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. 2024 Jul 2;27:101695. doi: 10.1016/j.ssmph.2024.101695

Familial transmission of mental health help-seeking: Does it “run in the family”?

Melissa J DuPont-Reyes a,⁎, Alice P Villatoro b, Jo C Phelan c, Kris Painter d, Bruce G Link e
PMCID: PMC11301375  PMID: 39108351

Abstract

Familial transmission of mental illnesses and health behaviors is well established. However, little research has examined familial transmission of mental health help-seeking behaviors despite social science theoretical traditions that support its occurrence including social learning theory and the network episode model. Among parent-adolescent dyads, extant literature supports consideration of adolescent-autonomy versus parent-gatekeeping according to whether or not parents recognize a mental health problem in their adolescent. Given this, we examined familial transmission of self-reported mental health help-seeking among parent-adolescent dyads over an 18-month period from a school-based study (N = 422; Texas, USA). Generalized estimating equations tested the effect of multiple forms of parent help-seeking on similar forms of adolescent help-seeking, controlling for personal/family characteristics. We also examined interaction by parent recognition of a mental health problem in their adolescent to discern unique intergenerational processes across these subgroups of parent-adolescent dyads. Owing to effect modification by parent problem recognition (p<0.01), two unique familial transmission of help-seeking pathways emerged. When parent problem recognition was present, parent self help-seeking history reduced adolescent help-seeking net of controls. In contrast, when parent problem recognition was absent, parent self help-seeking history increased adolescent help-seeking net of controls. Our findings provide evidence of familial transmission of mental health help-seeking behaviors, but the direction of influence fundamentally depends on parent recognition of a mental health problem in their adolescent in order to reveal intergenerationally transmitted processes. The findings support our hypotheses that familial transmission of help-seeking starts early in adolescence and is likely influenced by parent modeling and gatekeeping, though explanations for the patterns observed, such as short- and long-term positive and negative mixed impacts of past help-seeking experiences of parents, require further study to ascertain.

Keywords: Familial transmission, Mental health, Help-seeking, Stigma, Network episode model, Social learning

Highlights

  • •

    This study evidences familial transmission of mental health help-seeking.

  • •

    Direction of help-seeking transmission depends on parent problem recognition.

  • •

    Help-seeking transmission is influenced by parent modeling and gatekeeping.

  • •

    Adolescent autonomy increases their chances of help-seeking.

1. Introduction

1.1. Mental health help-seeking defined

Mental health help-seeking is the process through which mental illness onset is identified, defined, and acted upon (Thoits, 1985; Biddle et al., 2007; Moses, 2009; Pescosolido et al., 1998). Help-seeking typically occurs after other strategies such as self-care have been tried. For adolescents, Cauce et al. (2002) describe three unique, dynamic stages that may (or not) occur, and if so, in any sequence. The problem recognition stage involves a subjective, perceived assessment of whether the adolescent is believed to have a mental health problem, or an objective, epidemiologically defined assessment of whether the adolescent has a mental health problem based on scores of symptoms. The second stage is an assessment of whether or not a mental health problem is deemed as serious and necessitating help, which can be a coercive or voluntary process for adolescents depending on the role and actions of others. This “seriousness” assessment can be by the adolescent and/or those around them (e.g., parents, peers, teachers). A third stage includes selecting a help-seeking source which could involve talking to a parent, friend, or religious leader, or seeking services from an adolescent provider in clinical, school or other juvenile settings (Pescosolido et al. 1998, 2013; Cauce et al., 2002).

Familial patterns of help-seeking across multiple generations may potentially precede and influence this adolescent help-seeking process. This concept of familial transmission of help-seeking has not been sufficiently addressed even though social science processes support its occurrence. For example, there is robust evidence for familial transmission of mental illness (e.g., schizophrenia, major depression, substance abuse) where parental mental illnesses influence mental illnesses in their offspring via both nongenetic and genetic processes (Avison & Comeau, 2013; Rice et al., 2002; Schwartz et al., 1994; Sullivan et al., 2000). These studies identified key covariates to consider in this research, including genetic markers, disrupted neurotransmission, maladaptive parenting, stress/trauma (e.g., abuse, family conflict, job/housing loss), and variables capturing social position (e.g., gender, race/ethnicity, class) (Avison & Comeau, 2013). Social science research has also addressed familial transmission of health behaviors related to diet, physical activity, and sleep, leading to family-focused health promotion interventions (Wickrama et al., 1999; Loprinzi & Trost, 2010; Rossow & Rise, 1994). Given that help-seeking is so important to mental health, we connect these interdisciplinary literatures to ask why in some parent-offspring dyads both members experience help-seeking, while in others one member does but the other does not, and still in others, neither member seeks help. This research gap motivates our current study of familial transmission of help-seeking among parent-adolescent dyads.

1.2. Theoretical frameworks supporting familial transmission of help-seeking

Two theoretical traditions—network episode model (NEM) and social learning theory (SLT)—offer insight into the possibility of familial transmission of help-seeking among parent-adolescent dyads (Bandura & Walters, 1977; Michaud et al., 2015; Pescosolido et al., 2013; Pescosolido et al., 1998). Each theory supports unique pathways of familial transmission of help-seeking depending on whether or not the parent recognizes a mental health problem in their adolescent. In particular, parent problem recognition allows for the examination of familial transmission of help-seeking across two unique contexts: (1) parents either recognize a problem thereby enabling greater oversight concerning help-seeking decisions for the adolescent, supported by NEM, or (2) parents do not recognize a problem thereby enabling greater adolescent autonomy in help-seeking, supported by SLT. Still, explicit tests of effect modification between parental problem recognition on familial help-seeking variables remains scarce in prior literature.

A. The Network Episode Model (NEM) offers a complex theoretical explanation for why familial transmission of help-seeking might occur when parent problem recognition is present. In this context, we can examine the influence of parental personal help-seeking history on parental help-seeking decision-making for their adolescent because both the parent's own past help-seeking and current help-seeking decision-making for the adolescent involve the parent's actions (NEM). NEM is a conceptual map of how dynamic social networks influence the mechanisms through which individuals define a health problem and access healthcare as different members of the network are engaged at different times and provide different types of advice, pressure, or control (Pescosolido & Boyer, 2009; Pescosolido et al., 2013). Importantly, past healthcare experiences of family members can influence future healthcare use, referrals, and recommendations for other family members. The direction of family member influence depends on whether that family member shares similar values about healthcare as healthcare providers (Costello et al., 1998; Pescosolido, 1992; Pescosolido et al. 1998, 2013; Ryan et al., 2015). Therefore, the role of parental personal help-seeking history can shape future help-seeking of their adolescent offspring, which also creates familial patterning of help-seeking. NEM can be applied to help elucidate complex network functions among parent-adolescent dyads in terms of how parents can influence help-seeking decision-making for adolescents.

B. Social Learning Theory (SLT) offers a simpler explanation for familial transmission of help-seeking when parent problem recognition is absent, which suggests that adolescents exhibit greater help-seeking action. In this context, we can examine how parent help-seeking history influences learned help-seeking among adolescents based on social learning of parental personal help-seeking histories (SLT). In SLT, new patterns of behaviors for adolescents are acquired through either direct or situational observation of parental behaviors and their consequences—what Bandura and Walters call “vicarious experiences” (Bandura and Walters, 1977). If parental behaviors are deemed successful, then offspring adopt these behaviors. However, parental behaviors that are consistently punished are deemed unsuccessful and discarded by offspring. As SLT has furthered understanding of the social production of crime, deviance, and health behaviors (Pratt et al., 2010; Wickrama et al., 1999), we posit that SLT can also elucidate how adolescents learn help-seeking from their parents. When parents confront a personal mental health problem, they respond to it in a particular way, such as talking to a spouse/partner, seeking mental health services, taking medication, adopting lifestyle/behavioral changes, or doing “nothing” (Pescosolido et al. 1998, 2013). Adolescents note effectiveness of these behaviors, regardless of their ability to label their parent's problem (Bandura & Walters, 1977; Pescosolido et al. 1998, 2013). Based on SLT, we expect adolescents to adopt help-seeking and discard ineffectual strategies such as inaction, especially when parents have a help-seeking history and adolescents take on their own help-seeking action (Bandura & Walters, 1977). This process of observation and selection of approaches for confronting a mental health problem suggests that help-seeking can be learned in families and transmitted across generations.

1.3. Complex processes in familial transmission of help-seeking: “gatekeeping” and “autonomy”

This section describes the two unique processes of familial transmission of help-seeking depending on whether or not parents recognize a mental health problem in their adolescent, as this variable can shape the choice structure available to parent-adolescent dyads when deciding whether to take an adolescent help-seeking action (Rieker & Read, 2017; Winkler et al., 2020).

A. “Gatekeeping” Pathway When Parents Recognize a Problem. NEM supports the notion that parents who recognize a problem in their adolescent will exhibit a greater propensity to exercise an influence over healthcare decisions of their offspring. Literature on “gatekeeping” elaborates on the process of how important people (e.g., parents, siblings, etc.) play a role in help-seeking when people develop symptoms they do not recognize, understand, or know how to address (Gurin et al., 1960; Veroff & Kulka, 1981). Gatekeeping depends on context and values, and may include: inaction, which may include observable behaviors such as minimize, “wait-and-see”, provide alternative explanations for symptoms, avoid a symptomatic person, or discourage help-seeking; or take help-seeking action such as referral to another gatekeeper, a holistic method, self-help, or a healthcare provider. Interventions have focused on training gatekeepers including clergy, family doctors, bartenders, hairdressers, police, and others to facilitate help-seeking (Bissonette, 1977; Lipson, 2014). Parents are often key gatekeepers for adolescents in gaining entry into health services, for instance, owing to a reliance on parental health insurance and consent. A component of the parental gatekeeping role is that a parent may recognize that their adolescent has a mental health problem, which consequently enables greater parental oversight concerning help-seeking decisions for the adolescent. Our study focuses on this clinically relevant aspect of parent gatekeeping: encouraging or discouraging help-seeking when problem recognition is present. Furthermore, our expectation is that the parent's own help-seeking history for a mental health problem influences their decisions about their adolescent's help-seeking, as NEM emphasizes how past treatment experiences of parents can influence future recommendations for their offspring.

In this context, NEM allows for two possible directions of parental influence on adolescent help-seeking based on the parent's own help-seeking experience. One possibility is that parents view help-seeking as an attractive choice for their adolescent, which may lead to a positive help-seeking influence on their offpsring. This possibility may especially occur when parents perceive their own personal help-seeking as beneficial or necessary for healing and recovery. Parents may then make a personal assessment about the value of help-seeking based on their own lived experience, which ultimately influences their future help-seeking action for other family members—in this case, help-seeking action for their adolescent. Parents may expect a similar outcome for their adolescent—“it helped me, therefore it can help my child.” Kadushin (1969) suggested how parents in these familial environments can function as a “friend and supporter of psychotherapy” and move their child toward help-seeking to healthcare providers.

Yet another possibility is that parents do not perceive help-seeking as an attractive choice owing to the joint “package deal” effect of stigma that accompanies help-seeking (Rosenfield, 1997). Rosenfield (1997) described how labeling mental illness produces mixed effects on quality of life, as labeling both implies stigma and yields possible indirect positive effects through the receipt of services. Treatment may (or not) have alleviated parent symptoms, though with adverse side effects, and still, the stigma attached to treatment typically results in a loss of social support, employment, housing, income, quality of life, and self-esteem (Link et al., 1989; Rosenfield, 1997). Thus, Rosenfield (1997) concluded that “stigma defines the limits of treatment” and called for anti-stigma interventions and high-quality treatments to authentically and holistically improve the lives of people coping with mental illness. As stigma remains a pervasive problem, and therefore still defines the limits of potential benefits of treatment, coupled with parents tending to seek out better circumstances for their offspring over their own experiences, we expect that this “package deal” that a parent received becomes an unattractive choice when making a similar decision for their adolescent. Further, literature on courtesy stigma—stigma by association experienced by family members for having relatives that are affected by mental illness—supports how parents might avoid help-seeking for their adolescent with a mental health problems to prevent anticipated judgement, blame, and stigma for their adolescent (Corrigan & Frederick, 2004, Corrigan et al., 2001, Green, 2003, Norvilitis, Scime, & Lee, 2002). Parents may seek a “new deal” with few negative consequences for their adolescent in a young, sensitive age in the lifespan. Thus, when parents recognize a mental health problem in their adolescent and influences parental help-seeking behaviors for their adolescent, we expect parent help-seeking history to reduce parental action for help-seeking for their adolescent. In this context, the familial transmission of help-seeking effect reflects the parental choice to accept or discard the “package deal” for their offspring.

B. “Autonomous” Pathway When Parents Do Not Recognize a Problem. For adolescents whose parents do not recognize a problem, adolescents may exhibit greater help-seeking autonomy because the parent has a lower propensity to act as a gatekeeper and the choice structure changes for adolescents (Moses, 2009; Rieker & Read, 2017; Ryan et al., 2015; Ryan et al., 2014; Winkler et al., 2020; Wisdom & Agnor, 2007; Wisdom et al., 2006). In this context, familial transmission of help-seeking is likely to occur via social learning processes. The positive effects of the “package deal” from parent help-seeking are vicariously (i.e., directly or situationally) experienced by adolescents including that the parent improved their health and functioning. These familial environments may carry an openness to help-seeking that children observe, and sometimes includes the overhear of parental discussion, and thereby motivate adolescents to adopt help-seeking later for themselves: “it helped my parent, therefore it can help me”. Behaviors of young offspring may not yet be influenced by negative "package deal" effects among their parents as youth may not yet fully recognize the complete range and impact of these effects, which can require further maturation and reflection; thus, absent parent problem recognition, youth's help-seeking choices are less constrained and socially structured alternatives. Therefore, when parents do not recognize a problem, we expect parent help-seeking history to promote autonomous help-seeking among adolescents, which is reflective of a learned familial help-seeking effect via SLT.

1.4. Family and autonomy factors are important to help-seeking

A systematic review of 28 studies found seven of fifteen familial factors were associated with young people's mental healthcare use, including parent burden, parent problem recognition, parent perception of need, parent psychopathology, single parent household, change in family structure, and being in a sociohistorical dominant group (Ryan et al., 2015). Only a quarter of young people with mental health problems received treatment, and parents played a prominent role in access to this care. Parent problem recognition and parental history of service use were each significantly positively associated with adolescent service use in three of four cross-sectional studies (Goodman et al., 2000; Sayal, 2004; Teagle, 2002; Wu et al., 1999). However, four other cross-sectional studies examining parental treatment history did not find an association (John et al., 1995; Wu et al., 2001; Zimmerman, 2005). We posit that divergent findings occurred without an explicit test of effect modification between the parental problem recognition and treatment history variables. Specifically, the effect of parental treatment history in subsamples of parents who recognized an adolescent mental health problem may go in the opposite direction as in subsamples of parents who did not recognize a problem. Depending on the availability of subgroups in datasets, results could vary across studies and produce a pattern of inconsistency. Finally, the review highlights why longitudinal study of parent-adolescent dyads is necessary to establish directionality between variables and to assess subsamples by parent problem recognition. Prior studies also focused on specialty healthcare only. In sum, as few adolescents receive mental health services, more refined explanations using theory and longitudinal data are needed to further our understanding of pathways into mental health supports among parent-adolescent dyads. Guided by prior theory, our study contributes longitudinal assessments of common and accessible primary care, school-based, and informal help-seeking among parent-adolescent dyads.

Moreover, the importance of autonomous healthcare decision-making among adolescents has been underscored in the field of adolescent medicine that has extensively researched determinants of bodily autonomy, consent, and confidentiality (English, Ford, Kahn, Kharbanda, & Middleman, 2013; Michaud et al., 2015; Pathak & Chou, 2019). This literature suggests that adolescents may seek help for a mental health problem on their own, and that parent-gatekeeping may have a larger role in adolescent treatment gaps than previously considered. One cross-sectional, mixed-method study by Moses (2009) among 54 adolescents in treatment for serious mental illness demonstrated that adolescents self-label—a key predictor of autonomous help-seeking: 20% described their problems as mental illness, 37% labeled their problems as family/social problems, and 43% were uncertain. These adolescents, and those in treatment for depression in primary care, placed great value on autonomy and self-competence in their healthcare decisions (Moses, 2009; Wisdom & Agnor, 2007; Wisdom et al., 2006). Adolescence is also a time when symptoms begin to emerge; consequently, help-seeking also arises as a potential need (Goodwin et al., 2022; Merikangas et al., 2011). Thus, consideration of autonomy is important developmentally as adolescents require privacy and self-reliance, and turn to school, peer, and online supports for help with a mental health problem (Leavey, Rothi, & Paul, 2011, Wisdom et al., 2006). Finally, perhaps adolescent help-seeking occurs more often in an autonomous context when parents model and support help-seeking, compared to when parents act as gatekeepers and assert their own values about help-seeking from their own experiences that can deter adolescents, as described above.

1.5. Hypotheses

The processes previously described motivate the examination of familial transmission of help-seeking via two unique pathways according to whether or not parents recognize a mental health problem in their adolescent (Fig. 1). In both pathways, parent help-seeking history influences adolescent help-seeking, but the direction of influence depends on parent problem recognition. Our hypotheses are: (1) parent problem recognition in their adolescent modifies parent help-seeking history effects on adolescent help-seeking, signaling two unique pathways; (2) when parents recognize a problem and are more likely to constrain adolescent choices (i.e., “gatekeeping” pathway), parent help-seeking history reduces adolescent help-seeking; and (3) when parents do not recognize a problem and adolescents are less contrained (i.e., “autonomous” pathway), parent help-seeking history promotes adolescent help-seeking. Our empirical test is among an ethnically and socioeconomically diverse sample of parent-adolescent dyads (N = 422) with help-seeking measures collected at six-month intervals for two years. We examine familial transmission of help-seeking by testing the effects of parent help-seeking history on adolescent help-seeking variables, and effect modification by whether parents recognize a problem in the adolescent.

Fig. 1.

Fig. 1

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Conceptual model for examining familial transmission of mental health help-seeking across variation in parent-gatekeeping and adolescent-autonomy.

2. Materials & Methods

Data are from a longitudinal evaluation of a school-based intervention about mental illness knowledge, attitudes, and behaviors (2011–2015). The selection of participants, design, and procedures are described in detail elsewhere (Link et al., 2020, Painter et al., 2017). Briefly, 14 school administrators in an urban area in Texas agreed to participate in the study following invitation. Using a fully-crossed 2 × 2 × 2 factorial controlled design, each school's sixth-grade class was block-randomized to receive none, one, or a combination of three anti-stigma components. Pre-posttest assessments were completed on laptops during the participants' health class. Prior to randomization, a sub-sample of adolescent-parent dyads agreed to 6-, 12-, 18-, and 24-month follow-up assessments at their homes. All study materials were offered in English and Spanish. Both students and parents/guardians gave assent/consent for participation. Students were not included in the study without signed forms. Students and parents/guardians received a modest monetary incentive for returning signed forms and completing assessments.

All sixth-grade students from participating schools were invited to participate. At baseline, the mean age of adolescents was 11.5 years and parents was 38.4 years. Of the 751 total students agreeing to participate (60% of all invited), 721 completed pre-posttest assessments and were similar to publicly available classroom enrollment data across age, race/ethnicity, gender, and class indicating little non-response bias at baseline. Prior to randomization, a sub-sample (n = 484; 65% response rate) agreed to participate longitudinally. Short- and long-term samples, and any loss to follow-up, did not significantly differ by age, gender, class, race/ethnicity, or intervention (Link et al., 2020). In the longitudinal sample, 422 adolescents had a parent consent to complete at least one assessment during follow-up, resulting in 422 linked parent-adolescent dyads for the current study. Similar to the broader population it was drawn from, the dyad sample was ethnically/socioeconomically diverse (Table 1): 76% identified as a racial/ethnic minority, 69% had a household income of <$50,000 (2011 national and Texas median income), and 42% had a parent/guardian with ≤high school diploma. Just over half of the adolescent sample were girls while 85% of the corresponding parent/guardian participants were women.

Table 1.

Characteristics of parent-adolescent dyad sample; Texas Stigma Study, 2011–2015

Full Sample (N = 422) Sub-sample with Parent Problem Recognition (n = 119) Sub-sample without Parent Problem Recognition (n = 297) % Missing
Adolescent Characteristics
Intervention assigned, N % 317 75.12 220 74.07 91 76.47 0%
Female, N % 235 55.82 171 57.77 63 52.94 <1%
Race/ethnic minority*, N % 319 76.13 232 78.64 81 68.64 <1%
Family closeness (1−24), Mean S.D 13.92 6.02 14.23 6.04 13.16 5.84 <4%
Baseline mental health help-seeking (0–7)*, Mean S.D 0.89 1.66 1.20 1.85 0.77 1.57 0%
Mental illness familiarity (0–3), Mean S.D 1.20 1.06 1.15 1.03 1.31 1.13 <2%
Mental illness knowledge/attitudes (1–5), Mean S.D 3.57 0.36 3.58 0.36 3.56 0.35 <2%
High mental health symptoms*, N % 210 49.88 137 46.28 69 57.98 <1%
Perceived mental health problem*, N % 92 22.17 53 18.09 37 31.90 <3%
Parent Characteristics
Female, N % 338 85.35 234 84.17 102 89.47 <6%
Race/ethnic minority*, N % 305 72.79 222 75.25 77 65.25 <1%
Household income <$50,000*, N % 266 69.09 197 73.78 65 57.02 <9%
High school diploma or less*, N % 166 42.12 132 47.83 31 27.19 <7%
Broken unionship*, N % 162 39.04 103 35.27 56 47.86 <2%
Mental illness familiarity (0–3)*, Mean S.D 1.59 1.11 1.38 1.08 2.13 0.98 <1%
Mental illness knowledge/attitudes (1–5)*, Mean S.D 3.76 0.40 3.70 0.41 3.90 0.36 0%
Self mental health help-seeking history (0–6)*, Mean S.D 1.06 1.97 2.02 2.34 0.68 1.66 <2%
Problem recognition of adolescent mental health, N % 119 28.61 n/a n/a <1%
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NOTE: *p<0.05 for statistically significant differences across parent problem recognition subsamples.

2.1. Measures

Adolescent mental health help-seeking was assessed through seven unique items at each assessment asking whether the adolescent had taken medicine, or talked to a doctor, therapist, school counselor, parent, friend, or religious leader for a mental health problem; items were summed to create the primary dependent variable of interest (0 = None to 7 = All received). No differences in results were detected according to types of help-seeking (Appendix Tables 1–4).

Parent mental health help-seeking was assessed through six unique items at each assessment asking whether the parent had taken medicine, or talked to a doctor, therapist, partner/spouse, friend, or religious leader for a mental health problem; items were summed to create the primary independent variable of interest (0 = None to 6 = All received). No differences in results were detected according to types of help-seeking (available upon request).

Parent recognition of a mental health problem in their adolescent was used to assess moderation of the effect of parent help-seeking history (independent variable) on adolescent help-seeking (dependent variable). Parent problem recognition (modifier) was assessed using a single item that was modeled in other studies and common in mental health literature (Fleishman & Zuvekas, 2007): “Was there ever a time in the past six months when your child seemed to have an emotional or behavioral problem like being anxious, depressed, hyperactive, withdrawn, or always getting into trouble (1 = Yes/0 = No)?”

Covariates. All participants self-reported gender (female—referent) and race/ethnicity (non-Latinx white—referent), while parents reported household income (≥$50,000—referent), education (some college or more—referent), and marital/partner unionship (1 = Broken, 0 = Not), allowing for control of social factors that influence selection into treatment. Analyses also controlled for adolescent reports of family closeness using 10-items assessing frequency of communication about problems and reliance for support (alpha = 0.88) (Dix & Meunier, 2009). In addition, analyses controlled for two measures asked of all participants at all time points related to mental illness knowledge, attitudes, and behaviors that would influence help-seeking. First, an adapted measure asking about personal interaction with individuals with a mental illness in various contexts such as seeing a mentally ill person on television (least contact) or having a coworker or friend with a mental illness (most contact) created a ranked familiarity score (0–3) that indicated the most intimate level of contact reported (Corrigan et al., 2001). Second, an adapted 21-item measure (alpha = 0.76) assessed mental illness knowledge and positive attitudes; high scores indicate greater knowledge/attitudes (Painter et al., 2017). As the data for the current analysis come from a longitudinal evaluation of an intervention, analyses controlled for intervention versus control (referent), time, and baseline help-seeking score (0–7).

Self-reported symptom and perceived problem measures among adolescents controlled for mental health severity. A 23-item symptoms checklist of items from the National Institute of Mental Health Diagnostic Interview Schedule for Children, Version IV (Shaffer et al., 2000) provided a compact self-reported screen. Items examined attention-hyperactive (e.g., “felt too active/fidgety”), depressive (e.g., “felt really sad/depressed”), and anxious (e.g., “worried too much”) symptoms. Exploratory factor analysis indicated that a full scale (alpha = 0.87) best fit the data over sub-scales of specific symptoms; thus, all items were combined to create a global score. Adolescents with high levels of symptoms were identified as those scoring in the top tertile of the checklist at any assessment period (low/moderate-level—referent). Perceived mental health was also assessed using a single item, “I seemed to have a mental health problem like being anxious, depressed …” (1 = Yes, 0 = No). Although positive concordance between parents and adolescents about a mental health problem may initiate adolescent help-seeking, only 9% of parent-adolescent dyads were concordant in identifying a problem: 59% agreed no mental health problem was present and 32% reported disagreement. Alternatively, among the 24% of adolescents self-perceiving a problem, 42% of their parents agreed; among the 29% of parents perceiving a problem in their adolescent, 35% of adolescents agreed.

2.2. Data analysis

To assess familial transmission of help-seeking, generalized estimating equations (GEE) models examined parent help-seeking history effects on adolescent help-seeking using proxy variables constructed from all available longitudinal survey data among parent-adolescent dyads, rendering an estimation of these complex familial help-seeking processes. GEE models accounted for clustering of assessments within individuals and families over time. Negative binomial family and log link were specified to appropriately model the distribution of the count dependent variable, as shown in the main results; results were similar when using continuous and binary forms of the dependent variable (Ballinger, 2004; Homish et al., 2010). An exchangeable correlation structure and robust standard errors were used to allow the estimates to be maximally valid in the event of model misspecification (Ballinger, 2004; Homish et al., 2010). P-values <0.05 were considered statistically significant. Data analyses were performed on STATA/SE Version 16 (StataCorp, 2019).

Effect modification between parental help-seeking and parent recognition in the adolescent was tested using a two-way interaction term. First, we tested main effects of parent help-seeking on adolescent help-seeking controlling for baseline help-seeking, time, and the intervention. Second, parent problem recognition was added in the model followed by the interaction between parental help-seeking and problem recognition (p<0.01). Other covariates were then entered singly to examine whether coefficients changed for parental help-seeking and problem recognition and their interaction. We tested for potential interactions between all other covariates in the fully adjusted model and none were significant. Final analyses control for baseline help-seeking, time, intervention, parent and adolescent gender and race/ethnicity, parent income, education and unionship, family closeness, parent and adolescent mental illness familiarity and knowledge/attitudes, and adolescent symptoms and perceived problem.

Minimal missing data was found in the parent-adolescent dyad longitudinal sample: 2% of each parents and adolescents had missing help-seeking data due to nonresponse across all assessment periods. Most missing data affected the parent income (<9% missing), education (<7% missing), and gender (<6% missing) variables. Multiple imputation was used to impute missing values using other variables that were correlated with parent income, education, and gender, and also available covariate and outcome data in the GEE models. GEE analyses were conducted for each of 10 multiple imputed data sets and results were combined according to Rubin's rules (Rubin, 2004), resulting in increased analytic sample size overall. The size and direction of the effect of the covariates were similar in complete-case or imputed samples (Appendix Tables 1–4); results from the multiple imputation analysis are presented. From these final multiple imputation GEE multivariate models, predicted counts of adolescent help-seeking at the mean value of all covariates were obtained and plotted across parent help-seeking history and in dyads with and without parent problem recognition to visually inspect the effect modification.

3. Results

Parent problem recognition modifies parent help-seeking history effects on adolescent help-seeking, signaling two familial transmission pathways.

Analyses tested for modification of the effect of parent help-seeking history on adolescent help-seeking according to whether or not parents recognize a mental health problem in their adolescent. In the fully adjusted model (Table 2), parent recognition of a mental health problem in their adolescent (Incident Rate Ratio [IRR] = 1.64; 95% Confidence Interval [95%CI] = 1.07, 2.50; p<0.05) and parent help-seeking history (IRR = 1.14; 95%CI = 1.04, 1.25; p<0.01) each statistically significantly increased adolescent help-seeking. However, the interaction term between parent problem recognition and help-seeking history was significantly in the opposite direction (IRR = 0.84; 95%CI = 0.74, 0.95; p<0.01) indicating that the effect of parent help-seeking history on adolescent help-seeking was modified according to whether parent problem recognition was present or absent. The joint interaction test was also statistically significant (p = 0.0068). Further, we ran separate models in subsamples with and without parent problem recognition and found that parent help-seeking history effects were qualitatively different in direction and magnitude for the adolescent help-seeking outcome (Appendix Table 1, Table 2). Together the interaction term, joint interaction test, and subsample results signaled two distinct pathways of familial transmission (Hypothesis 1).

Table 2.

Incident rate ratios (IRR) and 95% confidence intervals (95%CI) from generalized estimating equations assessing parent self help-seeking history effects on adolescent help-seeking modified by parent recognition of adolescent mental health in imputed parent-adolescent dyad sample; Texas Stigma Study, 2011–2015

Obs = 1,314; n = 391
IRR 95%CI
Time
12-month 0.96 0.71, 1.29
18-month 1.01 0.74, 1.38
24-month 1.00 0.71, 1.41
Adolescent Variables
Intervention assigned 0.89 0.59, 1.33
Female 1.17 0.83, 1.65
Race/ethnic minority 1.33 0.77, 2.28
Family closeness, 1-24 0.97* 0.95, 1.00
Baseline help-seeking, 0-7 1.31*** 1.21, 1.42
Mental illness familiarity, 0-3 1.11 0.97, 1.26
Mental illness knowledge/attitudes, 1-5 0.81 0.51, 1.27
High mental health symptoms 0.96 0.67, 1.39
Perceived mental health problem 1.50** 1.11, 2.02
Parent Variables
Female 1.03 0.66, 1.63
Race/ethnic minority 0.64 0.39, 1.05
Household income <$50,000 0.88 0.58, 1.33
High school diploma or less 1.21 0.83, 1.76
Broken unionship 1.05 0.74, 1.49
Mental illness familiarity, 0-3 1.15 0.99, 1.34
Mental illness knowledge/attitudes, 1-5 0.93 0.63, 1.37
Self mental health help-seeking history, 0-6 1.14** 1.04, 1.25
Problem recognition of adolescent mental health 1.64* 1.07, 2.50
Problem recognition X Self help-seeking history 0.84** 0.74, 0.95
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Note: All models include parent self help-seeking history (0–6) and problem recognition of adolescent mental health (referent—none), and baseline adolescent help-seeking (0–7), plus controls for time (referent—6-months), intervention (referent—control), parent and adolescent gender (referent—male) and race/ethnicity (referent—non-Latinx white), parent income (referent—≥$50,000), education (referent—some college or more) and unionship (referent—no), family closeness (1−24), parent and adolescent mental illness familiarity (0–3) and knowledge/attitudes (1–5), and adolescent symptom severity (referent—low/moderate) and perceived problem (referent—none). *p<0.05, **p<0.01, ***p<0.001.

When parents recognize a problem, parent help-seeking history reduces adolescent help-seeking.

Table 2 displays the model with the interaction term between parental help-seeking and problem recognition. When parents recognized a mental health problem in their adolescent, parent help-seeking history significantly reduced adolescent help-seeking long-term (p<0.01). Fig. 2 shows how post-estimated adjusted predicted counts of adolescent help-seeking reduced across greater parent help-seeking history in dyads with parent problem recognition (0.71–0.54; p<0.05), thereby supporting Hypothesis 2. We examined whether parent treatment-related norms explained these patterns and they did not (Appendix Table 5). Also, while parents reported higher knowledge/attitudes than adolescents overall and in the subsample with problem recognition (Table 1), these differences also did not explain these patterns.

Fig. 2.

Fig. 2

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Interaction of parent self mental health help-seeking history and recognition of adolescent mental health problem predicting counts of adolescent mental health help-seeking; Texas Stigma Study, 2011-2015

Note: Covariates set at mean values including baseline help-seeking, time, intervention; parent and adolescent gender and ethnicity; parent income, education, and unionship; family closeness; parent and adolescent mental illness familiarity and knowledge/attitudes; and adolescent symptom severity and perceived problem. Joint interaction test p<0.01; within subgroup test by parent problem recognition p<0.05.

When parents do not recognize a problem, parent help-seeking history promotes adolescent help-seeking.

The model in Table 2 also evidences Hypothesis 3 regarding increased autonomous adolescent help-seeking in the absence of parent problem recognition. In Fig. 2, post-estimated adjusted predicted counts of adolescent help-seeking increased from greater parent help-seeking history in dyads without parent problem recognition (0.43–0.96; p<0.05). We examined whether Pearlin Mastery scores (7-items; alpha = 0.75)—the extent to which adolescents view their life chances as being in their control—explained this pattern and they did not (Appendix Table 6). In Fig. 2, just one post-estimated adjusted predicted count of adolescent help-seeking achieved a value of about one (0.96): the effect of parent help-seeking history among dyads without parental problem recognition (i.e., greater adolescent help-seeking autonomy). This estimate suggests that the adolescent group with the greatest likelihood of help-seeking action overall, and thereby greater likelihood of receiving mental health support/care, belong to this specific context: parent help-seeking history plus adolescent autonomy.

4. Conclusions

Study findings provide evidence of familial transmission of help-seeking among parent-adolescent dyads, but the direction of influence depends on whether a parent recognizes a mental health problem in their adolescent, signaling distinct familial transmission processes. When a parent observes a mental health problem in their adolescent and exhibits a greater propensity to exercise an influence over adolescent help-seeking, parent help-seeking history deters adolescent help-seeking including to healthcare—findings that are consistent with NEM concerning how family members can espouse attitudes and behaviors that are incongruent with healthcare providers. In contrast, in the absence of parent problem recognition when adolescents’ choices are less constrained thereby enabling greater autonomy, parent help-seeking history promotes adolescent help-seeking—findings supported by SLT. Results suggest that help-seeking is patterned within families, learned based on observing parental experiences, and shaped by parent problem recognition. Therefore, help-seeking is not an individual, self-determined health behavior, but rather a collective and learned one; for young people, the first experiences of shared help-seeking occurs in their family.

Study findings suggest that a familial and social environment supportive of help-seeking may be important to affirm adolescent help-seeking. These contextual determinants include parents that have engaged in a form of help-seeking for themselves when needed, as well as lowering the socially structured constraints for adolescents to be able to help-seek on their own. Study data suggests that these two contextual factors are likely to support adolescent help-seeking, and more so than just parent problem recognition, and parents with no help-seeking history.

4.1. Implications of a “deterring” effect

While the NEM suggests network members can encourage or discourage help-seeking, our study found that parent help-seeking history was associated with parents deterring adolescent help-seeking when parents recognize a mental health problem and therefore have a greater influence concerning help-seeking decisions. Our explanation is that mental illness stigma and its consequences that occurred when parents sought help as part of a “package deal” may have shaped the belief that help-seeking is an unattractive deal for their adolescent. The parent's “package deal” experience turned parents away from promoting help-seeking for their adolescent in the future. Parents may develop different norms and values from treatment providers or lack trust/confidence in the mental health system. Perhaps parents believe that they can “treat” the problem themselves and search for a “new deal”—one that offers little stigma. Our findings are consistent with an Australian longitudinal cohort study of 634 parent-adolescent dyads that found high levels of parent overcontrol reduced mental healthcare use among adolescents, net of controls (Ryan et al., 2014). Moreover, psychiatric epidemiology has found that adolescents generally do not receive the level of care required to meet their collective mental health need even after controlling for severity and insurance/economic factors (Goodwin et al., 2022; Merikangas et al., 2011). Perhaps familial transmission partially explains this treatment gap. Finally, adolescent medicine has found that parents do deter services for adolescents despite having received similar healthcare themselves (English, Ford, Kahn, Kharbanda, & Middleman, 2013, Michaud et al., 2015; Pathak & Chou, 2019). If supported in future studies, this “deterring” help-seeking effect from parents to adolescents should be addressed through intervention and policy.

4.2. Implications of a “learned” effect

When adolescents are less contrained in their own help-seeking in the absence of parent problem recognition, the parent help-seeking influence serves as a promoter of adolescent help-seeking—a learned influence from parental modeling. SLT suggests that the observation of parent help-seeking and the selective learning process that followed likely deemed help-seeking as favorable, culminating in help-seeking action. Evidence of learned, autonomous help-seeking among adolescents carries important implications. First, developing accessible, holistic, and authentic interventions outside of clinical settings to foster autonomous help-seeking is important to meet the diverse mental health needs of adolescents. Second, future research that increases adolescent's perceptions of mental health may be important to catalyze help-seeking (Villatoro et al., 2018). Third, our findings suggest that in contexts where adolescents exhibit more autonomy, adolescents tend to act along similar values as healthcare providers and exhibited no signals of “impaired” or “immature” decision-making (e.g., non-compliant, inaction), which are common biases towards young people and those with mental illness. Efforts to combat biases related to decision-making competence among people with mental illness and in adolescence is clinically important as our findings dispute these stereotypes and support autonomous help-seeking.

4.3. Findings cohere with prior stigma theory

Courtesy stigma can result in family members keeping their treatment private from others outside the immediate family, rejecting a recommended treatment plan, or socially withdrawing, all resulting in negative personal and social consequences as described in the “package deal” (Link et al., 1989; Rosenfield, 1997). Future research should explore how stigma shapes familial help-seeking in the longterm and intergenerationally. For example, in dyads where parents recognized a problem and deterred help-seeking for the adolescent owing to the parent's own help-seeking history, it is possible that adolescents in these dyads learn stigmatizing attitudes and behaviors towards mental illness and avoid help-seeking in the future as adults. Future research must examine courtesy stigma among unique family members during different periods of the lifespan. For instance, greater understanding is needed about the longterm impacts of parental treatment-seeking on offspring's perceptions in their adulthood about their early observations of their parents. Do offspring realize stigma's deleterious effects on family outcomes longterm or conclude that their parent received beneficial mental health treatment? Do longterm perceptions of offspring regarding the value of help-seeking for the parent influence intergenerational approaches and patterns to mental health concerns? Do offspring become more willing to help-seek when confronted with a mental health problem in their networks, or do offspring not seek help, or keep mental health problems a secret, or self-harm? Future research should examine how different components of stigma, and their timing before, during, and after treatment, placed on unique family members can influence future help-seeking endorsements in multigenerational family units to assess how learning is shaped in families that normalize and encourage help-seeking versus those that devalue and deter it. Future research in this area can further our understanding of familial patterns of mental illnesses and how families learn to cope with them.

4.4. Extending adolescent help-seeking theory

Our findings fit into a broader set of adolescent health issues about parent gatekeeping and contexts in which adolescents partake in autonomous healthcare decision-making. Concerning mental health, relying on parents as the primary gatekeeper for entry into services may be a barrier for adolescents. As one in four adolescents experience adversity, including having a parent with mental illness or substance use problem, these adolescents may lack a sufficient level of parent capital that is required for entry into treatment (Bethell et al., 2017). For adolescents who want mental health services yet come from households that are unsupportive of mental health treatment or with models of potentially harmful responses to mental health problems such as self-medication, these adolescents may go without treatment or depend on the social safety net. Also large discrepancies between parents and adolescents in identifying a mental health problem exists, and parents' own stigma prevents their recognition of mental health issues in adolescents (Villatoro, DuPont-Reyes, Phelan, Painter, & Link, 2018). Notably, other settings such as school and Internet-based settings, as well as peers' role in help-seeking, has not been sufficiently leveraged to promote adolescent mental health despite evidence of schools' and peers’ gatekeeping role in mental health issues (Juszczak et al., 2003; Singh et al., 2019; Prinstein et al., 2000; Dishion, 2012). New help-seeking pathways for adolescents also can help address the low agreement between parents and adolescents in mental health problem recognition. Our study demonstrates the need to consider autonomous help-seeking pathways for adolescents to innovate new access points to mental health supports and promote long-lasting, effective help-seeking for young people.

4.5. Methodological limitations and strengths

Limitations of this current analysis require discussion. First, the 60% participation response rate required that consent/assent forms be returned to researchers (Painter et al., 2017). Nevertheless, the achieved study sample was representative of district school data. Second, familial transmission of help-seeking was examined in early adolescence only when older adolescents and young adults may hold even greater autonomy and prevalent mental illness to determine if similar patterns occur across the life course. Third, only one parent was asked to respond to the parent/guardian assessment in the longitudinal study and no efforts were made by study coordinators to recruit both parents according to gender or caregiving role. Thus, our sample of parents resulted in 85% women. As help-seeking and social learning can be a gendered and racialized process (Cauce et al., 2002; Bandura & Walters, 1977), future studies could apply an intersectional lens to examining familial transmission of help-seeking such as a study among parents/guardians of diverse gender and sexual identity (e.g., fathers, LGBTQI+) and their offspring. Finally, the assessment of parent help-seeking is binary and self-reported among parents, limiting information about the quality of the outcomes of the help-seeking processes of parents. To this limitation, the following information would be important added data to acquire and include in future related studies: the type and severity of parental mental health problems; the quality, context, and consequences surrounding parental help-seeking experiences; the components and levels of stigma encountered; and adolescent reports of direct or situational observations of parental help-seeking. For instance, data on length of time of in-patient versus out-patient services or beneficial versus catastrophic experiences (e.g., those involving coercion, contact with criminal justice, income loss, or family separation), and adolescent observations of these experiences, could help create new knowledge about the mechanisms of the familial transmission of help-seeking. We are also not able to assess familial transmission of help-seeking by different types of mental health problems across generations. Similarly, our study identified parent problem recognition as one component of gatekeeping. Results could vary with different types of assessments of the many other components of parental gatekeeping. Together our study limitations, and the complex pathways that NEM and SLT theories point to, ultimately require newly enriched longitudinal quantitative data collection on stigma and help-seeking among intergenerational dyads to further our understanding of the familial transmission of help-seeking.

Despite these limitations, this study included an ethnically/socioeconomically diverse sample of parent-adolescent dyads, employed longitudinal measures with good psychometric properties, and collected data at an opportune age in the development of mental health problems. Further, the analysis included a robust set of controls important to the theoretical underpinnings of this area of research. As mental health problems are generally poorly understood, the study controlled for mental illness familiarity and knowledge/attitudes among both parents and adolescents. As family dynamics and parental quality can influence help-seeking, the study controlled for family closeness and parental union. Social selection into various treatment pathways was controlled for across race, ethnicity, gender, class, and clinical need. Finally, sensitivity analyses identified no interactions with race/ethnic identity and parent help-seeking to test if potential negative treatment experiences occurred among minority parents only, or if patterns varied according to adolescent gender or mental health severity or type.

4.6. Conclusion: family-informed future research directions

Our study's findings point to the value of examining familial transmission of help-seeking according to whether or not parents recognize a problem in their adolescent to reveal unique intergenerationally transmitted processes. The study findings support our hypotheses that familial transmission of help-seeking starts early in adolescence and can be influenced by parent modeling and gatekeeping of help-seeking, though explanations for the patterns observed require further study to ascertain. Future research on the familial transmission of help-seeking across parent problem recognition is important to innovate new ways to interrupt intergenerational cycles of mental health problems to better serve the needs of families coping with mental illness across multiple generations. This area of study is highly relevant to providers who work with dynamic family units. Generating new knowledge about familial transmission of help-seeking also confronts the long-standing accepted norm about mental illness fatalism and chronicity as scientific, clinical, and social settings (Cohen & Cohen, 1984), where familial transmission of mental illness is often perceived as a hopeless cycle when it may be partly due to familial transmission of help-seeking. Unlike this notion of incurability attached to intergenerational psychopathology, the concept of a familial transmission of help-seeking can be researched and understood, thereby informing action-oriented theory and interventions that promote acceptance and help families confront mental illness with coping strategies for improved health, social integration, and mobility. Examining modifiable etiological factors of familial aggregation of mental illness such as help-seeking is a promising, pragmatic approach to population mental health and rooted in the reality of the productive lives that people coping with mental illnesses lead and their family members.

Ethics statement

The study received research ethics approval from Columbia University and MHMR of Tarrant County.

Conflicts of interests

None to declare.

CRediT authorship contribution statement

Melissa J. DuPont-Reyes: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Validation, Visualization, Writing – original draft, Writing – review & editing. Alice P. Villatoro: Methodology, Validation, Visualization, Writing – review & editing, Formal analysis, Investigation. Jo C. Phelan: Data curation, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Visualization, Writing – review & editing. Kris Painter: Data curation, Funding acquisition, Investigation, Project administration, Resources, Supervision. Bruce G. Link: Data curation, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – review & editing.

Acknowledgement

This study was supported by National Institute of Mental Health [#R01MH095254; #T32MH13043] and registered with ClinicalTrials.gov [NCT03597048 “A School-Based Intervention to Reduce Stigma & Promote Mental-Health Service Use].

Footnotes

Appendix A

Supplementary data to this article can be found online at https://doi.org/10.1016/j.ssmph.2024.101695.

Appendix A. Supplementary data

The following is the Supplementary data to this article:

Multimedia component 1
mmc1.docx (67.8KB, docx)

Data availability

Data will be made available on request.

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