https://orcid.org/0000-0002-5214-1943
ABSTRACT
Understanding adolescents’ reasons for being reluctant to seek mental health help is important to improve early identification, for which schools represent important contexts. Subgroups may have unique reasons, thus requiring different strategies to overcome reluctance. Latent class analysis was conducted to identify classes of females and males based on their reasons for being reluctant to seek help from school adults. We used cross-sectional survey data collected in 2018–2019 from 70,794 students attending 136 Canadian secondary schools. The most frequently reported reason was preferring to handle problems themselves. Five-class solutions resulted, with four similar classes in males and females: “low reluctance”, “go alone”, “stigma”, and a class with high probabilities for all provided reasons. A “wouldn’t know who” (to approach) class in females and a “no one I would feel comfortable talking to” class in males also resulted. Students with depression and anxiety had higher odds of belonging to all reluctant classes relative to the low reluctance class. Help seeking reluctancy in school contexts remains common, particularly among students that may be most in need of support. Many adolescents that prefer to handle problems themselves have concerns about confidentiality and perceptions that school adults would not be able to help.
1. Introduction
The reluctance of young people to seek help for their mental health has been recognized as a key barrier to effective early identification and intervention efforts (Rickwood et al., Citation2007). Over the past decade, widespread mental health awareness and stigma-reduction campaigns have aimed to improve help seeking. While some evidence of increased service use suggests these strategies may have been effective, there continues to be a failure to reach young people most in need of mental health support with timely and appropriate care (Olfson et al., Citation2015; Ontario Child Health Study, Citation2017). It is important to acknowledge that many barriers to accessing support are outside of young people’s control (e.g., personnel and service availability, wait times, costs, transportation) (Radez et al., Citation2021; Velasco et al., Citation2020), and further, the responsibility should not lie solely with them to reach out, particularly when experiencing distress. Nonetheless, young people can take an active role in seeking help, especially with increasing age, and thus, contemporary research to understand adolescents’ concerns regarding seeking mental health help in key contexts may help inform policy and practice (Radez et al., Citation2021). Subgroups of adolescents may have unique concerns, thus requiring different and targeted strategies to overcome reluctance.
Experts point to the need to meet young people where they are; schools offer incomparable access, as the setting where almost all children and adolescents spend the majority of their weekday waking hours. Schools are often the context where mental health concerns are first recognized (Rowling, Citation2012; Velasco et al., Citation2020). They can act as universal access points to mental health support, with adults in the school environment part of a referral pathway, particularly for students who may not otherwise have access to family or community supports (Fazel et al., Citation2014; Rickwood et al., Citation2007; Veugelers & Schwartz, Citation2010). However, despite schools being identified as key contexts for the prevention and early identification and intervention for mental health concerns, and more attention being devoted to school mental health, we previously found that over half of secondary students were hesitant to seek help from school adults (Doan et al., Citation2020). Concerningly, help seeking reluctancy was more likely in students that felt unable to talk to their family or friends about problems (Doan et al., Citation2020). Systematic reviews have identified the greatest reasons for reluctance to seek help among youth include stigma and the fear of embarrassment, poor mental health literacy, negative family beliefs toward mental health services and treatment, a preference to be self-reliant, and concerns about confidentiality breaches when engaging with a mental health professional and/or an adult at school (Gulliver et al., Citation2010; Radez et al., Citation2021; Velasco et al., Citation2020).
Addressing help seeking reluctancy may require gender-specific strategies. It is often speculated that girls/women possess more positive help-seeking attitudes than boys/men, but empirical support is limited (Garland & Zigler, Citation1994; MacLean et al., Citation2013; Velasco et al., Citation2020). One theory is that adolescent girls have a greater understanding of mental health compared to boys, which may lead girls to seek help and disclose mental health concerns more frequently (Lynch et al., Citation2018; MacLean et al., Citation2013). In addition, help-seeking is theorized as a dependent interpersonal behaviour, conventionally associated with feminine stereotypes (Garland & Zigler, Citation1994). Masculine gender norms may lead boys/men to view help-seeking as a threat to their personal sovereignty and identity, especially as social pressures increase during adolescence (Garland & Zigler, Citation1994; MacLean et al., Citation2013).
While understanding reluctance to seek help among all students is valuable, in case they do experience a need for mental health support, identifying reasons for help seeking reluctancy is of particular importance among adolescents experiencing or at risk of mental health problems or disorders. Previous evidence suggests that individuals most in need of mental health support are often the most averse to help-seeking (Doan et al., Citation2020; Rickwood et al., Citation2007; Saunders et al., Citation1994; Velasco et al., Citation2020). Adolescents experiencing mental ill-health may have different reasons for help seeking reluctancy than their counterparts speculating about hypotheticalcircumstances. They may have sought help before, or considered doing so, and prior experiences are a key predictor of help seeking intention (Velasco et al., Citation2020). Also, internalized stigma or fear of stigma may be more pertinent. Further, symptoms of mental disorders, such as discomfort speaking to others, feelings of guilt, hopelessness, and worthlessness, and diminished cognitive functioning, may contribute to reluctance (Velasco et al., Citation2020).
This study aimed to better understand secondary school students’ reasons for being reluctant to seek help for mental health concerns in the school context. We explored classes of students based on reasons for help seeking reluctancy and whether these classes differed between males and females. As a priority subgroup, potentially in greater need of mental health support, we also investigated reluctancy class membership based on the presence of clinically-relevant anxiety and depression scores, two of the most commonly diagnosed mental disorders among young people (World Health Organization, Citation2021).
2. Methods
2.1. Design and participants
We used cross-sectional student-level data from 74,501 (84.2% response rate) students attending a convenience sample of 136 Canadian secondary schools that participated in the Cannabis, Obesity, Mental health, Physical activity, Alcohol, Smoking, and Sedentary behaviour (COMPASS) Study during the 2018–2019 school year (Leatherdale et al., Citation2014). Active-information passive-consent parental permission protocols were used, with all students attending participating schools and not withdrawn by a parent/guardian eligible to participate. Students completed a paper-and-pencil questionnaire during one classroom period. All procedures received ethics approval from the University of Waterloo (ORE#30118), Brock University (REB#18–099), CIUSSS de la Capitale-Nationale—Université Laval (#MP-13-2017–1264), and participating school boards. Additional details regarding COMPASS study methods can be found online (www.compass.uwaterloo.ca).
2.2. Measures
The current study examined measures of help-seeking reluctancy, gender, anxiety, and depression from the 2018–19 COMPASS student questionnaire. The COMPASS student questionnaire is a self-administered, anonymous, pencil-and-paper questionnaire completed by students during a 40-minute class period. Detailed information on questionnaire development and modifications (Patte, Bredin, Henderson, Elton-Marshall, Faulkner, Sabiston, Battista, Ferro et al., Citation2017; Patte, Bredin, Henderson, Elton-Marshall, Faulkner, Sabiston, Battista, & Leatherdale, Citation2017; Reel et al., Citation2019) and procedures for the questionnaire administration are available (Thompson-Haile et al., Citation2013). Initial conceptualization of the COMPASS mental health measures was informed by past and ongoing school-based youth and mental health research, national and provincial strategic priorities, school programming, and consultations with researchers, clinicians, school stakeholders, and public health partners, in order to reflect both science- and practice-based concerns. The draft questionnaire was pilot tested in a sample of purposefully selected schools participating in COMPASS (N = 8,344 grade 9 to 12 students attending 14 secondary schools), followed by focus groups with students in one of these schools to ensure appropriateness, comprehension, and comprehensiveness of the questionnaire (Patte, Bredin, Henderson, Elton-Marshall, Faulkner, Sabiston, Battista, Ferro et al., Citation2017, Patte, Bredin, Henderson, Elton-Marshall, Faulkner, Sabiston, Battista, & Leatherdale, Citation2017).
Help Seeking Reluctancy. Students were asked “If you had concerns regarding your mental health, are there any reasons why you wouldn’t talk to an adult at school (e.g., a school social worker, child and youth worker, counsellor, psychologist, nurse, teacher, or other staff person)? (Mark all that apply)”. Students were provided with seven response options and were asked to select all applicable options. Students that indicated the response option “I would have no problem talking to an adult at school about my mental health” were considered to not be reluctant to seek help. Six provided response options for reasons for being reluctant to seek help included: “worried about what others would think of me (e.g., I’d be too embarrassed)”, “Lack of trust in these people—word would get out”, “Prefer to handle problems myself”, “Don’t think these people would be able to help”, “Wouldn’t know who to approach”, and “There is no one I feel comfortable talking to”. The measure was developed based on similar measures used in comparable youth studies (e.g., Georgiandes, Citation2015) and modified based on pilot-testing to determine appropriateness of response options for the COMPASS study population (Patte, Bredin, Henderson, Elton-Marshall, Faulkner, Sabiston, Battista, Ferro et al., Citation2017, Patte, Bredin, Henderson, Elton-Marshall, Faulkner, Sabiston, Battista, & Leatherdale, Citation2017). Pilot testing supported comprehension and relevance of the measure and response options (Patte, Bredin, Henderson, Elton-Marshall, Faulkner, Sabiston, Battista, & Leatherdale, Citation2017).
Gender. The COMPASS student questionnaire in 2018–2019 asked students “Are you female or male?” with the response options “female” and “male”. While the dichotomous options and terms female and male can be considered biological sex, the question did not specify sex or gender. It is not clear how students interpreted the question; it may elicit gender identity (Johnson et al., Citation2009). Acknowledging the limitations and importance of within-group variation, we have chosen to use the term gender given the sociocultural focus of this study (Johnson et al., Citation2009).
Depression was assessed using the 10-item Center for Epidemiologic Studies Depression scale Revised (CESD-10) (Andresen et al., Citation1994). Items ask about the frequency of depressive symptoms experienced within the last 7 days on a 4-point Likert scale, and were scored from 0–3 and summed.
Anxiety was measured using the 7-item Generalized Anxiety Disorder scale (GAD-7) (Spitzer et al., Citation2006). Items ask how frequently symptoms of anxiety were experienced in the last 2 weeks on a 4-point Likert scale. Responses were scored 0–3 respectively and summed.
A threshold of 10 or higher was used to indicate clinically-relevant depression and anxiety on the CESD-10 and GAD-7, respectively. Both scales have demonstrated robust validity in adolescent populations in North America (Canada, United States) and Europe (France, Germany, Finland) (Andresen et al., Citation1994; Bradley et al., Citation2010; Cartierre et al., Citation2011; Haroz et al., Citation2014; Löwe et al., Citation2008; Mossman et al., Citation2017; Tiirikainen et al., Citation2019), including measurement invariance by grade and sex in the COMPASS study (Romano et al., Citation2022).
2.3. Statistical analysis
Students missing values for gender or help-seeking reluctancy were removed, resulting in an analytic sample of 70,794 students. Frequencies of help seeking reluctancy response options in male and female students were calculated and compared using Chi-square tests and Cramer’s V coefficient, given the large sample. Latent Class Analysis (LCA) was performed to identify potential classes of reasons for reluctancy in males and females. LCA is a person-centred mixture modeling approach that identifies distinct subgroups in a population based on an underlying unobserved variable inferred by their patterns of responses to categorical variables (Hagenaars & McCutcheon, Citation2002). The optimal number of classes was determined by several statistical criteria in conjunction with theoretical interpretability (Weller et al., Citation2020). Supplementary Table S1 presents the model fit and diagnostic criteria. Starting with a two-class model, we compared the Bayesian Information Criterion (BIC) and sample size adjusted BIC (SABIC) between the former and latter models with each subsequent addition of a class. We stopped when the fit of the latter models was not better than the previous models. Smaller BIC and SABIC values indicate a relatively better fit to the data. The BIC and SABIC are considered the most reliable fit statistics, particularly in large sample sizes; they reward model parsimony and can be used to compare LCA solutions (Weller et al., Citation2020). Classification certainty of the models was compared based on the entropy measure; higher entropy values indicate greater class separation (Weller et al., Citation2020). Guidelines on class sizes have been relaxed (Weller et al., Citation2020); given the large sample and the conceptual possibility and importance of small high-risk subpopulations for the current study, class prevalence of at least 2% was considered reasonable. A probability cut-off of ≥ 0.5 was used to assign class (Sinha et al., Citation2021). Two researchers (KAP, KB) were initially blinded to independently assign labels to classes and then came to consensus through discussion of any contrasting labels. Finally, logistic regression models examined the odds of belonging to the resultant classes if students had depression and anxiety. Descriptive analyses were conducted in SAS 9.4 and LCA was conducted in Mplus Version 8.
3. Results
The sample characteristics are presented in . Most students identified as White (69.6%), followed by Asian (10.0%), and attended schools in Ontario (40.9%) or Quebec (40.9%). Students were distributed across grades. Scores above the threshold indicating clinically-relevant depression and anxiety symptomatology were reported by 36.0% and 23.7% of students, respectively, and by a higher proportion of females (46.2%, 32.7%) than males (25.8%, 14.6%).
Table 1. Sociodemographic characteristics in a sample of Canadian secondary school students
presents the frequencies of responses to all provided options for help seeking reluctancy by gender. About half of males (53%) and one-third of females (35%) reported they would have no problem talking to an adult at school about their mental health. The most frequently reported reason for reluctancy in both females (36%) and males (26%) was preferring to handle problems themselves, followed by being worried what others would think of them (females 27%, males 16%), and lacking trust in adults at school that word would not get out (females 24%, males 14%). About one-fifth of females reported that there was no one they felt comfortable talking to at school (22%) and another one-fifth reported that they did not think adults at school would be able to help (21%), compared to 12% of males for both reasons. The least frequently reported reason by both females (15%) and males (8%) was not knowing who to approach for help. Males were less likely to indicate each reason for reluctancy than females.
Table 2. Frequencies of reported concerns regarding mental health help seeking at school among secondary school students
presents the results of the LCA, including the class prevalence and item response probabilities for the resultant five classes in both females and males. Assigned class labels for reluctance reasons included “low reluctance”, “go alone”, “wouldn’t know who”, “stigma”, “not comfortable”, and “all reasons”. The most prevalent class in both females and males, with approximately two-thirds of females (67.2%) and three-quarters of males (76.7%), was labelled “low reluctance” given the low item response probabilities on all reasons. The second most prevalent class for both females (18.5%) and males (12.4%) was termed “go alone” based on a low probability for not knowing who to approach and moderate probability for preferring handle problems themselves, as well as lacking trust in these people and not thinking they could help. In females, the third most prevalent class (6.1%) was labelled “wouldn’t know who”; this class did not emerge in males. Both females (4.9%) and males (4.9%) had a “stigma” class, characterized by being “worried about what others would think”. In males only, a “not comfortable” class resulted with a prevalence of 3.8%, defined by feeling there was no one they would feel comfortable talking to. Finally, the least prevalent class in both females (2.2%) and males (3.4%) had high probabilities for all provided reasons for reluctancy.
Table 3. LCA of concerns about seeking help for mental health from school adults among Canadian secondary school students
presents the logistic regression model results. Both males and females with clinically relevant depression and anxiety scores had substantially increased odds of belonging to all four reluctancy classes relative to the “low reluctance” class. The highest odds ratios were for belonging to the “all reasons” and the “go alone” class.
Table 4. Logistic regression model of depression and anxiety predicting mental health help seeking reluctancy class membership among Canadian secondary school students
4. Discussion
Only about half of males and one-third of females reported that they would have no concerns seeking help for their mental health from an adult at school. Five classes of help seeking reluctance resulted in the LCA in both males and females, with four of the five classes comparable across groups. One of the five classes was defined low reluctancy, and comprised about three-quarters of males and two-thirds of females. Students belonging the smallest class were reluctant for all provided reasons, while the remaining three classes highlighted different profiles of reasons for being reluctant to seek help. Concerningly, students with clinically relevant depression and anxiety symptom scores were more likely to belong to all four of the more reluctant classes than the low reluctancy class. The different reluctant classes point to unique strategies to improve help seeking in the school context among adolescents.
The second largest class (“go alone”) in both females and males, and the largest of the more reluctant classes, was defined by knowing where to access support, but preferring to handle problems themselves, as well as perceptions that adults at school would not be able to help and a lack of trust that their concerns would be kept private. This class may partly reflect adolescent developmental tendencies of growing autonomy. While self-management of everyday stressors is not a concern, it is critical to ensure that these adolescents have adequate mental health literacy to recognize when adult support is necessary and that they are willing and able to access help in these situations. The perceived need for mental health support has been shown to be a greater predictor of service use than symptom severity among young people (Kamali et al., Citation2023).
Preferring to handle problems themselves was the most frequently reported reason for reluctancy. The “go alone” class suggests that the drivers of students wanting to handle their problems themselves may be partly related to their concerns about confidentiality and scepticisms about the value of seeing help from school adults. Thus, strategies that may prove valuable to reduce reluctancy in these students include efforts to protect student confidentiality and privacy, and to ensure adolescents understand privacy and confidentiality and their limits, as they pertain to school mental health support. Also, providing positive examples of when seeking help has been effective may help improve student perceptions. Likewise, while we previously found no association between the availability of mental health professionals in schools and student reluctance (Doan et al., Citation2020), increasing awareness of these resources and their qualifications to students appears warranted.
Males and females each also had a unique class; 6% of females belonged to a class indicating they would not know who to approach, whereas among males, 4% belonged to a class defined by there not being anyone at school that they would feel comfortable talking to about their mental health concerns. This unique class in females suggests continued efforts to increase awareness of the availability of school mental health professionals and how to access them are needed. Whereas in males, strategies to improve comfort expressing mental health concerns and normalizing help seeking may be particularly beneficial, as well as ensuring that there are adults available that students would feel comfortable approaching. A recent study declared that more positive help-seeking behaviours are elicited by students when there is a positive and responsive teacher-student relationship in the classroom (Halladay et al., Citation2020). However, while school adults may be readily available to help, their presence in students’ daily lives may also introduce barriers. Students lack anonymity; school adults not only know them but also their peers and potentially family members. Students may worry about changing the way adults view and interact with them after revealing mental health concerns. Thus, for these reasons, it is critical to improve both relationships within the school and access to youth-friendly support outside of the school context.
Mental health stigma remains a concern for some students, with about 5% of males and females belonging to a class defined by reluctancy due to worries about what others would think and potential embarrassment. As discussed, continued efforts to normalize help seeking are needed. Peer-led initiatives show some promise. A recent systematic review on help seeking noted the importance of considering peer interactions (Velasco et al., Citation2020). Many adolescents echo the actions of those close to them, and peers have strong influence over each other, particularly during adolescence, thus being strong enablers of change in the school environment (Velasco et al., Citation2020). As discusssed, ensuring acceptable avenues of support outside of school are readily accessible to adolescents is also important to navigate barriers specific to the school context.
Concerningly, students that may be most in need mental health support—based on depression and anxiety scores—had substantially higher odds of belonging to all help seeking reluctancy classes than the low reluctance class. Early identification and intervention are critical to prevent escalating severity and chronicity of mental health problems and illnesses. Greater reluctancy may partly account for the continued failure to reach populations most in needed of mental health services, despite increases in the number of individuals seeking help (Olfson et al., Citation2015). This greater reluctancy may partly reflect internalized mental health stigma, which can lead to shame and embarrassment (Corrigan & Kosyluk, Citation2014) and may impair help seeking, as young people become more concerned with self-image and confidentiality (Kutcher et al., Citation2016). Additionally, the current experience of having clinically-relevant depression and anxiety symptoms may have enhanced the relevance of concerns regarding help seeking, or students’ awareness of them, as opposed to some students who may have been responding to the question for hypothetical mental health concerns. Finally, the nature of depressive and anxiety disorders themselves (e.g., difficulty talking to others, self-blame, withdrawal) may contribute to reluctancy to seek help (Velasco et al., Citation2020).
Males were more likely than females to report that they would have no concerns seeking help for mental health concerns from an adult at school and were more likely to belong to the low reluctancy class. It is unknown if the gender difference reflects a discrepancy in help seeking reluctancy or if it is an artifact of the measures and differences in the willingness to report the reasons for reluctancy. That is, indicating having no concerns about help seeking may be less vulnerable or easier than reporting the reasons for being reluctant about seeking help for their mental health. The same sociocultural influences that may lead males to be more reluctant to seek help may have contributed to their less frequent reports of concerns about help seeking. However, in a systematic review of help seeking intentions, two studies found females to report more barriers and one study found higher help seeking intentions in males, comparable to our results, although seven other studies reported no gender differences (Velasco et al., Citation2020). Another possible explanation for our results is the higher prevalence of clinically-relevant depression and anxiety symptoms among females, which were associated with higher likelihood of belonging to the more reluctant classes.
4.1. Limitations
Several limitations warrant consideration. As the COMPASS study was not designed to be nationally representative, results may not be generalizable to all Canadian adolescents. Self-report measures, nonparticipation, and missing data may introduce bias if students reluctant to help seeking were more or less likely to participate or respond. However, the full school samples, high response rate (>80%), and the diverse sample of schools (rural and remote to large urban, private and public, etc.) support generalizability. Also, the passive consent protocols and not requiring student names help to preserve anonymity and reduce response bias (Thompson-Haile et al., Citation2013), and are critical for robust youth research related to mental health (Chartier et al., Citation2008). As mentioned, the measure available to us was not specific to sex or gender. It is plausible that students responded according to their biological sex and have a nonbinary and non-cisgender identity. The measure did not provide transgender and gender diverse response options, thus missing key populations for studying barriers to mental health help seeking and necessitating further research. Adolescents may have other reasons for reluctance that were not covered by the provided response options in the closed-form measure. For example, in focus groups for the development of the measure, students suggested family beliefs regarding mental health as a possible response option (Patte, Bredin, Henderson, Elton-Marshall, Faulkner, Sabiston, Battista, & Leatherdale, Citation2017), which has also emerged in previous literature as a key barrier to help seeking (Velasco et al., Citation2020). Further research using qualitative approaches would allow for a more in-depth exploration of reasons for reluctance. It is also important to recognize that our measures assessed perceived comfort with help seeking for potential or hypothetical mental health concerns; actual help seeking behaviours may differ. Similarly, no measures of whether students had or were currently receiving mental health supports or had diagnosed mental illnesses were available.
5. Conclusions
Schools are often identified as a key context for early identification of mental health problems and disorders. However, despite widespread efforts in mental health awareness and stigma reduction, many students remain reluctant to seek help for their mental health from adults at their school. Concerningly, students with clinically relevant depression and anxiety symptoms were more likely to belong the more reluctant classes. Consistent with increasing autonomy during adolescence, the most frequently reported reason for reluctancy and the reason that characterized the largest class of reluctant students was a preference to handle problems themselves. Other reasons for reluctancy that students in this cluster endorsed may point to factors contributing to this preference, including concerns about confidentiality and perceptions that school adults would not be able to help. Addressing these reasons may prove valuable to improve help seeking intention among the most prevalent subgroups of reluctant adolescents. Results also point to potential gender-targeted strategies. While most classes were consistent across females and males, both females and males had a unique class.
Availabilty of data and material
COMPASS study data is available upon request through completion and approval of an online form: https://uwaterloo.ca/compass-system/information-researchers/data-usage-application The datasets used during the current study are available from the corresponding author on reasonable request.
Author contributions
KAP, JG, and JF led the writing. KB conducted all statistical analyses. STL and KAP secured funding. All authors (KAP, KB, JG, JF, STL) reviewed and edited drafts.
Consent to participate
All students attending participating schools were invited to participate using active-information passive-consent parental permission protocols. Parents were informed of the study and could withdraw their child by contacting study staff. Students not withdrawn from the study by their parents were considered eligible to participate. Under passive-consent protocols, parental informed consent is assumed for all students whose parents that did not contact COMPASS staff to withdraw their child from the study, and this pertained to all participating students.
Institutional Review Board statement
The study was conducted in accordance with the Declaration of Helsinki and was approved by an Institutional Review Board/Ethics committee. See details under Methods.
Acknowledgments
The authors would like to thank the schools, school boards, and students that have participated in the COMPASS study, and all COMPASS team members, staff, partners, and youth engagement committee members. It takes a large team, many collaborators, and particularly, students and schools themselves, to make this study possible.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
References
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