental health services and reinitiating or being redirected to other professional mental health services can be understood as proximal processes being directly impacted during these phases of help-seeking. The reciprocal interactions between children, important other people, objects, and each of the children’s and important other people’s respective environments, microsystems, and relevant mesosystems are being shifted to help children and parents acquire knowledge, skills, and abilities to manage the anxiety more effectively. How effective the interventions are, how consistently parents and important others implement the interventions across the child’s microsystems, and how parents respond to the intervention’s level of effectiveness at improving symptom severity and 138 functioning influence the synergistic relation between all these variables. From a TTM perspective, parents alternate between the contemplation, preparation, action, and maintenance stages of change while in the “hamster wheel.” If the level of effectiveness of the treatment is perceived to be low, parents are more like to return to earlier stages of change and develop a new plan. How long parents remain in the contemplation stage once they have returned depends on their knowledge about which service to access, as well as the availability and accessibility of the referred services. In this study, including follow-up sessions, the termination stage of change was not captured, as all families were still in the help-seeking process. Throughout the help-seeking process, the three time levels of the chronosystem are relevant. The proximal processes for anxiety-provoking situations or objects occur repeatedly over the course of the help-seeking process. For parents seeking help, these often occur multiple times within the day. Mesotime is also invoked during the help-seeking process, as the development of problematic anxiety occurs over time and the frequency of proximal processes and resulting dysfunction increases. When and for how long the proximal processes occur in the child’s development also influences the development of anxiety. Development occurs over time, and determining changes in developmental outcome requires time. Macrotime was involved with the onset of COVID-19 and the resulting changes to service utilization and delivery. In Relation to Extant Literature The findings from this study relate to help-seeking, service utilization and delivery, and treatment. In addition to helping generate a grounded theory, the findings are significant because of the value parents placed on participating in this study. Parents’ participation in this study can be viewed as an extension of their cause advocacy. They revealed their motivation to participate was driven by their desire to effect systemic change and facilitate the help-seeking process for 139 other families. Olivia’s comments illustrate the significance to participants: “I think it’s important. And should anyone in the right office happen to, you know, look at your paper and your research … it would get used.” The theory that emerged illustrates that parents engage in a nonlinear help-seeking process with five phases. The findings lend support to evidence suggesting that help-seeking is complex, nonlinear, and laden with barriers. The results also emphasize findings from previous research demonstrating that help-seeking behaviour is influenced by many variables and contextual factors (MacDonald et al., 2021). The theory not only elucidates the potential pathways to care and determinants of help-seeking but also identifies the explanatory role of being an advocate and enhancing mental health literacy throughout the process. Each parent had to overcome various barriers throughout help-seeking. Being an advocate provides a cohesive explanation of how parents addressed the particular barriers they each encountered throughout the help-seeking process. To effectively advocate, parents also had to learn more about a range of topics, resources, and services. Enhancing mental health literacy emerged as a subcategory of being an advocate and underscores the importance of gaining knowledge in advocacy work. The grounded theory that emerged lends support to findings that pathways to mental health care for children are varied and complex, involve multiple points of contact with formal and informal sources of help, and can often result in lengthy delays before children receive services (MacDonald et al., 2018; Shanley et al., 2008). Similar to the youth help-seeking and service utilization model (Srebnik et al., 1996), which identifies three stages in the help-seeking pathway, the current theory also describes stages along a help-seeking pathway. The current theory of help-seeking for parents of children with anxiety outlines five phases, which parents 140 can move through in a linear fashion or nonsequentially. The current theory diverges from the youth help-seeking and service utilization model by expanding its service utilization stage to into three distinct phases of initiating, receiving, and reinitiating or being redirected to services. The current theory also lends evidence to support the concept of a gateway provider, who recognizes an individual’s need for help and then must identify the service or support that best fits the individual’s need. In the gateway provider model, the more knowledge the gateway provider has about mental health resources, the more likely a service will be provided to the individual in need (Stiffman et al., 2004). The core category of being an advocate and the associated subcategory of enhancing mental health literacy in the current theory emphasize the role of a key individual, a parent, in the process of children accessing services, and how parents’ knowledge and attitudes can greatly impact service utilization in children. The findings from the current study provide evidence to support the role of school personnel in facilitating the recognition of anxiety as a problem (Boydell et al., 2013; Costello et al., 1998). The critical role of parents in help-seeking for both children and youth (Costello et al., 1998; MacDonald et al., 2021; Zwaanswijk et al., 2003) was confirmed in the current study, but the findings do not substantiate the claim by Boydell et al. (2013) that youth are active participants in the recognition of mental health problems, and youth, not parents, are central to the help-seeking process. The current study may not have found children to be active participants in the recognition of mental health problems for several reasons: the younger age of the children of focus, the limited number of parents of adolescent children included in the study, and the children’s experiences and perspectives of help-seeking were not explored. Barriers to treatment have been well documented in the extant literature (Anderson et al., 2017; Reardon et al., 2017; Reardon et al., 2018; Salloum et al., 2016) and recognized by the 141 provincial government (British Columbia Ministry of Mental Health and Addiction, 2019). Participants’ explicit and implicit identification of barriers converge with the barriers face by parents in the extant literature. In relation to seeking information about mental health treatments, both parents of children who had received mental health services and parents of children who had not received mental health services tended to identify health care providers, such as mental health providers, pediatricians, and psychiatrists, as the most trustworthy information sources (O’Connor & Langer, 2019). In the current study, many parents had difficulty accessing these trusted information sources directly. In British Columbia, a referral is typically required from a family doctor or nurse practitioner. Furthermore, the quality of information and level of mental health expertise varied greatly between primary care providers, who served as a gateway to specialized care providers, such as pediatricians and psychiatrists. Participants of the current study also voiced frustration about how mental health is currently framed within the health care system, and how disjointed and fragmented the health care system is. The structure of the mental health system highlights systemic barriers that parents continue to face and emphasizes the importance of actualizing the provincial plan for improving mental health and addictions care (British Columbia Ministry of Mental Health and Addictions, 2019). The discrepancies between service need and service use that have been documented in the extant literature were amplified by participants’ stories of their help-seeking process. These stories are of particular concern as the province released A Pathway to Hope (British Columbia Ministry of Mental Health and Addictions, 2019), a 10-year plan for improving mental health and well-being and access to early intervention and evidence-based care for people in the province. A 3-year progress report was released in 2023, outlining initiatives that have been 142 implemented, statistics on usage, and investments of funds (British Columbia Ministry of Mental Health and Addictions, 2023). This grounded theory illustrates that the provincial efforts are not yet reflected in the help-seeking process of parents of children with anxiety or their lived experiences. The concept of empowering and supporting parents has been explored in various populations in the extant literature. In developing a model of parents as agents of change for children’s mental health, Olin et al. (2010) highlighted the four determinants that influenced parents’ intentions to initiate or participate in mental health care. Although not framed from a mental health literacy perspective, those four variables can be viewed as corresponding with the four components of mental health literacy, as defined in Chapter 2 of this study: understanding positive mental health and how to obtain and maintain it, understanding mental disorders and their treatments, reducing stigma, and enhancing effective help-seeking. When investigating parent empowerment in parents of children with chronic neurological conditions, developing knowledge, skill, and confidence to actively partake in and collaborate with professionals about decisions for their child facilitated parents’ ability to effectively be heard by the professionals caring for their children (Gibson, 1995). Boshoff et al. (2018) explored parents’ advocacy for children with ASD and noted that advocating increased parents’ sense of control or focus on aspects that were within their control when faced with uncertainty about their child’s future. Searching for solutions contributed to feelings of empowerment. Taken together, these findings support the notion that enhancing parents’ mental health literacy fosters parents’ advocacy for their children and is integral to the help-seeking process. One finding that emerged was how intricately woven parents’ mental health literacy was into their ability to effectively advocate for mental health services on behalf of their children. To 143 advocate, parents had to enhance their mental health literacy at every phase of help-seeking. They enhanced their mental health literacy by seeking and requesting information relating to mental health and anxiety, interventions, supports, and services from a variety of sources. Other times, parents came upon information coincidentally and were offered or provided information by others from whom they were seeking emotional support or with whom they were socializing. These findings highlight how contextual factors, such as parents’ social networks and personality traits, influence help-seeking. Parents’ level of mental health literacy at the outset of the help-seeking process often influenced their help-seeking behaviour, as well as their seeking and gaining of knowledge to advocate for their child. The finding that mental health literacy impacts help-seeking is consistent with the extant literature exploring predictors of accessing professional services. A family history of anxiety or other mental health concerns and personal experience with counselling or therapy facilitated help-seeking for parents in this study. This finding is consistent with research indicating that parents’ prior use of mental health services for themselves was associated with help-seeking for their child (Reardon et al., 2020). Oh et al. (2015) identified parents previously accessing professional help for their own stress and parents perceiving their child’s behaviour as more problematic than that of the child’s peers as the strongest predictors of service use for young children. Similarly, mental health literacy has also been found to be a critical aspect in pathways to mental health care for adolescents. Past experiences with the healthcare system of either the caregiver or the adolescent affected mental health literacy, with positive experiences aiding in symptom recognition, identifying possible sources of help, and increasing the likelihood of seeking help. In contrast, negative experiences decreased the willingness of youth to reach out to the services if mental health care was needed in the future (MacDonald et al., 2021). 144 The current study also contributes to and expands upon Fearing’s (2024) findings, which identified four components of mental health literacy in formal mental health help-seeking. The current study adds to Fearing’s findings by providing evidence that additional components of mental health literacy influence the help-seeking process. In the current study, parents who had previously accessed professional mental health services, specifically counselling, for their own mental health challenges described how their experience influenced their beliefs about seeking help and provided them with knowledge of self-help tools they could apply when supporting their children. Thus, parents’ prior counselling experiences influenced several components of mental health literacy, including their beliefs and knowledge about mental health treatment, knowledge about how to seek help, and stigma. Participants reported use of self-help interventions prior to seeking professional help, and actively seeking evidence-based treatment for their child, also demonstrate some knowledge about interventions or treatment for anxiety. Some participants in the current study, especially those with a family history of anxiety, had awareness of the heritability of anxiety, indicating some knowledge of risk factors and an understanding of anxiety as a mental health disorder. When considering parents’ role in mental health help-seeking for their children, the developmental context should be taken into account. As previously discussed, developmental changes, and the related developmental tasks from childhood to the end of adolescence, including increasing autonomy in decision making and navigating changes in relationships with parents and peers may impact parents’ role (Barker, 2007; Rickwood et al., 2005). There is a developmental sequence of anxiety disorders, based on the typical age of onset (APA, 2022), which may add to the challenge of problem recognition (Leigh & Clark, 2018). There is evidence to suggest parents become a less central figure in help-seeking as children move into adolescence 145 and early adulthood (Ben-David et al., 2019; Boydell et al, 2013). There is also evidence supporting the idea that parents continue to play a crucial role in help-seeking for adolescents (MacDonald et al., 2021). It is important to note that all participants in the current study were highly involved and the key driver in the help-seeking process, including those who were seeking help for their adolescent children. It is possible that, in the current study, there were factors that mitigated some of the barriers identified in mental health problem recognition and seeking and accessing mental health services during adolescence. When determining if an adolescent seeks help, trust has been identified as potentially more influential than the need for help itself (Barker, 2007). For adolescents, trust in help providers (e.g. parents, other adults, peers, and institutions) influences adolescents’ perceptions of how helpful the social support will be, and whether or not adolescents will rely on the social support (Barker, 2007). As discussed, mental health literacy (Fearing, 2024; MacDonald et al., 2021; Reardon et al., 2017; Woodgate et al., 2023), and stigma and attitudes about mental health (Clark et al., 2018; Reardon et al., 2017; Zerr & Pina, 2014) can be facilitators or barriers to help-seeking. Many parents in the current study had high levels of mental health literacy, were able to enhance their mental health literacy, and reported having positive attitudes towards mental health and mental health care. Parents’ knowledge and attitudes about mental health may have fostered adolescents’ trust in their parents. Some parents also described parenting philosophies that emphasize attachment and connection with their child. Although parents’ recognition of anxiety as problematic involved parents’ observations, in the current study, parents also described how their children discussed their concerns and distress with parents. This communication helped parents better understand their child’s distress, and gain insight into the extent of the impact of anxiety on functioning. Parental mental health 146 literacy, beliefs and attitudes about mental health, parenting values, and children communicating about their anxiety with their parents, suggest that participants in this study had established safe and trusting relationships with their children, and were perceived by their children as a valuable source of support, regardless of the child’s age. Understanding parents’ emotional experience of seeking mental health services for their children is an important, but often ignored, aspect of the help-seeking. Parents described feeling unsupported and alone throughout the process, despite having social supports. They made financial and employment sacrifices, and from their perspective, the burden to seek help and advocate for their children was disproportionately placed on mothers. To the detriment of their physical health and well-being, some parents ignored their own mental health out of a necessity to prioritize their child’s needs. The connection between parents’ mental health and their child’s mental health is not a new concept, as discussed below. However, this study shows that support for parents’ mental health has not permeated mental health care for children in a way that parents find effective. When parent-support services were offered, the services typically focused on parenting and not on parents’ emotional needs. Although parents were mixed in their opinion of the helpfulness of parent-support services, there was agreement that these services did not sufficiently meet parents’ mental health needs. Parents face difficulties with receiving a service or treatment intervention that adequately matches their child’s mental health needs. In other words, the fit and effectiveness of mental health services, in terms of decreasing symptoms and functional impairment, is important. When parents are reaching out for mental health services, the shift in balance has already occurred and they, or another important adult involved in the child’s life (e.g., teacher), have already identified anxiety symptoms as problematic. Furthermore, the severity of the anxiety is already 147 outweighing the interventions and supports in place. Parents seeking mental health services for their child typically described needing help tailoring interventions to their specific situation, so prevention interventions such as the parenting programs, though helpful, were reported to be insufficient. Much of the discussion about the therapeutic process focused on receiving therapy. Most parents’ experiences with assessment and diagnosis of their child’s anxiety were informal or nonexistent. The lack of focus on assessment in the therapeutic process and mental health professionals’ poor diagnostic skills led to unsatisfactory treatment planning, which was reflected by perceived poor treatment fit. This lack of fit then led to parents to being redirected to other mental health services and cycling back into an earlier phase of help-seeking. This was especially true for children with a comorbidity. Consider Addison, whose initial family doctor dismissed her concerns several times before eventually referring her son to services for anxiety. When working with a new family doctor, her son was quickly referred for an ASD assessment and questioned why this was not recommended earlier. The inability of medical or mental health professionals to accurately assess the child’s symptoms contributed to getting “stuck in the hamster wheel.” Implications for Practice and Policy Systemic barriers have been well documented in the literature (see Collins et al., 2004; Ma et al., 2023; Reardon et al., 2017) and have been discussed in this study. Due to the fragmented nature of the mental health system and the various disconnected settings in which services can be accessed, parents called for better interdisciplinary collaboration. As primary care providers are often an initial point of contact for mental health services, it is crucial that primary care providers are well informed about mental health concerns, how to assess them, 148 available resources, and effective treatments. Other frontline professionals (e.g., school staff, after-school care workers) should also be well informed about reliable information sources and resources. When professionals, who are often the initial contact point for mental health services, are well informed and collaborate with families, the help-seeking process is facilitated and possibly expedited, as was the case for Sarah. The help-seeking process was not efficient for most families, and parents experienced avoidable redirection to other services. This redirection was due, in part, to the presenting problem being inaccurately identified or not identified in full. One way to reduce the number of service redirections is to focus on improving assessments and referrals to services that are targeted enough and of good fit for the family. Parents also emphasized the importance of the fit of the therapeutic approach and providers’ therapeutic style with the child and parent. In the extant literature, there is a recognition of parents’ desire for collaboration with knowledgeable trained professionals and active engagement in the child’s mental health treatment. Mental health providers working with children should consider how to work collaboratively with parents throughout the therapeutic process. This collaboration may include adapting and tailoring treatment while maintaining the integrity of the therapeutic approach. Parents have expressed a desire to enhance the mental health literacy of both parents of young children and school staff. Although informational resources are available for child and youth mental health, parents are not always informed about how or where to access this information. Efforts to make this information universally available are vital. Some parents have suggested modelling the delivery of child and youth mental health information after the delivery of information about developmental milestones and health care for infants. Parents believe this 149 information delivery would help alert parents to early symptoms of mental health concerns and facilitate early identification and early intervention. Several parents expressed the desire for human support during the help-seeking process to navigate resources, barriers, and service options. Though parents found online information helpful, a human connection was highlighted as especially desirable. Having a knowledgeable and trusted person dedicated to helping navigate the system and do the legwork would help ease some of the burden parents feel during the help-seeking process. It would also help address some aspects of parents’ emotional experiences of the help-seeking process, including feeling alone, lost, and overwhelmed. Limitations of the Present Study Limitations of the study include the lack of demographic and cultural diversity among participants, which are known variables impacting service utilization. Participation bias was likely. A desire to advocate may have motivated parents’ participation in this study. This desire likely led to a sample of parents with higher levels of knowledge, skills, and confidence to advocate. All participants had sought and received some form of professional mental health help for their child. Participation from parents who had not utilized services would have contributed to the thickness of description when identifying the theory. Although targeted attempts were made to connect to parents of diverse backgrounds and parents in areas where children’s emotional health was rated lower, and advertising took place in locations targeting the general public as well as more targeted locations, such as care providers offices, they were ultimately unsuccessful. The lack of broad participation reflects findings in the extant literature about rates of service use varying across cultural groups (Alegría et al., 2012; Brice et al., 2015). It also emphasizes the need for research on individuals with diverse racial, 150 ethnic, and immigration backgrounds. Those who are less likely to seek services face different barriers and may have different beliefs about mental health and mental health services. Those variables may also impact participation in a study examining a personal and potentially stigmatized topic. It is possible that the depth and variation of concepts explored in the study may have been enhanced with the inclusion of more diverse individuals. Not all parents participated in the follow-up. Those who indicated why they were unable to participate cited lack of time and high levels of stress due to family changes. Whether these stressors are related to the impact of help-seeking or the ongoing stress that families with a child with mental health concerns face is unknown. Strengths of the Present Study The grounded theory generated in this study contributes to addressing gaps in the literature. This study corroborates findings about gaps between need and provision of mental health services, and indicates the need for further work from stakeholders to address systemic barriers that parents face when seeking and utilizing mental health services. Although many frameworks and models of help-seeking for mental health, more broadly, exist, the theory that emerged from the present study provides a cohesive understanding of parents’ help-seeking process for the most common mental health concern, anxiety. The theory also underscores the emotional impact of parents’ experience as they seek professional services for their child with anxiety. Movement through the phases of the help-seeking process are explained by integrating the barriers encountered, the supports accessed, and the sociocontextual factors influencing the process. The theory acknowledges and incorporates broader conditions when discussing the various contextual systems directly and indirectly affecting the child at each phase of the help-seeking process. These broader conditions include the systemic barriers that parents encountered 151 and how parents’ mesosystems (e.g., family, work, and social or community environments) impact help-seeking (e.g., access to benefits, flexibility to arrange time off, social connections to facilitate obtaining services). The discussion of the impact of COVID on mental health, service utilization, and service delivery also reflects the broader conditions of the help-seeking process. This study lends further evidence to the notion that help-seeking for parents of children with mental health concerns is complex and dynamic. It also contributes to the extant literature by further advancing theories of parental help-seeking. Specifically, the findings elaborate on the role of advocacy and mental health literacy in the help-seeking process for parents of children with anxiety, and how these factors explain how families progress through the phases of the help-seeking process. The complexity of the help-seeking process is further illuminated by situating the grounded theory within the PPCT model of human development (Bronfenbrenner & Morris, 1998, 2006). The discussion of the grounded theory within a PPCT context helps to conceptualize the synergistic effect contextual factors and environments, personal characteristics of each the parent and the child, and barriers and facilitators may have on the help-seeking process for parents. The grounded theory that emerged from the current study is also discussed within the framework of the TTM (J. O. Prochaska, 2008; J. O. Prochaska & Prochaska, 2011) to highlight that psychological readiness for behavioural change can be understood to be part of the help-seeking process and influence the sometime circuitous progression through the phases of the help-seeking process. Another strength of this study was the effort made to increase theoretical sensitivity. In addition to the use of critical friends and reflective journalling, I sought differing perspectives, theories outside of my clinical orientation and the help-seeking literature, and informal 152 discussions about the topic with professionals outside of the mental health field to expand, contradict, and verify my conceptualizations of the data and findings. Parents were invested in participating in the study and many found it meaningful. This study not only contributes to the generation of knowledge in the field of mental health, it also provided value to the participants. Participation in the present study allowed parents to reflect on and share their experiences and continue their advocacy work to improve service access for families with children with anxiety. Future Directions Filling Gaps in the Literature The literature highlights the need for research on individuals with diverse racial, ethnic, and immigration backgrounds. As the parents participating in the study were typically well educated and well resourced, it is important to explore the specific needs of people with diverse backgrounds including those with different sociocultural backgrounds, varying levels of stigma toward mental health, lower levels of mental health literacy, more barriers to resources, and less familiarity with advocacy. This need for diversity also includes research exploring fathers’ help-seeking, as there is evidence that fathers and mothers have different help-seeking preferences (Sawrikar at al., 2024). Efforts to simplify or facilitate the seeking of information for parents of all backgrounds would contribute to parents’ advocacy and involvement in decisions about services for their child. When considering the transferability of the findings from the current study to older adolescents, it would be prudent to reflect on how trust, quality of the parent-child relationship, nature of the youth’s mental health concerns, mental health literacy and stigma may impact the role of parents in the help-seeking process. Adolescents who experience more stigma, hold 153 beliefs that minimize mental health concerns, experience higher than developmentally typical levels of public self-consciousness, lack a trusting relationship with their parents, or have limited access to a knowledgeable trusted parent who can help direct them to services or advocate on their behalf may be less likely to rely on their parent to help with problem recognition and help-seeking. Given the developmental changes in adolescence and mixed findings about the role of parents in youth accessing mental health care, more research exploring how the role of parents and the help-seeking process for parents of children with anxiety may change across developmental stages is warranted. All participants in the current study had accessed services for their child and were still engaged with mental health services to varying degrees at the time of the interviews. Gaining a better understanding of parents’ experiences and processes at the beginning and end points of pathways to care would be fruitful. The experiences and processes of parents or caregivers who have contemplated seeking services but have not initiated services would provide valuable insight into the gap between mental health service need and utilization. For families who have sought professional mental health services, understanding how and why parents terminate services for their children with anxiety may highlight service shortfalls as well as what contributes to treatment satisfaction and effective professional mental health services. Waddell et al. (2020) argued that comprehensive population monitoring of determinants, status, and service use is essential for better meeting the needs of children with mental health concerns. Furthering knowledge about the beginning and end points of the help-seeking process may help inform policy initiatives to improve children’s mental health. 154 The Need for Practice-Based Implementation Research The gap between mental health service need and mental health service utilization has been well established and investigated comprehensively in the literature. However, as indicated by this study, this gap remains. Some key areas would benefit from further exploration. Because of the previously discussed implications for practice and policy, it would be valuable for future research to focus on practice-based implementation research. Some participants emphasized a discrepancy between the provincial mental health plan and their lived experience of seeking and accessing mental health services. Further investigation of parents’ experiences of mental health policy implementation would help determine more about the gap between research, practice, and implementation. In addition, further research is needed to better understand how mental health providers, especially frontline providers, informally and formally assesses and diagnose children’s mental health conditions. Exploring their training needs in this area may also be of benefit. Because the findings suggest that enhancing mental health literacy and advocacy are key to the help-seeking process, and because parents have emphasized the need and desire for easy access to information about children’s mental health and ways to help children, more research is needed about effectively meeting these identified needs of parents. Efforts to explore ways to enhance the mental health literacy of parents of all backgrounds, facilitate parents’ navigation of the systems offering professional mental health services, and create a more streamlined entry to mental health services would be valuable. The concept of supporting parents to benefit the child and family unit is not new. Peer-based support for parents has been researched (Hoagwood et al., 2008; Hoagwood et al., 2018; Olin et al., 2010), but participants’ experiences indicate that these 155 types of services, though available, are not reaching all parents in need. More research is needed to further promote and universally integrate these parent-support services into mental health care. This study focused on accessing mental health services, which includes a range of psychosocial and psychiatric treatments. Parents were able to access some type of mental health services, and some spoke about the importance of evidence-based services. Parents also emphasized the importance of the fit of the therapeutic approach and providers’ therapeutic style with the child and parent in the perceived effectiveness of the treatment. Research demonstrates that evidence-supported treatments, though not the only services leading to improved outcomes, maximize the likelihood of improvement (Kendall & Frank, 2018). Given that service use is often operationalized broadly in research to include a variety of professional and nonprofessional services, future research could focus more specifically on parents seeking evidence-based or evidence-supported treatment for anxiety. Conclusion This grounded theory study revealed a five-phase, nonlinear help-seeking process for parents of children with anxiety. The theory suggests that advocacy and mental health literacy influence and are influenced by how parents navigate and overcome barriers when seeking professional mental health services for their children, while considering interactions between the context of the child, parent, family, school, community, and greater sociocultural environments and how they shape the help-seeking process. This understanding also points to how the barriers that have been acknowledged in the literature and taken into consideration in mental health plans by government agencies have not yet been adequately addressed in practice, as illustrated by the convoluted journeys described by participants and the sentiment of the help-seeking process being akin to getting “stuck in a hamster wheel.” 156 Parents with high levels of education, skills, and resources are struggling to seek and obtain effective mental health services for children with anxiety, the most common mental health concern. The process is filled with challenges, due in part to a disjointed mental health system that is closely intertwined with the health care and school systems. Parents feel lost, overwhelmed, and unsupported, despite having social supports available. 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European Child & Adolescent Psychiatry, 12(4), 153–161. https://doi.org/10.1007/s00787-003-0322-6 198 Appendices Appendix A: Interview Guide As you know, I am conducting research on how parents engage in help-seeking for their children with anxiety. Before we get started, I’d like to hear about you and your family. Potential prompts: • Who lives in the family home? • How many children do you have? • Can you tell me more about ________ [child identified as having anxiety]? I’d like you to think back over the last few months. What was it like for you to seek out psychological services for your child? Additional prompts, if needed: • What led you to explore services for your child? • Tell me about your decision to access formal psychological services. • Can you tell me about your thought process? • Was there anything that helped or hindered this process for you? • Was there anyone or anything that influenced your decision? • What do you wish could have been different about this process? Are there any other comments or thoughts you would like to share on this topic? Thank you for participating and taking the time to share your experiences with me. 199 Appendix B: Screening Questionnaire Date: __________________________ Name: _________________________________ Relation to the child: ______________________________ What is your child’s date of birth: _____________________________ (____ yrs, ____months) Where is your place of birth: ______________________________ Are you primarily responsible for the care and upbringing of a child? Y N Are you fluent in written and spoken English? Y N Has your child been diagnosed with a mental health disorder(s)? Y N If yes, what is the primary disorder? _______________________________________ Has your child been diagnosed with a learning disorder? Y N neurodevelopmental disorder? Y N Does your child experience or exhibit signs of anxiety? Y N Has your child been diagnosed with an anxiety disorder by a trained professional? Y N ______________________________ (type of professional) Have you sought psychological treatment for your child’s anxiety in the last 6 months? Y N Have you/your child engaged in psychological treatment for his/her anxiety? Y N What type: ____________________________ (e.g., talk therapy, play therapy, CBT, etc.) 200 Appendix C: List of Community and Online Resources Organizations and Websites • Here to Help: https://www.heretohelp.bc.ca/ • Kelty Mental Health Resource Centre https://keltymentalhealth.ca/ • Family Smart – Parent in Residence https://familysmart.ca/program/parent-youth-in-residence/ • AboutKidsHealth https://www.aboutkidshealth.ca/mentalhealth • Anxiety Canada https://anxietycanada.com/ • Parent Support Services Society of BC https://www.parentsupportbc.ca/ Counselling Services Child and Youth Mental Health Services: http://www.vch.ca/your-care/mental-health-substance-use/children-youth-mental-health-services Free mental health services for children 18yrs and under in locations around BC Scarfe UBC Counselling Clinic – 604-827-1523 https://ecps.educ.ubc.ca/counselling-centres/scarfe-free-counselling-clinic/ Free counselling provided by counselling psychology graduate students, supervised by a Registered Psychologist. Clinic runs from September to April. UBC Psychology Clinic – 604-822-3005 http://clinic.psych.ubc.ca/ Counselling services for adults provided by doctoral student interns, supervised by registered psychologists. Sliding scale: $15-$50/hour for individual therapy. Simon Fraser University Burnaby Clinical Psychology Centre – 778-782-4720 - https://www.sfu.ca/psychology/clinical-psychology-centre.html Counselling for adults, children and youth provided by supervised graduate students in clinical psychology. Services are offered on a sliding scale. Family Services of Greater Vancouver, Counselling Program - 604-874-2938 www.fsgv.ca/find-the-support-you-need/counselling/ Counselling fees based on household income. Master-level therapists. Offices in Vancouver, Richmond, Burnaby, New Westminster and Surrey. Adler Centre - Counselling Clinic - 604-742-1818 http://www.adlercentre.ca/clinic.html Services offered based on a sliding scale. Counselling provided by counselling psychology graduate students at the Adler Centre, supervised by an experienced clinician. 201 Appendix D: Demographic Questionnaire Which city/town do you live in? __________________________  prefer not to answer What is your age, in years? _____________  prefer not to answer Please specify your ethnicity: _________________  prefer not to answer Please specify your current gender identity: _______________  prefer not to answer Please specify your current relationship status? _______________  prefer not to answer What is the highest level of education you have completed?  some high school  high school  some college/university  Bachelor’s degree  Master’s degree  Ph.D. or higher  vocational or trade school  prefer not to answer What is your occupation? ______________________  prefer not to answer  full-time  part-time  casual  other How many children live with you?  prefer not to answer _____ biological _____ adopted _____ foster _____ step-child(ren) What are their ages, in years? ___________________________________ Which languages are you fluent in? _________________________________________________ Please specify your estimated combined annual household income  less than $20,000  $20,000 to $34,999  $35,000 to $49,999  $50,000 to $74,999  $75,000 to $99,999  $100,000 to $149,000  $150,000 and over  prefer not to answer 202 Appendix E: Parent Consent Form Faculty of Education Vancouver Campus Educational & Counselling Psychology, and Special Education 2125 Main Mall Vancouver, BC, Canada V6T 1Z4 www.ecps.educ.ubc.a Christine’s Dissertation (H19-03574): Help-Seeking Process Study: Parent Consent, V2, 23Dec2020 Page 1 of 5 THE HELP-SEEKING PROCESS FOR PARENTS OF CHILREN WITH ANXIETY: A GROUNDED THEORY “Help-Seeking Process Study”: Parent Consent for Parent Involvement Principal Investigator: Laurie Ford, PhD, Department of Educational & Counselling Psychology & Special Education, Co-Investigators: Christine M. Yu, PhD Candidate, Department of Educational & Counselling Psychology & Special Education, Richard Young, EdD, R Psych, Department of Educational & Counselling Psychology & Special Education, Project Office: Dear Parent/Guardian, Please read the following letter carefully. This is a request for you to take part in the study that we are doing. If after reading this letter, you would like to take part, please sign one copy and return to the researcher in the prepaid postage envelope provided or scan the signed copy and return by email to . Keep the other copy for your records. This study is the doctoral dissertation study for the student co-investigator, Ms. Christine Yu. What is the purpose of the study? • To gain an understanding of the process parents engage in when seeking help for their children with anxiety. What is involved in this study? Screening Process Taking part in the study means that you: • Are a primary caregiver of a child under the age of 18-years • Have been living in Canada for at least the last 5-years • Have a primary concern of having a child struggling with anxiety • Have sought out psychological services for childhood anxiety in the past six months • Are fluent in English (written and spoken) • Based on the screening questionnaire results, you may not be selected to be part of this study. • Need access to the internet and a computer or mobile device in a private location 203 Faculty of Education Vancouver Campus Educational & Counselling Psychology, and Special Education 2125 Main Mall Vancouver, BC, Canada V6T 1Z4 www.ecps.educ.ubc.a Christine’s Dissertation (H19-03574): Help-Seeking Process Study: Parent Consent, V2, 23Dec2020 Page 2 of 5 Time commitment • Taking part in the study means that you are willing to complete different parts of this study: a brief questionnaire, an online interview and 1 to 2 follow up sessions. • These parts of the study will happen at a mutually convenient date and time • You will be asked to meet with the researcher for an online interview using Zoom, a video-conferencing service (90 to 120 minutes) • After this interview, you will be asked to be contacted at a later stage for follow up questions, if any (15 to 30 minutes). • At the end of the study, you will be asked to provide feedback on the researcher’s summary (30 to 45 minutes) Parent questions and interviews • Taking part in this part of the study means that you will be asked to complete a brief (1-page) demographic questionnaire • You will complete a parent interview on Zoom about your experience of and thoughts about seeking psychological services for your child regarding anxiety (90 to 120 minutes). • With permission, these interviews will be video recorded for research purposes. If you are not comfortable with the interview being video recorded, the interview may be audio recorded instead. If you are not comfortable with any question, you may skip the question. • You are always welcome to ask any questions and can withdraw from the study at any time. • Please see the attached guidelines for best practices using Zoom Are there any risks to the research? • There is a potential risk in taking part in this study • Due to the sensitive nature of the topic, it is possible that participants may experience emotional distress during the interview. Responsibility to reports abuse and neglect • As is true of all professionals who work with children, if, while working with the parent during this study, the researchers becomes aware of any abuse or neglect of the child they must report their concerns to the appropriate authorities, and any abuse or neglect that was video- or audio-recorded can be used as evidence. • While we view this as a rare occurrence in a study like this, we must inform you of the limits of our confidentiality. Additional support available • A list of community resources will be provided if you are interested in or need available community or online supports. • If your child requires immediate assistance due to serious distress (e.g., in danger of harming themselves), you can call the crisis intervention line to determine the best appropriate action and available supports within their community (Youth Crisis Line: 604-872-3311) or visit your local emergency hospital. Taking part in this study is voluntary. You have the right to withdraw from the study at any time and you have the right to not answer any of the questions. 204 Faculty of Education Vancouver Campus Educational & Counselling Psychology, and Special Education 2125 Main Mall Vancouver, BC, Canada V6T 1Z4 www.ecps.educ.ubc.a Christine’s Dissertation (H19-03574): Help-Seeking Process Study: Parent Consent, V2, 23Dec2020 Page 3 of 5 Will my confidentiality be protected? • The information you give us is confidential. • Any files we store (such as interview transcripts or questionnaires) will not have names on the documents, only a code which matches to a list stored separately. • Video recordings (or audio recordings) of the interviews will be recorded to the researcher’s computer and will be encrypted and password protected. Recordings will be destroyed 5-years after the study has completed. • No individual information will be reported, and no participant will be listed by name in any reports about the study. • The only people who will have access to the information you give us are the researchers working on this project. • The only situation where confidentiality is not protected is in the case of perceived abuse or neglect as highlighted above. • Reports about the study or data from the study may be made publicly available (i.e. anyone on the internet can access the report), for research purposes (e.g., presentations or publications) but your individual information, name, and names of your family members will not be included. • Once reports or data are made publicly available, they will not be able to be removed. We acknowledge that this may pose an additional risk to taking part in this study but again no person is identified by name or location. What are the benefits of the research? • By participating in this study, you will have the opportunity to reflect on and share your experience. • If interested, you will receive a brief summary of the study findings. • As a thank you for the time spent in this study, you will receive a $20 electronic gift card. • If you choose to withdraw from the study at any time, you will receive a gift card to thank you for the time you spend in the study. Who do I contact for more information about the study? • If you have any questions or would like more information about this project you may contact Christine or Dr. Ford at the email or phone number on the first page. Who do I contact for concerns about the rights of research participants? • If you have any concerns about your rights as a research participant and/or your experiences while participating in this study, contact the Research Participant Complaint Line in the UBC Office of Research Ethics at or if long distance e-mail or call toll free 205 Faculty of Education Vancouver Campus Educational & Counselling Psychology, and Special Education 2125 Main Mall Vancouver, BC, Canada V6T 1Z4 www.ecps.educ.ubc.a Christine’s Dissertation (H19-03574): Help-Seeking Process Study: Parent Consent, V2, 23Dec2020 Page 4 of 5 Zoom Best Practices for Participants To help protect your identity and increase the protection of your personal information, please: o Do not share the meeting link with anyone or post to social media or any other public outlet. o Do not use your real name when signing on. Use a different name or a nickname when signing on. o Keep your camera and microphone on during the interview. 206 Faculty of Education Vancouver Campus Educational & Counselling Psychology, and Special Education 2125 Main Mall Vancouver, BC, Canada V6T 1Z4 www.ecps.educ.ubc.a Christine’s Dissertation (H19-03574): Help-Seeking Process Study: Parent Consent, V2, 23Dec2020 Page 5 of 5 THE HELP-SEEKING PROCESS FOR PARENTS OF CHILREN WITH ANXIETY: A GROUNDED THEORY “Help-Seeking Process Study” Consent to Participate in this Research Project Taking part in this project is voluntary and you may refuse to take part or withdraw from the study at any time. Your signature below indicates that you consent to participate in this research project. When you sign below it also means that you have received a copy of this consent form (pages 1, 2, 3, & 4) for your own records. I. Willingness for your involvement in the study Please check: ____ Yes, I agree that I am willing to take part in interviews and complete a questionnaire. Parent’s/Guardian’s signature (please sign) Parent’s/Guardian’s name (please print your name) Your Phone or Email Date
Thesis/Dissertation
eng
Counselling Psychology
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Ford, Laurie
Young, Richard A. (Richard Anthony), 1942-
The help-seeking process for parents of children with anxiety : a grounded theory
Text