Childhood anxiety in rural and urban areas: Presentation, impact and help seeking

Abstract

The current study investigated relationships between anxiety symptoms and residential location on problem recognition, service use and resultant impact. Clinically significant differences between rural and urban residents were not found on mental health symptoms, problem recognition or history of service use. Parent and family interference was found to be strongly linked to a child's anxiety level in both regions, with a child's negative experiences and direct interference on the child's life being attributed a smaller role. The impact of anxiety in rural areas was found to be higher than that experienced by similarly anxious children from urban areas. Finally patterns of service use were found to vary with a greater reliance on medical and school services in rural areas, and specialist and allied health services in urban areas. The findings together provide support for the development of specialised services for rural communities, and have implications for targeted education of parents to improve the number of children receiving appropriate help.

Anxiety disorders have consistently been found to be one of the most common mental health problems experienced by children (Breton et al., 1999; Ford, Goodman, & Meltzer, 2003). Immediate results of anxiety include impaired peer relationships, low self-esteem, poor attention/concentration capacity, reduced academic performance, somatic symptoms and poor social relationships (Bernstein et al., 1997; Strauss, Frame, & Forehand, 1987). In addition, the nature of anxiety implies the avoidance of age-appropriate activities, for example anxious children are less likely to visit friends and may not participate in extra-curricular activities, restricting their life experiences. Long-term outcomes for anxious children are also poor with higher rates of adult anxiety, depression and substance abuse, and less successful transitions into employment and independent living (Hofstra, van der Ende, & Verhulst, 2002; Last, Hansen, & Franco, 1997).

Recent research has led to the development of efficacious assessment and treatment methods that can be used to prevent future difficulties and improve current functioning (Albano & Kendall, 2002; Schniering, Hudson, & Rapee, 2000). Despite the existence of these methods, widespread availability has not been achieved and dissemination of evidenced-based methods is a priority among researchers and policy makers (Commonwealth Department of Health and Aged Care, 2000; Kendall, 2002). Providing adequate services to rural communities has proved particularly problematic (National Rural Health Policy Subcommittee & National Rural Health Alliance, 2002). While research is under way that examines alternative ways of providing services to these communities, it is unclear as to whether there are inherent differences in the way children from rural communities experience anxiety and its consequences.

Influence of geographic location on mental health

The question of whether location of residence impacts on mental health experience has been a contentious issue. Early research assumed that rural lifestyle was characterised by social stability, supportive interpersonal networks and community cohesion that would protect rural residents against the development of mental health problems. Urban living in contrast was associated with changing environment, interpersonal estrangement and social dislocation. Consequently it was believed to increase the risk for mental health problems (Crowell, George, Blazer, & Landerman, 1986; Quinton, 1988). However, recent events such as the rural economic downturn, high rates of urban migration and improved access to technology have significantly changed the nature of rural living (Crowell et al., 1986; Judd et al., 2002). Concurrently there has been a marked increase in rates of suicide by children and young adults in rural areas relative to stable urban suicide rates. This disparity suggests a decline in rural mental health over recent years (Al-Yaman, Bryant, & Sargeant, 2002; Dudley, Kelk, Florio, Howard, & Waters, 1998).

Several socioeconomic factors have been correlated with the presence of mental health issues including low income (Costello, Angold, Burns, Strangl, & Tweed, 1996; Paykel, Abbott, Jenkins, Brugha, & Meltzer, 2000). Given the general relationship between socioeconomic disadvantage and rural residence it is possible that such factors are a better explanation for prevalence differences. In addition, for rural children a consequence of living in smaller isolated communities may be limited opportunities for social interaction and a decreased exposure to risk or threat due to the restricted range of learning experiences available. These geographic restrictions potentially increase their vulnerability to mental health problems such as anxiety, which is partially maintained by behavioural avoidance (Albano & Kendall, 2002).

Research into rural versus urban aspects of child mental health are rare and findings have been contradictory. Direct comparison of prevalence rates in rural and urban populations for example have resulted in inconsistent data. For those studies that examine rates of anxiety or internalising disorders specifically, rural – urban differences have not been found in some studies (Breton et al., 1999; Canino et al., 2004), while others have shown higher rates in urban populations (Offord et al., 1987; Zahner, Jacobs, Freeman, & Trainor, 1993). In contrast, Hope and Bierman (1998) found that although no differences were evident in home settings for externalising and internalising problems, in school settings children from rural locations were reported to have higher rates of internalising problems and their urban counterparts were reported to have higher rates of externalising problems. No studies have reported complete data on the prevalence of specific anxiety disorders across rural and urban locations. It is also of interest to understand whether functional impairment varies according to geographic location. One study that examined impairment across rural and urban locations using a sample of all children who presented to a mental health service, failed to show any differences (Walrath et al., 2003). To date, however, no study has specifically examined the differential impact of anxiety in rural and urban children.

Help-seeking Patterns and determinants

Despite high rates of psychopathology in the community, levels of service use have been found to be low. Only 20 – 50% of children identified as having a mental health problem, access the services (Canino et al., 2004; Farmer, Stangl, Burns, Costello, & Angold, 1999; Sawyer et al., 2001). The overwhelming majority use services provided by schools, with specialist services utilised by relatively few children (Canino et al., 2004; Farmer, Burns, Phillips, Angold, & Costello, 2003; Farmer et al., 1999; Zubrick et al., 1995). In studies that have examined service use in rural and urban areas results have been mixed, with findings indicating both no differences (Offord et al., 1987) and less service use in rural areas (Al-Yaman et al., 2002; Cohen & Hesselbart, 1993).

The discrepancy between disorder rates and service use has been the subject of some research. Although it is unlikely that the current system would cope if all children in need presented for help, the fact is that many of the children not receiving help have never presented to a service for assistance. Research into those who have presented and those who have not has found several factors that influence the likelihood of a child being identified as in need of help. Demographic factors such as coming from a low – middle income background, female gender, belonging to a cultural minority and living in a rural area have all been linked with lower use of services (Bussing, Zima, Gary, & Garvan, 2003; Cohen & Hesselbart, 1993). In addition, parental recognition of the problem, the impact of symptoms on the parent/family and the presence of child impairment have been found to significantly increase the likelihood of service use (Angold et al., 1998; Farmer, Burns, Angold, & Costello, 1997; Teagle, 2002).

Because children rarely self-present for help, parents are most often responsible for initiating help seeking. Teagle (2002) found that in a sample of children diagnosed with any psychiatric disorder only 39% of their parents perceived a problem and that perception of the problem was predictive of speciality service use over and above the influence of the child's symptoms. Similarly Zubrick et al. (1995) reported that of the one in six children who were found to have a mental health disorder, 54% of their principal caregivers did not perceive an emotional or behavioural problem and a further 18% perceived a problem but did not see a need for professional help. Additionally, the findings in these studies suggested that parental problem perception was particularly poor for childhood anxiety disorders.

Interrelated with the issue of problem perception is the experience of parent/family impact as a result of the child's difficulties. Child psychopathology has been shown to impact significantly on family life and routines, parental wellbeing, time for self, relationships with others, income and a parent's sense of competence (Messer, Angold, Costello, & Burns, 1996). The experience of these impacts significantly increases the likelihood that a parent will perceive a problem and increases the likelihood that professional help will be sought (Angold et al., 1998; Farmer et al., 1997; Teagle, 2002). Specific relationships between individual disorders and the type of impact experienced by the parent and family and the influence of rural – urban residence on this impact have not been investigated.

The final factor commonly identified as having an influence on service use is child impairment. This factor includes variables such as the quality of the child's relationships, self-care, school performance, and recreation. Functional impairment increases the likelihood of service use, particularly when combined with the presence of a defined disorder (Canino et al., 2004). Significant functional impairment also improves parental problem recognition (Costello, Angold, Burns, Erkanli et al., 1996; Teagle, 2002). Canino et al. (2004) recently highlighted the link between child impairment and the need for mental health services, differentiating between disorder-specific and global impairment. They found that global impairment was more important than presence of diagnosis in predicting service use.

Purpose of study

Given the crucial role of parents in identifying child problems and subsequently a child's need for help, targeted education that helps parents to recognise not only the symptoms of different disorders but also indicators of child impairment and what is unusual in terms of family impact could greatly increase the hit rate of children receiving services. For this to be successful, education would need to account for the differences likely to result from distinct categories of disorders. That is, the information provided to parents would need to cover the different child impairments and parent/family impacts likely to arise from externalising and internalising disorders at a minimum and should also be tailored to any environmental aspects that are found to impact on mental health presentations.

To provide this level of education, a more specific understanding of impairment and impact related to the different categories of disorder is needed. Additionally, given the inconsistent findings with regard to location of residence and its influence on symptoms and service use, and the lack of research on its relationship with problem recognition and impact, the current study sought to explore the effect of residential location on symptoms, problem recognition, service use and the total impact experienced by child and family as a result of anxiety.

Methods

Participants

A total of 2189 questionnaires were distributed through nine urban primary schools and 2427 questionnaires were distributed through 18 rural primary schools. Completed questionnaires were returned by 1261 mothers (mean age, 38.95 years, SD = 5.17 years), 676 from rural areas (return rate 27.9%) and 585 from urban areas (return rate 26.7%). The average age of the children was 8.75 years (SD = 2 years, range 5 – 12 years), 49.1% of whom were male and 50.9% female. Socioeconomic characteristics of the families were examined using the Australian Bureau of Statistics Index of Relative Socioeconomic Advantage/Disadvantage (IRSAD), which evaluates the income, education, expenditure, and occupation of residents based on their post code (Australian Bureau of Statistics, 2004). Consistent with the general trend of rural residents experiencing socioeconomic disadvantage, a substantial difference in index values was evident between rural and urban residents, F(1,1256) = 3982, p < .001. Index values and comparative data are included in Table I. Table I also presents the economic, geographic and structural characteristics of the families with comparative census data.

Table I. Subject sociodemographic characteristics

Ethnicity	Rural		Urban		All participants		Census%
	n	%	n	%	n	%
Australian	569	84	405	69	976	77	72
European	75	11	88	15	163	13	11
Asian	5	1	60	10	65	5	4
Other	25	4	32	6	57	5	13
ARIA category^1
Major cities			585	100	585	46	61
Inner regional	104	15			104	8	25
Outer regional	498	74			498	40	12
Remote/very remote	73	11			73	6	3
Family structure
Single-parent	96	14	57	10	154	12	25
Two-parent	580	86	527	90	1107	88	75
Index of Relative Socioeconomic Advantage/Disadvantage				Rural Participants	Urban Participants	Census Rural^2	Census Urban
				M	929	1111	927	1061
				SD	46	61	45	98
Note. ARIA = Accessibility/Remoteness Index of Australia.
Census data obtained from the Australian Bureau of Statistics (2001). ^1ARIA census values based on 1996 figures. ^2Census comparisons for ARIA values >1.84 for rural and 0 for urban.

Measures

Spence children's Anxiety Scale – Parent Version.

The Spence Children's Anxiety Scale – Parent Version (SCAS-P; Nauta et al., 2004) was included to provide a parent-report measure of anxiety symptoms experienced by children. It contains six scales designed to mirror diagnostic categories that are summed to give a total anxiety score. The scale shows satisfactory to excellent reliability and is able to differentiate between anxious and non-clinical children (Nauta et al., 2004).

Strengths and Difficulties Questionnaire – Parent Version.

Given the likelihood of comorbidity in the sample, the Strengths and Difficulties Questionnaire – Parent Version (SDQ-P; Goodman, 2001a) was included so that children high on externalising behaviours could be identified and excluded from analyses in which relationships with pure anxiety were of interest and to provide a contrast group. The SDQ-P is a brief measure of prosocial behaviour and psychopathology for children aged 3 – 16 years. There are five scales within the questionnaire: emotional symptoms; hyperactivity – inattention; conduct problems; peer problems; and prosocial behaviour. The questionnaire has been shown to have good reliability and validity, can be used to accurately screen for likely presence of a psychiatric diagnosis (Goodman, Ford, Simmons, Gatward, & Meltzer, 2003; Muris, Meesters, & van den Berg, 2003) and accurately discriminates children with externalising and anxiety disorders as well as those with no disorder (Lyneham & Rapee, 2005).

The SDQ-P also includes an impairment scale that asks parents to identify if their child has an emotional or behavioural problem. Parents who believe there is a problem are asked to report the level of impact that the difficulties are having on their child in the classroom, at home, with friendships and leisure activities as well as how much distress the difficulties cause the child.

To gain a more specific measure of participation in activities that may be affected by anxiety, an 8-item set of questions was developed. Items were designed to cover most activities typically engaged in by children. Mothers were asked to endorse a 7-point scale (never to more than 4 times per week) indicating how often their child experienced each activity. The activities included out-of-school sport, out-of-school activities other than sport, extracurricular activities during school, community participation, visiting friend's houses, having friend's visit their home, attending parties, and going to sleepovers. In addition to these questions an additional four questions regarding common negative experiences were included. These were being absent from school, going to the doctor, getting extremely upset and having difficulty completing everyday tasks such as homework or sleeping. These questions were responded to on the same 7-point scale. Positive activities and negative experience scores were derived by summing the relevant individual items.

To gain information about the impact that the child has on the family and parent's life, an 11-item set of questions was developed. Items were based on issues typically raised by parents who bring their child for assessment at a child anxiety clinic, and on suggested areas of impact from prior research. The questions were responded to on a 5-point scale (never true to always true). The items included willingness of the child to be left with a babysitter, limitations on how often the family or parents go out and how often invitations are turned down because the child would not cope, time spent providing reassurance, need for a parent to accompany the child to age-appropriate activities, reduction of parent work hours, parent experiencing increased stress because of the child's needs, parental concern over the child's future and expressions of concern (from teachers, friends, etc.) about the child's ability to cope with everyday activities. Responses to these items were summed to give a total parent/family interference scores.

Finally, mothers were asked if they had ever sought help for an emotional or behavioural difficulty being experienced by their child and, if so, where they went and whether they were continuing to receive help. They were also asked to indicate where they would seek help in the future (from a list of eight categories) should they become concerned about their child's mental health.

Procedure

Ethics approval was sought and granted by the University Ethics Board and by the Department of Education's Research Directorate. The principals of private and state schools were approached with an outline of the proposed research and a written request for participation. Schools were chosen on the basis of the value of the Accessibility and Remoteness Index of Australia Plus (ARIA+) for their area. ARIA is an index that indicates the level of health service accessibility for each community with values that range from 0 to 15. Major metropolitan areas have a value of < 0.2. Values >0.2 are classified into inner and outer regional or remote communities, with higher values indicating increasing isolation from health services (Trewin, 2001). In the current study all urban schools had an ARIA index of 0, indicating no isolation from services, with the selection of schools being chosen to cover the broader geographical area of Sydney. Rural schools were chosen if they had an ARIA value >1.84, a value representative of some accessibility restrictions to services and a locality that is a significant distance from a metropolitan area (Commonwealth Department of Health and Aged Care, 2001). Selections were made to ensure the rural schools covered the full range of index values from 1.84 to 15. A greater number of schools were required from rural and remote regions because these schools had smaller enrolments than the urban schools.

On receiving permission from a school's principal, sufficient questionnaire packs addressed specifically to mothers (which included an information and consent form, the questionnaire booklet and a reply paid envelope) were sent to the school to enable one pack per family to be sent home with the school's newsletter. Principals were asked to print a small comment in the school newsletter stating that the packs had been sent home with the school's permission and asking mothers to complete and return the pack directly to the university in the supplied envelope. In the following newsletter, principals were asked to print a single reminder to return the packs. Other than this printed reminder the schools were not asked to follow up on the return of questionnaires and did not have access to the responses. Distribution of the questionnaires occurred during the second and third terms of the four-term school year.

Mothers who were willing to participate were instructed to complete the questions with regard to the child in their family who was in the primary school age range (5 – 12 years). If they had more than one eligible child they were asked to complete the questions on the child whose name appeared first in the alphabet. Packs were completed anonymously and did not require any identifying information other than the school their child attended.

Results

Symptom measures

Table II presents the means and standard deviations on the total and subscales of the SDQ-P and SCAS-P for rural, urban and all children. Analyses of variance (ANOVAs) were conducted to determine the presence of rural – urban differences. Because socioeconomic differences existed between the groups and have previously been suggested as an explanation for rural – urban differences (Paykel et al., 2000), the IRSAD was included as a covariate in all analyses. No differences were found between rural and urban children on total SDQ score, F(1,1252) = 1.82, p = .18, or any of the SDQ subscales. On the SCAS-P, a rural – urban difference was evident on the physical injury subscale, F(1,1252) = 4.99, p < .025, η² = .004, with urban children reported to experience slightly higher fears of physical injury. There was no difference on the SCAS-P total score, F(1,1255) = 0.10, p = .92, or the other subscales.

Table II. Symptom measure according to location (M ± SD)

	Rural	Urban	Total
SDQ-P Total	9.87 ± 6.79	8.87 ± 5.92	9.41 ± 6.42
Emotional symptoms	2.22 ± 2.38	1.94 ± 2.02	2.09 ± 2.23
Conduct problems	1.90 ± 1.82	1.76 ± 1.80	1.84 ± 1.81
Hyperactivity/inattention	3.86 ± 2.65	3.67 ± 2.60	3.77 ± 2.63
Peer problems	1.89 ± 2.02	1.50 ± 1.63	1.71 ± 1.86
Prosocial behaviour	7.85 ± 1.93	8.04 ± 1.86	7.93 ± 1.90
SCAS-P Total	16.69 ± 11.75	16.63 ± 9.87	16.66 ± 10.91
Panic/agoraphobia	0.99 ± 1.92	0.83 ± 1.60	0.92 ± 1.78
Separation anxiety	3.63 ± 3.17	3.72 ± 2.77	3.67 ± 2.99
Social anxiety	4.47 ± 3.41	4.16 ± 3.01	4.33 ± 3.23
Physical injury	2.91 ± 2.29*	3.22 ± 2.27	3.06 ± 2.28
Obsessive – compulsive	1.22 ± 1.84	1.22 ± 1.71	1.22 ± 1.78
Generalised anxiety	3.52 ± 2.48	3.46 ± 2.15	3.49 ± 2.33
Note. SCAS-P = Spence Children's Anxiety Scale; SDQ-P = Strengths and Difficulties Questionnaire.
*Rural – urban difference significant at p < .025.

Clinical group and problem recognition

Based on the norms available for the SCAS-P and the recommendation that to identify children who have an anxiety problem a clinical score on any of the subscales or the total score should be considered (Nauta et al., 2004), children were identified as anxious if the parent report placed them on or above the 90th percentile anywhere in their profile. Based on this criterion 38% of rural and 39% of urban children were anxious, χ²(1) = .004, p = .95. Using the norms for the SDQ-P, children were identified as externalising if the parent report placed them on or above the 90th percentile on the hyperactivity/inattention or conduct problems subscales. Using this criterion 26% of rural and 23% of urban children were classified as externalising, χ²(1) = 2.18, p = .14. A small proportion (12%) of children were identified as both anxious and externalising.

Following the symptom measures, mothers were asked if their child had “difficulties in one or more of the following areas: emotions, concentration, behaviour or being able to get on with other people”. Of the children identified as purely anxious, 58% of rural and 49% of urban mothers identified difficulties, χ²(1) = 2.72, p = .10. For children identified as purely externalising, 82% of rural and 80% of urban mothers identified their child as currently experiencing difficulties, χ²(1) = .184, p = .67. Mothers were more likely to indicate a problem if their child was both anxious and externalising (91% indicated difficulty) or purely externalising (81%) than if their child was purely anxious (54%), χ²(2) = 82.32, p < .001.

Help seeking: Past, present and future

Within the entire sample there was no difference in the percentage of mothers who indicated that they had sought professional help for an emotional or behavioural difficulty experienced by their child, χ²(1) = 0.22, p = .64, with 28% of rural and 26% of urban mothers indicating past help-seeking. Within this subsample 27% of rural and 22% of urban children were still receiving help at the time of questionnaire completion. This difference was not significant, χ²(1) = 0.57, p = .45. Among the children who were purely anxious, 32% of both rural and urban families had sought help at some point, χ²(1) = 0.01, p = .97. Of those families who had sought help 30% of the rural and 8% of the urban families continued to receive help, χ²(1) = 4.41, p < .05. Among the purely externalising children, 30% of rural and 46% of urban families had sought help, χ²(1) = 2.50, p = .11, of whom 23% of rural and 33% of urban families continued to receive help, χ²(1) = 0.51, p = .48.

Participant responses indicated eight categories of professionals from whom help had been sought. Figure 1 presents the proportion of rural and urban families who had sought help from each category of professional. Differences in source of help were evident dependent on the region, χ²(8) = 36.62, p < .001. An examination of the frequency table indicated that the differences were due to higher use of school counsellors and paediatricians among the rural families and higher use of specialist clinics and allied health professionals (such as occupational and speech therapists) among the urban families.

Figure 1. Source of help for child's emotional and behavioural problems in rural and urban families

In regard to future help-seeking the majority of mothers (69%) indicated that if faced with a concern about their child's mental health they would first try to work it out at home. The professional/service a parent would first approach for assistance differed among the rural and urban participants, χ²(6) = 20.47, p < .01. As shown in Figure 2 the most common sources for future help were general practitioners (favoured by urban residents) and school counsellors (favoured by rural residents).

Figure 2. Future intentions for help-seeking if concerned about child's emotional and behavioural health in rural and urban families

Relationship between anxiety symptoms and impact

To assess the relationship between anxiety symptoms and variables that were expected to relate to impact, a stepwise multiple regression analysis was conducted. The dependent variable was the total SCAS-P score. Independent variables were the total scores from the SDQ-P (child) interference scale and the total scores from the specifically created positive activities scale, negative experience scale and the parent/family interference scale. The criterion for a variable to be entered into the model was set at p < .005 and that to be removed from the model was set at p < .01. The total model accounted for 46.3% of the variance in anxiety scores, with three of the four independent variables entering the model. The vast majority of the explained variance, 42%, was attributable to parent/family interference (standardised β = .47, t = 16.46, p < .001), with negative experiences accounting for an additional 4% (standardised β = .22, t = 8.35, p < .001) and child interference making a minor contribution of 0.04% (standardised β = .09, t = 3.15, p = .002). Participation in positive activities was found not to relate to total anxiety score. Regression analyses conducted separately on the rural and urban samples resulted in the same set of relationships.

Influence of region and anxiety on impact

To enable comparison of the impact experienced by rural and urban residents as a result of child anxiety, two groups were drawn from the total sample. The high group consisted of the 190 children who scored on or above the clinical cut-off on the SCAS total score. The average group was selected by taking an equivalent-sized random sample of all children who scored below the cut-off. A total impact score was calculated using the beta coefficients established in the above regression analysis. A Region × Anxiety level ANOVA was then conducted on the impact score. A main effect was found for anxiety level, F(1,376) = 203.13, p < .001, η² = .33 but not for region, F(1,376) = 1.79, p = .18, η² = .003. A Region × Anxiety level interaction was found, F(1,376) = 13.52, p < .001, η² = .02, with higher impact being reported among the high anxious children in rural regions, as illustrated in Figure 3.

Figure 3. Impact as a function of region and anxiety status

Discussion

The findings of the current study are based on an anonymous survey design that does not represent a random or stratified sample from the population. The response rate was acceptable and there were indications that the participants were similar to the general population on basic sociodemographic variables to the Australian population. Additionally the mean scores on the SCAS-P and SDQ-P assessment measures were similar to those found in respective norming studies (Goodman, 2001b; Nauta et al., 2004). The findings from a survey design may be influenced by unknown self-selection biases and caution is needed in generalising findings. Results will require replication in a large stratified sample in the future.

The substantial disadvantages experienced by rural residents that are imposed by geographic location are reflected in measures of socioeconomics including a generally lower level of income, free expenditure, education and occupation in comparison to their urban counterparts. While such factors can relate to the presence and severity of mental health problems other unique aspects of rural life may also contribute to mental health status. The current study investigated the possibility of a geographic pattern to the experience of child anxiety. After accounting for socioeconomic factors no meaningful differences were found between the rural and urban children on symptom measures of anxiety, emotional and behavioural problems or prosocial behaviour. Although a statistically significant difference was noted on the physical injury subscale of the SCAS-P the effect size was very small, indicating that this difference would have little clinical importance (Kraemer et al., 2003). While the design of the study does not allow for conclusion regarding prevalence given the lack of individual diagnostic interviews, supporting the lack of a geography-based, clinically significant difference were the findings that similar numbers of children were classified as externalising or anxious in the rural and urban locations. Future research with clinically diagnosed populations would be worthwhile.

The importance of parental problem recognition in children receiving appropriate services has been recognised. Similar to the findings of Teagle (2002), the current study found that 81% of mothers identified a difficulty when their child was high on externalising problems but only 54% of mothers of anxious children did the same, with rural and urban mothers not differing in their ability to detect problems. The discrepancy between recognition of externalising and anxiety problems may be a result of the impact and symptoms of these child difficulties as experienced by parents. In externalising problems symptoms are often visually more obvious and unacceptable, particularly in situations where the difficulty is disruptive to many people, such as the classroom (Bussing et al., 2003). The symptoms and impact of anxiety are often less visible, more acceptable (e.g., perfectionism is more likely to be valued than aggression), and are more likely to impact solely at home or in non-disruptive ways. Anxious symptoms may consequently not be defined as a problem or may be accepted as part of the child's temperament and therefore not a target of change. The relative likelihood of being referred for externalising or internalising problems is consistent with the low level of recognition of anxiety. Research has found that children with externalising problems are more likely to be referred than children with internalising problems (Weiss, Jackson, & Suesser, 1997; Weisz & Weiss, 1991).

The importance of impact in facilitating help-seeking has been found across all mental health problems (Farmer et al., 1997). Consequently, education regarding the link between impairment and need has been identified as necessary by Canino et al. (2004). To effectively do this, a more thorough understanding of how each particular set of disorders impact on a child and their family is needed. The current study suggests a link between a child's symptoms of anxiety and the impact that the symptoms have on the parent's life and the family's activities. The direct impact of emotional and behavioural difficulties on a child in daily life and the number of negative experiences that the child has were not found to strongly reflect the child's level of anxiety. Further, a child's participation in positive activities did not relate to their level of anxiety.

Although no differences were found at the symptom level between rural and urban residents, an interaction between high anxiety and location of residence was evident on the impact experienced by the child and family. Children who had average levels of anxiety reported similar levels of impact in both rural and urban areas. While children reported to have high levels of anxiety as a group were also reported to experience higher total impact, the impact reported by rural mothers of high anxious children was greater than the levels reported by mothers of high anxious urban children. The reason for this finding is not clear. Participant self-selection may account for the difference if other (unmeasured) variables differed systematically between the two groups such as if rural mothers wanted to convey a greater need for help. Alternatively anxiety in rural areas while occurring at a similar level may necessitate more involvement from parents, because there may be a greater number of anxiety-provoking activities to deal with. For example rural parents may need to accompany children to activities that are a distance from home or may need to provide more reassurance, because there are more activities that are likely to occur rarely. This additional involvement would consequently increase the impact of an anxious child on the parent's life. It is also possible that the results reflect poor assessment of the construct of family interference specific to anxiety. The only measures available at the time of the present study were interview based and could not be suitably converted into a short written form. Further investigation of how anxiety impacts on children and their families using a psychometrically proven interference measure should consider the rural – urban dimension to ensure that potential differences are accounted for.

Patterns of help-seeking did vary dependent on location of residence. The most marked difference in previous help-seeking was the high use of school counsellors in rural areas, contrasting with the higher use of specialist clinics in urban areas. School counsellors are providing more than one third of mental health services in rural areas, with less than 5% of rural residents accessing specialist services compared to almost 25% of urban residents. The use of free versus fee services may partially reflect differing levels of income among rural and urban residents but the finding also highlights the need to develop more equitable ways for rural residents to access specialist services. It appears that the role that school counsellors are being expected to fulfil in rural areas is to provide information and assistance regarding all types of child mental health problems irrespective of whether the difficulties relate to school performance. This is beyond their official role, which is to “provide counselling and psychological assessment of students with specific needs … to improve student learning outcomes” (R. Stonehouse NSW Department of Education, personal communication, 11 March 2004) and is consistent with findings that in rural areas the school counsellor's role often extends beyond the school and its children (Sutton & Pearson, 2002). The reliance on school counsellors in rural areas was further evident in mothers' intentions for help-seeking in the future. In both rural and urban areas the preponderance of families indicated that the first professional from whom they would seek help would either be a school counsellor or general practitioner. Rural residents favoured approaching school counsellors, and urban residents, general practitioners. These future intentions likely reflect the availability of these types of services across locations.

Increasing the number of in-need children who access mental health services is a priority (Commonwealth Department of Health and Aged Care, 2000). Given that the long-term consequences of anxiety and the positive outcomes for those who receive efficacious treatments are well documented, work is needed on assisting parents to recognise the symptoms and impacts likely to be indicative of anxiety in children so that their needs are not neglected. The current findings have several implications for any education that targets anxiety in children. It is clear that parents can identify the impact experienced by their family as a result of anxiety. Education is needed that highlights impact as an indication of a child's difficulty, encouraging parents to consider seeking help if they are experiencing such an impact, and that informs parents about the serious short- and long-term consequences of anxiety for children to help motivate them to seek treatment early. It is possible that the small contribution that stigma causes in relation to preventing help-seeking (Bussing et al., 2003; Starr, Campbell, & Herrick, 2002), may be partially related to parents interpreting family impact as an unacceptable reason to seek help. By educating parents that these consequences are typical results of anxiety there may be a corresponding increase in help-seeking. A further implication of the findings is that any educational materials or advertising regarding new access points for specialist services should be targeted at general practitioners and school counsellors because it is clear that they are favoured as the first source of help-seeking by parents.

Notes

^*Accepted under the previous Editorial Board.