Abstract
Too few children receive the mental health care that they need. This cross-sectional study aimed to investigate the non-perception of children’s mental health problem care needs among parents of children aged 3 to 17 years identified as having mental health difficulties (MHDs) and to explore the associated factors. In the French random population-based EpiCov study, 21,092 parents reported, for one randomly selected child, their perceptions of the child’s needs for care and the child’s MHDs using the Strengths and Difficulties Questionnaire (SDQ). Multivariable Poisson regression models were used. Among the participating parents, 57.6% were women, and 44.9% of their children were female. A total of 6,338 parents reported at least one abnormal SDQ subscale score pertaining to emotional problems, peer relationship problems, hyperactivity/inattention problems or conduct problems; however, 65.1% of these parents did not perceive their child to be in need of psychological care. The risk factors associated with the nonperception of the need for mental health care among both boys and girls included being a male parent, having a lower educational level, living in an area characterized by low access to primary care, and having no personal history of mental health conditions. Children who were younger than 5 years old faced a greater risk of an unrecognized need for mental health care, whereas the need for care exhibited by children who experienced a greater number of MHDs was less likely to remain unrecognized. These findings highlight the underperception of mental health difficulties among children and emphasize the importance of public health initiatives aimed at improving mental health literacy and access to care among parents.
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1007/s00787-026-03127-y.
Keywords: Mental health, Children and adolescents, Need for care, Parental perception, Strengths and difficulties questionnaire
Introduction
Childhood and adolescence are peak periods for the onset of common mental health disorders such as anxiety, depression, and ADHD [1, 2]. Approximately one in eight children and adolescents suffers some degree of impairment because of mental health problems [3] and half of the adults diagnosed with such disorders had their first episode during childhood or adolescence [4]. The COVID-19 pandemic resulted in widespread psychological distress, in which context children and adolescents have been identified as particularly vulnerable groups [5–7]. The life condition of families changed suddenly and deeply during this period, as children interacted nearly exclusively with their parents in the home environment. This change resulted in increased parental stress and exhaustion, which might have made it difficult for parents to distinguish between their children’s normal reactions in this context and issues that required medical attention. Despite increasing needs in this regard, only a small proportion of children and adolescents with mental health needs actually receive care [8–10]. National surveys conducted in the U.S., the UK and Australia have estimated that only 25–56% of children and adolescents with mental health needs have access to mental health care services, and particularly low access rates have been reported with respect to internalizing problems in comparison with externalizing problems [11]. If children with mental and behavioral health disorders are left untreated, they may experience academic difficulties, including repeated absences, higher rates of school suspension or expulsion, and an increased risk of failing or dropping out of high school [12, 13]. Moreover, they are at increased risk for serious negative outcomes into adulthood, including lower income, substance abuse, family conflict and violence [2, 14]. Thus, childhood and adolescence represent critical periods for efforts to promote prevention, early detection, and interventions aimed at improving these individuals’ mental and behavioral health (APA, 2019) [15].
As children and adolescents are rarely able to seek care on their own [11] and thus depend on a parent or caregiver [8], adult gatekeepers, particularly their parents, are expected to identify problematic behaviors or disorders and to seek help and request care on their behalf. The ways in which parents recognize mental health problems in their children may significantly influence the help-seeking process and shape the future illness trajectories of children with mental health disorders [9]. Cauce and colleagues reported that the process of help-seeking by parents involves three interrelated steps: first, the perception of the problem, i.e., the perception that the symptoms and/or behaviors observed are problematic, followed by the decision to seek help and request care, and, finally, the choice of treatment [16]. Difficulties may be identified by parents through several complementary pathways. Such difficulties may become apparent in light of changes in their child’s behavior, mood or habits and/or the impacts of those factors on the child’s daily functioning, such as family interactions, academic performance, or relationships with peers. Parents may also detect concerns through direct observations, particularly by comparing their child’s behavior and development to what is expected of children at the same age. Difficulties can also be identified through the use of psychometric tools. However, the presence of symptoms may not always align with the ways in which parents perceive mental difficulties in their children and whether they consider specific symptom patterns to be problematic [16]. Perception of the need for care can be assessed by examining the extent to which parents acknowledge the presence, severity, and potential consequences of their child’s health problems, including in terms of their intentions or actual behaviors regarding consultation with health care services. Although studies have reported that parents’ perceptions of their child’s need for help increase the likelihood of the child receiving services [17], factors pertaining to parents’ nonperception of this need, including a failure to detect symptoms or an underestimation of the severity and impact of such symptoms, have received less exploration than have factors associated with service use, whether by parents or by young people.
Previous studies have highlighted several influential factors that contribute to parents’ perceptions of mental health problems among adolescents, including the nature of the problem, parents’ previous exposure to mental illness, and parents’ knowledge of mental health and family characteristics [9, 18]. However, no study has examined this question by reference to a large sample extending from childhood to adolescence. To obtain a better understanding of the factors that influence parents’ ability to recognize their child’s mental health needs even before they seek care, this study aimed to (a) estimate the proportion of nonperception of problems among parents of children who are between the ages of 3 and 17 years and have been identified as experiencing mental health difficulties in the general population in France and (b) explore the factors associated with parents’ nonperception of the need for mental health care among children who experience mental health difficulties. We also investigated potential differences in these risk factors between boys and girls, which might be to the result of disparities in the clinical presentation of mental disorders and/or gendered expectations and norms regarding children’s mental health and healthcare [19].
Methods
Study design and population
This cross-sectional study used data obtained from the second follow-up of the French national random population-based EpiCov (Epidémiologie et Conditions de vie au temps du COVID) study, which was designed to assess the main characteristics of the COVID-19 pandemic and its impacts on sociodemographic and health outcomes [20]. The EpiCov study followed 134,391 individuals who consented to participate from a total population of 371,000 individuals aged 15 years or older, who were randomly selected in May 2020 from the French National Administrative and Tax Register, which covers 96.4% of the population living in France, across four rounds of data collection that were conducted between spring 2020 and autumn 2022. All the selected individuals were contacted by post, e-mail and text messages. Data were collected through self-computer-assisted web interviews (CAWIs) or computer-assisted telephone interviews (CATIs) and covered a wide variety of health characteristics, including mental health, healthcare, and sociodemographic characteristics.
Among the 85 074 participants in the second follow-up, which took place in July 2021, 21,092 individuals were parents with at least one child aged 3–17 years. They were asked to complete the Strength and Difficulties Questionnaire (SDQ) for one randomly selected child and to answer questions concerning the child’s lifestyle and healthcare use. The SDQ is a valid and simple screening instrument that targets children’s internalizing and externalizing behaviors and has been widely used in both research and clinical settings; furthermore, this instrument is renowned for its rapid administration and acceptable psychometric properties [21, 22]. This 25-item questionnaire is divided into five subscales: four that assess mental health difficulties (emotional problems (EPs) and peer relationship problems (PPs), which can be grouped as internalizing behaviors, as well as hyperactivity/inattention problems (HPs) and conduct problems (CPs), which can be grouped as externalizing behaviors, and one that assesses prosocial behavior (which is not considered in the present study) over the past six months [23–25]. The psychometric properties of the French version of the SDQ were evaluated by reference to a subgroup of the original cohort EpiCov study that included participants who had at least one child aged 3 to 17 years and indicated acceptable internal consistency [26]. Items are scored on a 3-point scale: “not true” (0), “somewhat true” (1), and “certainly true” (2). The responses are summed to yield subscale scores ranging from 0 to 10, with higher scores indicating greater difficulties (except for prosocial behavior). The recommended cutoff scores used to identify children with mental health difficulties were as follows: ≥ 5 for EPs, ≥ 4 for PPs, ≥ 7 for HPs, and ≥ 4 for CPs [27]. Internalizing problems were considered when the scores were ≥ 5 for EPs and/or ≥ 4 for PPs; externalizing problems were considered when the scores were ≥ 7 for HPs and/or ≥ 4 for CPs. In the present study, only the 6,338 parents of children who were identified by the SDQ as experiencing at least one mental health difficulty were included in the analyses (Fig. 1).
Fig. 1.
Study population flowchart. Percentages were weighted to account for the EpiCov study design and nonparticipation
The study was approved by the French Data Protection Authority (Commission Nationale Informatique et Libertés, CNIL, MLD/MFI/AR205138) and an ethics committee (Comité de Protection des Personnes Sud Méditerranée III 2020-A01191-38).
Outcome: children’s mental health care needs according to their parents
To identify children’s mental health care needs as perceived by their parents, two questions were posed: “Since the beginning of the epidemic (March 2020), has your child consulted a health professional for psychological difficulties or because he or she was not feeling well?” (yes vs. no) and “Did you feel that your child needed help for psychological difficulties or because he or she was not feeling well?” (yes vs. no). On the basis of these questions, a two-category variable was created: (i) parents’ perception of the child’s mental health care needs, with or without care use, and (ii) parents’ nonperception of the child’s mental health care needs.
Covariates: potential risk factors pertaining to the nonperception of the need for mental health care
Andersen’s behavioral model, which aims to explain healthcare utilization, was used to identify potential risk factors pertaining to the nonperception of the need for mental health care available in the EpiCov study [28]. This model focuses on three core components: predisposing factors, enabling resources and need factors. Given that the parents included in the analyses were selected if their child was identified as experiencing at least one mental health difficulty, all were considered to need mental health care. Therefore, only predisposing factors and enabling resources were selected from the set of the variables available in the EpiCov study, including children’s and parents’ sociodemographic characteristics, living conditions, social and family resources, and parental health status [28, 29].
Child and parent sociodemographic characteristics
The following parental sociodemographic variables were used: age (divided into groups of < 30, 30–39, 40–49, and ≥ 50 years), sex, place of birth (born outside France, born in France to parents born in France, or born in France to parents born outside France), household composition (couple vs. single parent), number of children per household, perceived financial situation (comfortable, adequate, tight, difficult or unbearable), educational level (none, lower secondary school certificate, higher secondary school certificate, bachelor’s degree or equivalent, or higher than a bachelor’s degree or equivalent) and occupational status.
The children’s characteristics included sex and age group (3–5 years, 6–10 years, and 11–17 years).
Living conditions and social family resources
The following characteristics pertaining to selected living conditions were considered : household overcrowding (< 1, 1 and > 1 room per person), access to an outdoor space at home (i.e., a balcony or garden), residence in a priority neighborhood (which was defined as an area in which the poorest inhabitants of cities live and as a high-priority target for urban policies), access to general health care, as determined by the density of primary care physicians per department and per 100,000 inhabitants (Conseil National de l’Ordre des Médecins) ( https://www.conseil-national.medecin.fr/lordre-medecins/conseil-national-lordre/demographie-medicale ), and both the average daily time that children spent using screen media and the average daily time that children spent engaging in physical activity (< 1 h per day, between 1 and 6 h per day, and > 6 h per day).
Social support was assessed by the Oslo Social Support Scale (OSSS-3). This three-item scale focuses on the number of close confidants, the level of perceived concern from others, and relationships with neighbors, with a focus on the accessibility of practical help. Total scores range from 3 to 14, and the relevant cutoffs indicate low (3–8), moderate (9–11), and strong (12–14) levels of social support [30].
Parental health status
The following variables pertaining to both the somatic and the psychiatric health of parents were considered: self-reported history of somatic conditions (yes/no), body mass index (BMI in kg/m2 categorized as < 18.5, 18.5 and less than 25, ≥ 25 and less than 30, ≥ 30), self-reported history of psychiatric conditions (yes/no), self-reported suicidal ideation in the past 6 months, and depression and anxiety levels, which were assessed via the self-administered nine-item Patient Health Questionnaire (PHQ-9) and the seven-item Generalized Anxiety Disorder Scale (GAD-7), respectively. The PHQ-9 refers to symptoms that have been experienced during the previous two weeks and produces total scores that range from 0 to 27. A validated cutoff score ≥ 10 was used to indicate moderate to severe depression [31]. The GAD-7 assesses symptom severity over the previous two weeks and yields total scores that range from 0 to 21, with a validated cutoff score of ≥10 indicating moderate to severe anxiety [32]. Based on the PHQ-9 and GAD-7 scores, as well as data concerning suicidal ideation and self-reported psychiatric history, a three-category variable was created to describe parents’ mental health status: (i) parents with a history of psychiatric conditions; (ii) parents with no history of psychiatric conditions but with current PHQ-9 or GAD-7 scores ≥ 10 and/or suicidal ideation in the past six months; and (iii) parents with no history of psychiatric conditions, no suicidal ideation, and current GAD-7 and PHQ-9 scores < 10.
Statistical analyses
Analyses were performed on the full sample and stratified by child sex. Study weights, calculated as previously described [20], were applied to all descriptive analyses to account for the EpiCov study design and nonparticipation bias. Categorical variables are thus described as frequencies and weighted percentages. All tests were two-sided, and the type I error rate was set at 5% with no correction for multiple testing. Given that numerous—potentially collinear—risk factors for the nonperception of the child’s mental health care needs were identified in EpiCov by reference to Andersen’s theory, we chose to preselect the variables that were included in our final multivariable models on the basis of statistical criteria. Bivariate analyses were conducted in accordance with parental perceptions of children’s mental health care needs using weighted chi-square tests to identify potential risk factors associated with nonperception (p < 0.20). A weighted multivariable modified Poisson regression model with robust error variance (svyglm function of the survey package in R) was then used to identify factors that were independently associated with the nonperception of the child’s mental health care needs (vs. perception with or without care use) [33]. The number of mental health difficulties (1 to 4) and the child’s age group were entered into the model. The type of difficulty was not entered into the model because of collinearity with the number of mental health difficulties. All other variables were selected following bivariate analyses, and a backward stepwise selection procedure was employed: at each step, the variable with the highest p value was removed from the model if the parameters of the remaining variables changed by 10% or less after its removal. Variance inflation factors (VIFs) were used to assess multicollinearity. The strength of associations is expressed in terms of prevalence ratios (PRs) with 95% confidence intervals (CIs). We tested for interactions between child sex and each variable in a global model including both boys and girls using nested model tests. Missing data concerning covariates (up to 18.8%) were addressed through multiple imputation by chained equations (MICE) with the mice package in R (see Supplementary material 1) [34–36], and the results obtained in this manner were compared with the results obtained on complete cases in a sensitivity analysis. All analyses were performed using R software, version 4.5.1 (R Foundation for Statistical Computing).
Results
Children’s mental health difficulties and parents’ perceptions of their mental health care needs
As indicated in Fig. 1, among the 6,338 parents with a child identified as having at least one mental health difficulty, EPs and PPs accounted for 37.7% and 45.5% of the children, respectively, whereas CPs and HPs accounted for 36.8% and 31.5%, respectively. Consequently, 69.4% of the children were identified as having an internalizing behavior difficulty, and 54.3% were identified as having an externalizing behavior difficulty. With respect to the number of mental health difficulties, 62.5% of the children had one mental health difficulty, 25.6% had two, 9.8% had three and 2.0% had four. Among the 6,338 parents, 65.1% did not recognize their child as needing mental health care. Figure 2 presents the distribution of the parental perceptions of mental health care needs according to the number of mental health difficulties, the type of behaviors (i.e., internalizing vs. externalizing), and the specific type of mental health difficulty, stratified by child sex. The frequency of parental nonperception was high in the case of both internalizing or externalizing disorders, and statistically significant differences were observed between parents who perceived a need and those who did not according to the number of difficulties and the type of behaviors exhibited (see Supplementary materials 2 & 3).
Fig. 2.
Distribution of parental perceptions of children’s mental health needs according to the number and type of difficulties in boys and girls. MHD, Mental Health Difficulty identified using the Strengths and Difficulties Questionnaire; MH, Mental Health; EP, Emotional Problems; PP, Peer relationships Problems; CP, Conduct Problems; HP, Hyperactivity/InattentionPercentages were weighted to account for the EpiCov study design and nonparticipation
Participants’ sociodemographic, living and health status characteristics
Participants’ sociodemographic characteristics are summarized in Table 1, and their living conditions, social support and parental health status characteristics are presented in Table 2, according to the child’s sex and the level of parental perception of the child’s mental health needs. Most parents were female (57.6%), and 79.5% were aged between 31 and 50 years, Among the children, 55.1% were male, and more than half were aged 3–10 years. With respect to their parents’ mental health status, 15.6% of parents had a history of psychiatric conditions, whereas 11.1% had no such history but reported current suicidal ideation and/or moderate to severe levels of anxiety and/or depression. One-quarter of parents lived in an area that was identified as featuring low access to primary care. No need for care was perceived for 58.7% of the girls and 66% of the boys. In both boys and girls, significant differences were observed according to parental perceptions of the child’s mental health care needs. Nonperception was more frequent among younger children (aged 3–5 years), when the responding parent was male (72.4% and 67.3% of nonperception for boys and girls, respectively; p values < 0.001), among those with a lower educational level, and when the responding parent did not report any mental or physical health problems (72.3% of nonperception for boys and 66.0% for girls; p values < 0.001). Nonperception was also more frequent among parents who lived in areas with a low density of primary care physicians.
Table 1.
Sociodemographic characteristics of the sample (N = 6338)
| Total sample N = 6338 |
Boys N = 3416 |
Girls N = 2900 |
||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Nonperception of needs for care | Nonperception of needs for care |
|||||||||
| N | % | N | n | % | p value | N | n | % | p value | |
| Age | ||||||||||
| < 30 | 138 | 3.3 | 68 | 46 | 68.2 | 0.399 | 69 | 46 | 61.9 | 0.190 |
| 30–39 | 1975 | 36.0 | 1076 | 692 | 65.4 | 891 | 570 | 65.3 | ||
| 40–49 | 3044 | 43.5 | 1627 | 1077 | 68.8 | 1405 | 805 | 59.3 | ||
| ≥ 50 | 1181 | 17.3 | 645 | 439 | 70.7 | 535 | 281 | 59.4 | ||
| Parent’s sex (missing = 2) | ||||||||||
| Male | 2427 | 42.4 | 1347 | 942 | 72.4 | < 0.001 | 1070 | 700 | 67.3 | < 0.001 |
| Female | 3909 | 57.6 | 2067 | 1311 | 64.3 | 1830 | 1002 | 57.6 | ||
| Parent’s place of birth (missing = 351) | ||||||||||
| France to parents born in France | 4985 | 75.0 | 2703 | 1757 | 65.5 | 0.038 | 2265 | 1296 | 59.3 | < 0.001 |
| France to parents born outside France | 505 | 9.1 | 268 | 177 | 70.4 | 236 | 134 | 53.9 | ||
| Outside France | 497 | 16.0 | 260 | 188 | 75.6 | 235 | 153 | 74.1 | ||
| Child age group | ||||||||||
| 3–5 years | 1217 | 20.4 | 704 | 509 | 73.8 | 0.001 | 510 | 379 | 76.7 | < 0.001 |
| 6–10 years | 2104 | 34.4 | 1172 | 721 | 62.4 | 923 | 556 | 59.1 | ||
| 11–17 years | 3017 | 45.2 | 1540 | 1024 | 69.4 | 1467 | 767 | 57.1 | ||
| Marital status | ||||||||||
| Married/living with a partner | 5396 | 82.2 | 2935 | 1945 | 68.5 | 0.292 | 2444 | 1498 | 64.5 | < 0.001 |
| Single parent | 942 | 17.8 | 481 | 309 | 64.4 | 456 | 204 | 48.4 | ||
| Number of children under 18 at home | ||||||||||
| 1 | 2532 | 39.2 | 1318 | 892 | 68.9 | 0.533 | 1208 | 676 | 59.1 | 0.521 |
| 2 | 2881 | 43.8 | 1555 | 1002 | 67.0 | 1316 | 788 | 63.2 | ||
| 3 | 738 | 12.9 | 429 | 279 | 70.0 | 303 | 196 | 63.3 | ||
| 4 or more | 187 | 4.1 | 114 | 81 | 61.8 | 73 | 42 | 62.4 | ||
| Parental education level (missing = 13) | ||||||||||
| None | 282 | 11.1 | 156 | 115 | 74.2 | 0.114 | 125 | 93 | 81.5 | < 0.001 |
| Lower than high school certificate | 2099 | 39.0 | 1126 | 774 | 68.6 | 966 | 615 | 64.8 | ||
| High school certificate | 789 | 12.0 | 401 | 271 | 68.4 | 387 | 220 | 58.1 | ||
| Bachelor’s degree or equivalent | 1179 | 16.6 | 638 | 421 | 68.2 | 537 | 309 | 56.3 | ||
| Higher than bachelor’s degree or equivalent | 1976 | 21.3 | 1087 | 667 | 62.0 | 881 | 463 | 52.5 | ||
| Occupational status (missing = 9) | ||||||||||
| Employed | 5237 | 76.5 | 1880 | 69.2 | 0.072 | 1405 | 61.3 | 0.766 | ||
| Unemployed | 1092 | 23.5 | 371 | 63.5 | 293 | 62.2 | ||||
| Self-perceived financial status (missing = 3) | ||||||||||
| Comfortable | 923 | 10.5 | 516 | 343 | 68.5 | < 0.001 | 404 | 236 | 59.8 | 0.639 |
| Adequate | 2499 | 35.1 | 1377 | 919 | 69.6 | 1115 | 658 | 62.6 | ||
| Tight | 2037 | 35.2 | 1058 | 718 | 71.5 | 972 | 567 | 60.4 | ||
| Difficult/unbearable | 876 | 19.2 | 464 | 273 | 57.9 | 407 | 239 | 63.2 | ||
The percentages are weighted by the sampling weight (the inverse of the inclusion probability), corrected for nonresponse probability and calibrated on the margin of the census. The prevalence is not equal to n/N
Table 2.
Living, social support and participants’ health status characteristics (N = 6338)
| Total sampleN = 6338 | BoysN = 3416 | GirlsN = 2900 | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Nonperception of needs for care | Nonperception ofneeds for care | |||||||||
| N | % | N | n | % | p value | N | n | % | p value | |
| Usual residence overcrowded (missing = 12) | ||||||||||
| < 1 room per person | 671 | 10.9 | 355 | 218 | 64.3 | 0.495 | 314 | 171 | 58.8 | 0.216 |
| 1 room per person | 5212 | 81.1 | 2820 | 1877 | 68.0 | 2374 | 1415 | 62.5 | ||
| > 1 room per person | 443 | 8.0 | 233 | 152 | 69.5 | 208 | 114 | 55.7 | ||
| Living in a priority neighborhood | ||||||||||
| No | 6051 | 91.3 | 3262 | 2147 | 67.4 | 0.281 | 2769 | 1617 | 60.5 | 0.008 |
| Yes | 287 | 8.7 | 154 | 107 | 73 | 131 | 85 | 73.8 | ||
| Access to a private outside space (missing = 39) | ||||||||||
| No access | 397 | 9.1 | 221 | 150 | 74.7 | 0.093 | 176 | 93 | 61.9 | 0.951 |
| Private balcony/garden | 5902 | 90.9 | 3172 | 2087 | 89.0 | 2708 | 1601 | 61.9 | ||
| Time spent by the child on physical activity (missing = 1197) | ||||||||||
| < 1 h a day | 1209 | 24.6 | 553 | 362 | 64.1 | 0.259 | 648 | 346 | 59.6 | 0.416 |
| 1–6 h a day | 3379 | 64.4 | 1901 | 1277 | 69.6 | 1466 | 878 | 62.3 | ||
| > 6 h a day | 553 | 10.9 | 335 | 231 | 69.0 | 217 | 143 | 65.7 | ||
| Time spent by the child on screen media (missing = 707) | ||||||||||
| < 1 h per day | 529 | 9.2 | 276 | 172 | 69.6 | 0.126 | 251 | 153 | 64.3 | 0.005 |
| 1–6 h per day | 3852 | 69.3 | 2049 | 1352 | 64.1 | 1789 | 1073 | 62.3 | ||
| > 6 h per day | 1250 | 21.6 | 703 | 453 | 69.0 | 542 | 257 | 52.2 | ||
| OSSS-3 (missing = 17) | ||||||||||
| Low | 1411 | 25.1 | 784 | 500 | 66.5 | 0.759 | 622 | 344 | 56.6 | 0.063 |
| Moderate | 3105 | 47.4 | 1661 | 1103 | 68.0 | 1435 | 848 | 62.5 | ||
| Strong | 1805 | 27.5 | 967 | 648 | 68.6 | 833 | 504 | 64.0 | ||
| Parental mental health status (missing = 22) | ||||||||||
| No history of psychiatric conditions and scores on PHQ-9 and GAD-7 < 10 | 4579 | 73.3 | 2487 | 1742 | 72.3 | < 0.001 | 2078 | 1316 | 66.0 | < 0.001 |
| History of psychiatric conditions | 975 | 15.6 | 522 | 299 | 57.3 | 448 | 234 | 52.2 | ||
| No history of psychiatric conditions and scores on PHQ-9 and GAD-7 ≥10 | 762 | 11.1 | 397 | 206 | 52.2 | 362 | 144 | 46.7 | ||
| Parent’s body mass index (missing = 42) | ||||||||||
| Underweight | 164 | 2.4 | 103 | 58 | 56.6 | 0.034 | 61 | 29 | 57.3 | 0.286 |
| Normal | 3045 | 44.4 | 1604 | 1045 | 65.9 | 1430 | 822 | 59.2 | ||
| Overweight | 1994 | 33.5 | 1092 | 719 | 69.4 | 893 | 547 | 62.7 | ||
| Obesity | 1093 | 19.6 | 592 | 415 | 72.3 | 499 | 294 | 64.7 | ||
| Presence of chronic somatic disorders | ||||||||||
| Yes | 1762 | 28.0 | 930 | 587 | 63.1 | 0.011 | 827 | 435 | 57.7 | 0.041 |
| No | 4576 | 72.0 | 2486 | 1667 | 69.7 | 2073 | 1267 | 63.1 | ||
| Primary care physician density (missing = 59) | ||||||||||
| 1rst quartile (lowest rate) | 1573 | 25.9 | 875 | 587 | 73.2 | 0.032 | 691 | 439 | 68.7 | 0.004 |
| 2nd quartile | 1214 | 18.7 | 657 | 444 | 66.3 | 554 | 328 | 60.3 | ||
| 3rd quartile | 1522 | 23.3 | 790 | 527 | 67.8 | 725 | 427 | 58.8 | ||
| 4th quartile (highest rate) | 1970 | 32.1 | 1061 | 676 | 64.9 | 904 | 492 | 58.4 | ||
OSSS-3, Oslo Social Support Scale; PHQ-9, 9-item Patient Health Questionnaire; GAD-7, 7-item Generalized Anxiety Disorder Scale
The percentages are weighted by the sampling weight (the inverse of the inclusion probability), corrected for nonresponse probability and calibrated on the margin of the census. The prevalence is not equal to n/N
Factors associated with parents’ nonperception of the need for care
Among the variables tested in the bivariate analyses, those considered as candidates for inclusion in the multivariable models (p < 0.2) were the responding parent’s sex, place of birth, marital status, educational level, occupational status, and self-perceived financial status, as well as access to a private outdoor space, the time spent by the child on physical activity and screen media, the density of primary care physicians in the area of residence, social support, and parental chronic somatic and mental conditions. The VIF values were less than 2, thus indicating no evidence of multicollinearity. The results of the multivariable analyses of factors associated with parents’ nonperception of their child’s need for care are presented in Table 3 and illustrated in Supplementary material 4.
Table 3.
Factors associated with parents’ nonperception of the need for care
| Nonperception of the need for care | |||||||
|---|---|---|---|---|---|---|---|
| Boys | Girls | ||||||
| PR | CI | p value | PR | CI | p value |
Interaction
p value |
|
| Sociodemographic characteristics | |||||||
| Sex (male vs. female) | 1.07 | 1.01–1.14 | 0.026 | 1.08 | 1.01–1.16 | 0.026 | 0.23 |
| Marital status (ref: married/lived-with a partner) | 0.626 | 0.001 | 0.22 | ||||
| Single parent | 0.98 | 0.89–1.07 | 0.81 | 0.72–0.92 | |||
| Parental educational level (ref: ≥ bachelor’s degree) | 0.001 | < 0.001 | < 0.005 | ||||
| None/lower than high school certificate | 1.14 | 1.06–1.22 | 1.34 | 1.23–1.47 | |||
| High school certificate | 1.11 | 1.03–1.20 | 1.12 | 1.01–1.23 | |||
| Place of birth (ref: in France to French parents) | 0.11 | < 0.001 | 0.06 | ||||
| In France to parents born outside France | 1.07 | 0.96–1.19 | 0.91 | 0.79–1.05 | |||
| Outside France | 1.10 | 0.99–1.22 | 1.18 | 1.07–1.31 | |||
| Self-perceived financial status (ref: adequate) | 0.06 | 0.41 | 0.03 | ||||
| Comfortable | 1.02 | 0.92–1.12 | 0.97 | 0.87–1.09 | |||
| Tight | 1.03 | 0.97–1.09 | 0.96 | 0.88–1.03 | |||
| Difficult/unbearable | 0.88 | 0.79–0.99 | 1.04 | 0.94–1.15 | |||
| Child age group (ref: 3–5 years) | 0.012 | < 0.001 | < 0.005 | ||||
| 6–10 years | 0.87 | 0.80–0.94 | 0.80 | 0.74–0.87 | |||
| 11–17 years | 0.95 | 0.88–1.02 | 0.77 | 0.71–0.83 | |||
| Living characteristics | |||||||
| Access to a private outside space (ref: yes) | 1.09 | 0.98–1.20 | 0.11 | 1.03 | 0.89–1.20 | 0.66 | 0.76 |
| Time spent by the child on physical activity (ref: 1–6 h a day) | 0.43 | 0.36 | 0.84 | ||||
| <1 h a day | 0.95 | 0.87–1.03 | 0.95 | 0.88–1.06 | |||
| > 6 h a day | 1.01 | 0.92–1.11 | 1.07 | 0.94–1.20 | |||
| Primary care physician density in the place of residence living (ref: 4th quartile-highest rate) | 0.04 | 0.01 | 0.45 | ||||
| 1st quartile-lowest rate | 1.13 | 1.04–1.22 | 1.14 | 1.05–1.24 | |||
| 2nd quartile | 1.07 | 0.97–1.18 | 1.01 | 0.91–1.12 | |||
| 3rd quartile | 1.07 | 0.98–1.16 | 1.01 | 0.92–1.11 | |||
| Parental and child health status | |||||||
| Presence of chronic somatic disorders (ref: no) | 0.95 | 0.88–1.02 | 0.13 | 0.92 | 0.85–0.99 | 0.04 | 0.90 |
| Parental mental health status (ref: no history of psychiatric conditions and normal scores on GAD-7/PHQ-9 and no suicidal ideation) | < 0.005 | < 0.005 | 0.82 | ||||
| No history of psychiatric disorders and abnormal scores on GAD-7/PHQ-9 or suicidal ideations | 0.88 | 0.80–0.98 | 0.86 | 0.76–0.96 | |||
| History of psychiatric disorders | 0.80 | 0.71–0.90 | 0.77 | 0.67–0.88 | |||
| Number of MHDs on the SDQ (ref: one) | < 0.005 | < 0.005 | 0.15 | ||||
| Two | 0.74 | 0.68–0.80 | 0.69 | 0.63–0.76 | |||
| Three | 0.63 | 0.54–0.73 | 0.76 | 0.65–0.89 | |||
| Four | 0.24 | 0.11–0.53 | 0.45 | 0.27–0.74 | |||
GAD-7 7-item Generalized Anxiety Disorder Scale, MHD mental health difficulty, PHQ-9 9-item Patient Health Questionnaire, PR prevalence ratio, SDQ Strengths and Difficulties Questionnaire
In both boys and girls, a male parent, a parental educational level below a bachelor’s degree or equivalent, and lower access to primary care physicians in the area of residence were associated with an increased risk of nonperception of the need for mental health care. A significant interaction was observed between the parent’s educational level and the child’s sex (p < 0.005), indicating a higher risk of nonperception among girls when the parent had a low educational level compared with boys. In contrast, an older child age group, a higher number of mental health difficulties, and both current and past parental psychiatric conditions were associated with a lower risk of nonperception. A significant interaction was also observed between the child age group and child sex (p < 0.005), indicating a lower risk of nonperception for older children among girls than among boys.
Among girls only, the risk of nonperception of mental health care needs was greater when the responding parent was born outside France (PR = 1.18, 95% CI: 1.07–1.31) and lower when the parent was a single parent (PR = 0.81, 95% CI: 0.71–0.92) or reported a chronic somatic condition (PR = 0.92, 95% CI: 0.85–0.99). Among boys, the risk of nonperception was lower when the responding parent perceived his or her financial situation as difficult or unbearable (PR = 0.88, 95% CI: 0.79–0.99; significant interaction with child sex, with no such association observed in girls). All the values are presented in Table 3.
Discussion
Among parents of children who exhibit at least one SDQ-identified mental health difficulty, nearly two-thirds did not perceive their child’s behaviors as sufficiently problematic to warrant intervention. Previous studies have also reported that preschool- and school-aged children who met the criteria for a psychiatric disorder were often not perceived by their parents as needing help, although not to such a high extent [37, 38]. This finding may be partly explained by the fact that the SDQ used is a screening tool rather than a diagnostic instrument, although the revised cutoffs reported in a Brazilian study improved specificity without compromising sensitivity, which favors approaches based on screening and diagnosis with the SDQ [39]. Spitzer noted that diagnosis and the need for treatment are not the same [40]. In line with this, the particularly high proportion of nonperception does not entail that all children have a clinical need for care. However, abnormal scale scores indicate a cause for concern, and further clinical assessment would theoretically be required to better understand the problems identified through these scales to characterize the nature and frequency of the difficulties, and determine the most appropriate form of support [41]. Without parental concern as an initial catalyst, referrals to mental health services rarely occur, thereby delaying interventions during a critical developmental window.
Given that parents serve as the drivers of most referrals, understanding the factors that influence parents’ nonperception of the need for mental health is crucial. In terms of sociodemographic characteristics, male sex on the part of the responding parent was identified as a significant risk factor for nonperception for both boys and girls. As reported by previous studies [42, 43], this finding might be explained by differences in parent‒child interactions, availability, and the time mothers and fathers typically spend with their children, making mothers more aware of problematic behaviors. While previous research has reported inconsistent findings regarding parents’ educational level and perceived need for help and unmet needs [37, 44, 45], the present study indicates that parents with higher educational levels are more likely to recognize their child’s mental health difficulties. These results may reflect greater mental health literacy among more educated parents, thus enabling them to identify emotional and behavioral problems among their children more effectively. Single parenthood was also identified as protective factor, as has previously been reported [38, 46], but only for girls in our study. Girls, who are more susceptible to internalizing problems, may spend more time helping their single parent with household responsibilities, thus making their difficulties more visible within this one-on-one relationship. Another explanation could be that in two-parent households, parents may temper or relativize their initial perception of problematic behaviors with their partner, whereas single parents lack such a counterbalance.
In contrast to an Australian study highlighting a marked difference in the underperception of children’s mental health problems by parents across income quintiles [47], our findings did not indicate that parents with a self-perceived difficult financial status were less susceptible to identifying problematic behaviors. However, among boys, a difficult or unbearable perceived financial situation appeared to be a protective factor against nonperception. Financial hardship may increase parents’ stress and vigilance toward behavioral issues, particularly among parents of boys, whose externalizing behaviors (e.g., agitation, impulsivity, and defiance) may be perceived as more disruptive in a strained household environment. Differences in the ways in which children’s behavioral problems are perceived and reported across cultures and ethnic groups have previously been described [48]. What parents consider problematic and to what extent they do so are influenced by their cultural model, thereby reflecting the traits and values that they prioritize and those that they wish to foster in their children as they grow up [49]. In our study, only girls with a parental migrant background were less likely to be identified as engaging in problematic behavior. These findings could be explained by different thresholds for service use or measurement nonequivalence among girls, whose difficulties might sometimes be less visible because of culturally influenced norms or attitudes, such as social withdrawal or their desire to keep their thoughts and emotions to themselves, which may be more accepted or even expected in girls in some cultural contexts.
In line with previous studies that have identified parental psychological factors as key determinants in this context [38, 45, 50], our results indicate that parents who had a history of psychiatric conditions or current psychological difficulties were more likely to recognize their child’s problems. Such parents may be more aware of these symptoms and/or possess greater mental health literacy on the basis of their own experiences. Another possible explanation for this finding is that children and adolescents whose parents have psychiatric disorders may have lower thresholds for reporting their own difficulties to their parents, thereby increasing parental awareness [44].
With respect to children’s characteristics, the more behavioral difficulties that children experienced, the more likely those difficulties were to be noticed by their parents; this finding is certainly due to the fact that greater impairment and symptom severity are typically observed when multiple problems cooccur, as has previously been reported [37, 38, 44]. The increased rate of parental nonperception of children’s difficulties observed in our study may be related to the fact that parents overall perceive the child to be functioning well, thus suggesting that future studies that rely on the SDQ should include daily functioning measurements to assess children’s difficulties in daily life (social functioning, academic performance, family functioning, adaptative life skills, etc.). Interestingly, children who were younger than 5 years old were less frequently recognized as needing care. Parents of younger children may be more tolerant of their child’s behavior, emotions, and fantasies across different situations due to an assumption that these manifestations reflect the child’s temperament or will naturally decrease with age. Additionally, such parents may have fewer opportunities to compare their child’s behavior with that of their child’s peers, thus making it more difficult for them to determine what is developmentally normative [37]. These results concerning children younger than five years old also raise questions regarding the tool itself and the standard reference cutoff values for this specific population of preschool-aged children, who are undergoing social, motor and emotional development.
In terms of environmental factors, our study revealed that children living in areas that feature a lower density of primary care providers were less likely to be perceived by their parents as engaging in problematic behaviors. As primary care professionals are often the first point of contact for concerned parents [51], limited access to such services may reduce the opportunities available for families to receive information concerning childhood symptoms and support in the context of recognizing healthcare needs. These findings highlight the need to promote public health strategies aimed at improving access to mental health care for children and families living in areas that feature a low density of healthcare providers. Such measures could include regular medical monitoring or developmental surveillance through online consultations, as well as interventions led by professionals who serve as intermediaries between families and healthcare systems, such as health workers or school nurses.
The present study has several strengths, including the relatively large, randomly selected sample of representative parents, making estimates generalizable to France, and the use of a validated parent-report instrument. Furthermore, this study is the first to assess the factors associated with the nonperception of mental health care needs while simultaneously accounting for sex differences. Beyond the level of statistical significance, the observed results are likely to be clinically meaningful, as they are associated with outcome changes that are relevant to patient care. However, the results of this research should also be interpreted in light of several limitations. First, this research relied solely on parent-reported perceptions of both health needs and the SDQ. Although parents know their children well, their reports may be influenced by their individual characteristics, which are sources of common method bias. Future studies should therefore incorporate both child and parent and/or teacher assessments to strengthen the validity of the findings of this research. Second, this study did not include certain well-known risk factors, such as maltreatment or neglect, and parental somatic or mental health disorders may have been underreported because of social desirability bias. Third, as a result of the current lack of evidence regarding the mechanisms underlying parental nonperception and the numerous risk factors that have been identified via Andersen’s theory, the variables included in our final model were selected on the basis of statistical criteria (including the statistical significance of bivariate analyses and change-in-estimates during backward stepwise selection) rather than exclusively on the basis of a priori knowledge. We acknowledge the potential bias resulting from this choice, including potential overfitting and instability with respect to our model. Fourth, this study may have been influenced by seasonal factors, as the data were collected during the summer, which may affect children’s lifestyles, particularly their physical activity and screen time. Finally, parents’ perceptions of the impact of their children’s problems on daily life (i.e., family life, schooling, and leisure activities) were not recorded here. Some parents may identify the consequences of the problems more than the problems themselves before they recognize a need for care in light of problematic behaviors.
In conclusion, as parents’ perceptions play a crucial role in the process of determining whether their children receive medical, psychological or psychiatric care, our findings highlight the fact that the perception of behavioral problems among children between the ages of 3 and 17 years varies across different child, parent and contextual characteristics. These results support efforts to strengthen prevention and early intervention strategies targeting parents with the aim of reducing the number of children who do not receive adequate help or remain untreated because of a lack of parental perception of their difficulties. To ensure that access to a health professional for psychological difficulties does not depend solely on parents, our findings support efforts to strengthen the implementation of a mental health protocol for school-aged children by the national education system [52] ( https://eduscol.education.fr/4063/agir-pour-favoriser-la-sante-mentale-et-le-bien-etre-des-eleves ). The development of a national screening program for young children on the basis of this type of instrument and multi-informant assessments that include contributions from teachers, schools, and primary care physicians in addition to parents could facilitate early identification and access to health services through the development of school-to-care referral pathways.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
We sincerely thank all the participants in the EpiCov study. We also thank the Centre Hospitalier de Versailles for editorial assistance.
EpiCov Study Group: Josiane Warszawski (principal investigator and scientific co-director), Nathalie Bajos (scientific co-director), Guillaume Bagein, Vianney Costemalle, Emilie Counil, Thomas Deroyon, Florence Jusot, Laurence Meyer, Philippe Raynaud, Alexandra Rouquette, Ariane Pailhé, Delphine Rahib, Patrick Sillard, Alexis Spire.
Author contributions
A.B performed the statistical analysis. S.B-B and A.R interpreted the data with support from A.P. S. B-B and A.R wrote the main manuscript. All authors read and approved the final manuscript. The corresponding author attests that all listed authors meet authorship criteria and that no other authors meeting the criteria have been omitted. SB-B and A.R act as guarantors.
Funding
This research was supported by research grants from Inserm (Institut National de la Santé et de la Recherche Médicale) and the French Ministry for Research, by Drees-Direction de la Recherche, des Etudes, de l’Evaluation et des Statistiques, and the French Ministry for Health, and by the Région Ile de France.
Data availability
Upon request. The variables generated and analyzed during the current study are available upon request.
Declarations
Ethics approval
The study was performed in accordance with the relevant guidelines and regulations. The survey was approved by the CNIL (the French data protection authority) (Ref: MLD/MFI/AR205138) and the relevant ethics committee (Comité de Protection des Personnes Sud Méditerranée III 2020-A01191-38) in April 2020. The survey was also approved by the “Comité du Label de la Statistique Publique”.
Competing interests
The authors declare no competing interests.
Contributor Information
Stéphanie Bourion-Bédès, Email: stephanie.bourion-bedes@uvsq.fr.
The EpiCov study group:
Josiane Warszawski, Nathalie Bajos, Guillaume Bagein, Vianney Costemalle, Emilie Counil, Thomas Deroyon, Florence Jusot, Laurence Meyer, Philippe Raynaud, Alexandra Rouquette, Ariane Pailhé, Delphine Rahib, Patrick Sillard, and Alexis Spire
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This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Upon request. The variables generated and analyzed during the current study are available upon request.