Help-Seeking Measures and Their Use in Adolescents: A Systematic Review
Help-Seeking Measures and Their Use in Adolescents: A Systematic Review
Natalie Divin 0 1 3
Patrick Harper 0 1 3
Emma Curran 0 1 3
Dagmar Corry 0 1 3
Gerard Leavey 0 1 3
0 Gerard Leavey
1 Patrick Harper
2 Natalie Divin
3 Bamford Centre for Mental Health and Wellbeing , Coleraine Campus, Cromore Road, Coleraine BT52 1SA, Northern Ireland , UK
Despite increasing numbers of adolescents experiencing poor mental wellbeing, adolescents are often reluctant to seek help for mental health problems. In response, there is increasing interest in the development of evidence-based interventions to increase help-seeking behavior. However, the evidence base may lack validity if help-seeking measures used in adolescent research contain age-inappropriate language or content such as seeking help from a spouse; no previous review has assessed this. A review of adolescent mental health help-seeking research was conducted to identify help-seeking measures used, assess their psychometric properties and linguistic appropriateness in adolescent populations, and organize measures by facet of help-seeking for ease of future use. We found 14 help-seeking measures used in adolescent research, but only 17/72 (24%) studies found used one of the identified measures. Help-seeking measures identified were categorized into one of four help-seeking facets: attitudes toward help-seeking, intentions to seek help, treatment fears regarding help-seeking, and barriers to help-seeking. The content and language of measures were deemed appropriate for all but one help-seeking measure. Recommendations for future research include greater utilization of identified measures, particularly in researching help-seeking behavior in different cultures, subcultures and between stages of adolescence.
Adolescence; Youth; Wellbeing; Help-seeking; Measures; Psychometrics
Increasing numbers of young people experience poor mental
(Meltzer et al. 2003)
, with 20–25% of mental health
disorders being diagnosed in adolescence and emerging
(Gore et al. 2011)
. It is recommended for those
suffering from poor mental health to communicate their
difficulties to others as a method of seeking assistance and
further treatment options; this is known as mental health
(Rickwood et al. 2012)
. These difficulties
may be communicated to informal sources of help such as
family members, or formal sources such as mental health
practitioners. While the prevalence of poor mental health
is increasing in young people, mental health help-seeking
remains low: only one-third of adolescents meeting
diagnostic criteria for a mental health diagnosis seek professional
(Green et al. 2005; World Federation for Mental Health
. Adolescents suffering from serious and debilitating
mental health difficulties may still avoid seeking help or
considerably delay getting appropriate help
(Biddle et al. 2006;
Goodman et al. 2002)
. Failing to seek help or delaying the
help-seeking process can lead to adverse health outcomes
such as substance abuse, engaging in risky sexual behavior,
lower quality of adult life and premature death
and Lowen 2010; Brindis et al. 2002, 2007; Laski 2015)
Current research suggests that when adolescents engage
in help-seeking, they are more comfortable doing so from
informal sources such as parents
(Rickwood et al. 2005)
While parents can be a valuable resource for initiating the
referral process for formal help-seeking
(Langeveld et al.
, parental referrals occur disproportionately in families
with a higher socioeconomic status
(Benjet et al. 2016)
finding places economically vulnerable adolescents at risk
as they are otherwise unwilling to speak with formal sources
(Leavey et al. 2011)
. Investigations into why
adolescents may be unwilling to engage in formal help-seeking
have uncovered barriers such as fears of unfriendly
clinicians, the fear of receiving a “stigmatizing” mental health
diagnosis, and the fear of being treated “like a child” by
(Rickwood et al. 2007; Zachrisson et al. 2006; Corry
and Leavey 2017)
. Barriers to informal help-seeking have
also been identified such as fearing negative judgment from
friends and family
(Gulliver et al. 2010)
. The fear of
negative judgment from others is heightened in certain cultures
(Chen et al. 2014)
, with parents of Moroccan and Turkish
adolescents fearing judgment from the community if their
child sought help
(Flink et al. 2013)
. In order to improve
help-seeking behavior in adolescents, it is imperative to
understand why such help-seeking barriers exist and how
they can be broken down.
There is a growing policy interest in developing early
intervention programs to break down barriers to adolescent
(Biddle et al. 2006; Rickwood et al. 2007;
Rothì and Leavey 2006)
. In order to develop effective
interventions to encourage help-seeking, the research base must
be examined to achieve greater understanding of these
helpseeking barriers and how they may be overcome. However, a
review by the World Health Organization posits that the
adolescent help-seeking research base may be flawed in two key
areas that impact the development of interventions
. The first issue put forth by the review refers to a
lack of knowledge of how reliable and valid help-seeking
measures are when used in adolescent populations.
Previous reviews of help-seeking measures on adult populations
have found that reporting psychometric properties in
helpseeking research is a relatively uncommon practice: only
38% of help-seeking studies identified reported
(Wei et al. 2015)
. This limits our knowledge of
whether help-seeking measures are reliable and valid outside
of populations beyond the initial assessment population. The
second issue identified is the lack of a clear definition of
what help-seeking as a research area encompasses. While
help-seeking involves a number of topics such as attitudes
towards clinicians and fearing negative judgment from
(Rickwood et al. 2007; Zachrisson et al. 2006; Corry and
, no previous review has attempted to identify
and synthesize the multiple facets of help-seeking
behavior and the measures available to assess these factors. The
review argues that greater clarity is needed regarding the
multiple facets of help-seeking behavior and the measures
available to assess these facets.
The lack of clarity and knowledge on validity of
help-seeking measures hinders adolescent help-seeking
interventions for two reasons. Firstly, no review has
explored whether measures used in the current adolescent
help-seeking research base are reliable, valid and
ageappropriate. For example, measures which include
questions pertaining to the workplace or the raising of children
are often not relevant to adolescents. If interventions are
developed using data gathered from measures that are not
valid or age-appropriate, this limits the validity of
interventions as measures are not truly capturing the beliefs
and behaviors of adolescents. Secondly, the lack of clarity
on help-seeking measures and which help-seeking facet
they measure may act as a deterrent for future
help-seeking research. It is paramount that researchers are aware of
potential measures to use in the field, which facets of
helpseeking they assess and whether they are valid and
ageappropriate for adolescent use. This clarity can facilitate
future research and aid the development of interventions
by exploring help-seeking barriers in various populations
and potentially identifying new help-seeking barriers.
While the number of adolescents experiencing poor
mental health is increasing, mental health help-seeking remains
low. Policy interest in evidence-based help-seeking
interventions is increasing, but the research base contains
limitations. No previous review has explored whether help-seeking
measures used in adolescent research are reliable, valid and
age-appropriate for this population, potentially harming
the validity of interventions. To address this limitation, a
review of adolescent mental health help-seeking research
was conducted with three aims. The first aim was to identify
and organize all help-seeking measures used in adolescent
research by their corresponding facet of help-seeking. The
second aim was to record the psychometric properties of
these measures to gauge their reliability and validity for
adolescent populations. The third aim was to review the
content and linguistic appropriateness of identified measures
to ensure that questions are applicable and understandable
The search terms “help-seeking”, “adolescence”,
“adolescent”, “youth”, “young people” and “mental health” were
used to locate journal articles in the following databases:
Science Direct, Web of Knowledge, JSTOR, Wiley Online
Library, SAGE Journals Online, PubMed, Google Scholar
and Ingenta. Articles were also obtained via
reference-chaining of articles deemed to be relevant for the review. This
search was undertaken by three reviewers between January
2012 and September 2016.
Inclusion and Exclusion Criteria
Studies were retained if they assessed attitudes, beliefs,
intentions or engagements toward mental health
helpseeking in adolescents; no restriction was placed on year
of publication. Journal articles were excluded if they were
not written in English, if they assessed physical health
helpseeking only, or if the study’s sample did not include an
adolescent population. For the purpose of this review, this
was defined as a lower limit of 11 years old and an upper
limit of 18 years old.
Where articles met the inclusion criteria, information was
recorded as to how help-seeking was measured in the study.
The psychometric properties of measures were also recorded
where applicable. If a study used a pre-existing measure, the
origin article of the measure was sourced to obtain
information on its content and original psychometric properties.
Measures were then read by the reviewers to ensure that
there was no age-inappropriate content for adolescents such
as discussing spouses or work colleagues. The extraction
progress can be summarized in Fig. 1.
Following the review’s inclusion criteria, 72 studies were
retained which assessed factors related to help-seeking in
an adolescent population; this process has been outlined in
Fig. 2. Out of 72 studies, 14 measures were identified which
measured facets of help-seeking. These measures were found
to assess four distinct facets: attitudes toward help-seeking,
intentions to seek help, treatment fears regarding
helpseeking, and barriers to help-seeking. However, use of these
scales was found to be low as only 17/72 (24%) studies used
an identified scale. Of the 17 studies identified, 12/17 (71%)
reported at least one psychometric property.
Each identified scale, its original psychometric
properties and its psychometric properties when used in adolescent
research can be viewed in Table 1. We discuss these scales in
respect to their corresponding help-seeking facet.
Search databases for adolescent mental health help-seeking research:
Science Direct, Web of Knowledge,
JSTOR, Wiley Online Library, SAGE
Journals Online, Ingenta, PubMed and Google Scholar
Review abstracts for target age group (11-18) and evidence of measuring help-seeking
Record how help-seeking was measured and any reported psychometric proper es from the study
If a pre-exis ng measure
was used, locate the
origin paper for further
informa on on the measure and its
psychometric proper es
Three scales were used in help-seeking research to assess
adolescents’ attitudes toward seeking help. The first scale
was the Attitudes Toward Seeking Professional Psychiatric
(ATSPPHS; Fischer and Turner 1970)
consisting of 29 items which evaluate attitudes toward seeking help
from professional sources. It has four sub-scales: recognition
of personal need for professional help, tolerance of stigma
associated with psychological help, interpersonal
openness, and confidence in mental health professionals. The
ATSPPHS was also adapted into a ten-item short form
version of the scale
(ATSPPHS-SF; Fischer and Farina 1995)
Similarly, the Inventory of Attitudes toward Seeking
Mental Health Services scale
(IASMHS; Mackenzie et al.
assesses inclination to seek help from a trained mental
health professional and consists of 24 items within three
subscales: psychological openness, help-seeking propensity, and
indifference to stigma. While the ATSPPHS and
ATSPPHSSF do not include questions that would be inappropriate or
inapplicable to adolescents, the IASMHS includes questions
pertaining to co-workers and spouses. The adolescent study
which used the IASMHS did not detail how these questions
(Perry et al. 2014)
Intentions to Seek Help
Five scales measured help-seeking intentions. The General
Help Seeking Questionnaire
(GHSQ; Wilson et al. 2005)
examines the intentions of the respondent to seek help from
several sources. These sources range from informal sources
(such as family and teaching staff) to professional sources
such as the family doctor. This was the most commonly used
measure identified in the review.
Two scales assessing the use of professional sources of
help are the Intentions to Seek Professional Help
(ISPHQ; O’Connor et al. 2014)
and the Intentions to
Seek Counseling Inventory
(ISCI; Cash et al. 1978)
ISPHQ consists of five questions on willingness to use
professional help and how proactive they would be in seeking
treatment. The ISCI presents participants with 17 known
influencers of poor mental health (such as anxiety and
loneliness) and asks how likely they would be to seek counseling
for each of these influencers. For assessing utilization of
social support, the Multidimensional Scale of Perceived
(MSPSS; Zimet et al. 1988)
is a 12-item
questionnaire which measures the quality of support and
ability to seek help from significant others, friends and
The Children’s Coping Strategies Checklist
Ayers et al. 1996)
contains 45 items which correspond to
the following sub-scales: (a) problem-focused strategies; (b)
direct emotion-focused strategies; (c) distraction strategies;
(d) avoidant strategies; and (e) support-seeking strategies.
The CCSC uniquely considers help-seeking along with
several behaviors and strategies that young people may use to
negate negative feelings. Although the CCSC was primarily
developed for use with children, it was found to be reliable
for use in an adolescent sample
(Rodriguez et al. 2014)
found that all scales used to measure help-seeking
intentions used language that was appropriate and relevant to
Treatment Fears Regarding Help‑Seeking
The main scale used for the analysis of treatment fear is the
Thoughts About Psychotherapy Survey
(TAPS; Deane and
. This scale has been adapted from the
Thoughts About Counseling Scale
(Pipes et al. 1985)
adding more questions and additional sub-scales. The TAPS
contains four sub-scales which assess the following factors:
(a) therapist responsiveness (perceived competence of
counselors or therapists); (b) image concerns (how the respondent
feels about themselves); (c) coercion concerns (perceived
lack of autonomy by accessing therapy); and (d) stigma
concerns (how they believe others view their diagnosis). This
scale was considered to be appropriate and applicable to
Barriers to Help‑Seeking
Five scales were identified for assessing barriers to
helpseeking in adolescents. The Barriers to Adolescents
Seeking Help scale
(BASH; Kuhl et al. 1997)
includes 37 items
assessing 13 help-seeking barriers such as self-sufficiency
and knowledge of resources. This scale was shortened to
form the BASH-B
(Vogel et al. 2006)
, an 11-item version
aSub-scale reliability; binternal consistency; ctest–retest reliability; dsplit-half reliability; enot recorded
which specifically retains items relating to barriers to
The Barriers to Help-Seeking Scale (BHSS)
et al. 2005)
consists of 31 items corresponding to five
subscales: (a) need of control and self-reliance; (b)
minimizing problems and resignation; (c) concrete barriers and
distrust of caregivers; (d) concerns about privacy; and
(e) concerns about emotional control. The Self-Stigma of
Seeking Help scale
(SSOSH; Vogel et al. 2006)
the degree to which participants may avoid help-seeking to
preserve autonomy and self-worth. The scale contains ten
items related to the factor of self-stigma, a concept which
refers to the internalization of stigmatizing attitudes about
mental illness such as negative social attitudes and
stereotypical behaviors about people with mental illness
et al. 2004; Major and O’Brien 2005)
. Finally, the
Barriers to Access to Care Evaluation scale (BACE) (Clement
et al. 2012) is a 30-item questionnaire which assesses both
stigma and non-stigma related barriers to seeking mental
health services. The stigma subscale can be divided into
self-stigma (judging oneself) and external stigma (fearing
judgment from others), while non-stigma barrier questions
enquire about knowledge of resources, previous negative
experience with healthcare workers and fears of negative
repercussions such as involuntary hospitalization. We found
that all scales used to measure barriers to help-seeking used
language that was appropriate and relevant to adolescents.
The adolescent population is experiencing an increase in
poor mental wellbeing
(Gore et al. 2011)
, but adolescents’
willingness to engage in mental health help-seeking remains
(Green et al. 2005; World Federation for Mental Health
. Encouraging help-seeking behavior in adolescence is
important for reducing future risk behaviors and fostering
a higher quality of adult life
(Anderson and Lowen 2010;
Brindis et al. 2007)
. Interventions to encourage help-seeking
behavior should aim to break down barriers to help-seeking
identified in research, but this research base contains
limitations. No previous review has investigated whether
helpseeking measures are valid and age-appropriate for
adolescent use, potentially harming the validity of interventions.
Help-seeking as a research topic may also be difficult to
measure due to a lack of clear understanding of the
multiple facets of help-seeking and how they can be assessed.
To address these limitations, a review of adolescent
helpseeking research was conducted.
This review identified help-seeking measures used in
adolescent research, organized each measure into its respective
help-seeking facet, noted the psychometric properties of
each measure in adolescent use, and assessed the linguistic
and content appropriateness of measures for adolescent use.
The review uncovered 72 studies which used 14 pre-existing
measures to assess four facets of adolescent help-seeking:
attitudes toward help-seeking, intentions to seek help,
treatment fears regarding help-seeking and barriers to
helpseeking. However, an unexpected finding from the review
revealed that use of these measures was relatively low. Of
the 72 studies identified which measured adolescent
helpseeking, only 17 (24%) used one of the measures identified
in the review; 12/17 (71%) reported at least one
psychometric property when used in an adolescent sample. These
findings indicate the existence of numerous help-seeking
measures that are applicable and valid for adolescent use,
yet are not often utilized.
Studies that did not use a pre-existing measure used
selfdeveloped single-use measures or used techniques such
as vignettes. Single-use scales most commonly included
a list of sources, both formal and informal, from which
participants might seek help from. Help-seeking vignettes
were used in a number of ways. Vignettes would typically
describe someone suffering from a mental illness such as
depression. Participants were then asked if they would seek
help if they were experiencing similar symptoms
et al. 2012)
or if they would be happy to talk to this person
about their illness
(Wright et al. 2011)
. Studies using
singleuse scales did not disclose how these measures were
developed, their psychometric properties, their factor structures or
whether they were subject to prior testing via pilot studies.
As adolescent help-seeking has been critiqued as a research
field which lacks clarity in the multiple facets that it
, it is possible that the low utilization of
pre-existing measures is a direct result of the lack of clarity
in the field. The current review may serve as a useful tool for
prospective adolescent help-seeking researchers by
identifying and categorizing help-seeking measures that are suitable
for adolescent use into their respective help-seeking facet.
Although the use of established help-seeking measures
in adolescent research was relatively low, it was found
that adolescent studies which did use pre-existing
measures were nearly twice as likely to report at least one
psychometric property than adult studies
(Wei et al. 2015)
While this is a positive finding from the review, it should
be noted that 100% of psychometric properties reported
in adolescent research were reliability statistics. This is
an understandable limitation as researchers may lack time
and space in publications to conduct and report on
validity assessments. Instead, conducting validity tests such as
construct and criterion validity on adolescents may be an
avenue for future research to further ensure the
appropriateness of measures in this population.
All but one of the measures reviewed were deemed
appropriate for adolescent use. In the IASMHS
(Mackenzie et al. 2004)
scale, participants are asked how they
would feel if their spouse and their work colleagues knew
that they had sought help from mental health services. The
adolescent study that used the IASMHS did not comment
on how these questions were managed in the study. Two
recommendations can be made from this finding. Firstly,
in studies where measures are used which include content
not entirely applicable to the target population, researchers
should uphold transparency and state how these questions
were managed in the study. Secondly, future studies may
adapt items from the IASMHS to be adolescent-friendly
(such as “partner” and “classmates” respectively) and
assess whether the measure retains the same factor
structure in the population.
This review allowed for the examination of the adolescent
help-seeking research base and the identification of gaps in
knowledge that should be addressed for future interventions.
Two research gaps were identified in this review. The first
research gap identified was a lack of research from poor
help-seeking countries such as Japan and Nigeria
et al. 2007)
. An examination of help-seeking beliefs in
countries with the lowest rates of help-seeking would provide
valuable insight into adolescent help-seeking barriers, but
this was not possible to achieve in this review. We also did
not uncover any studies which primarily investigated ethnic
minority populations or refugee youths. While adult research
of these populations suggest the presence of
populationspecific help-seeking barriers such as lack of trust
(Lindsey et al. 2013; Leavey et al. 2004, 2007; Chakraborty et al.
, there is insufficient evidence to establish whether
these cultural help-seeking barriers exist in adolescence.
Future research should explore help-seeking beliefs in
these cultures and sub-cultures to identify barriers to
helpseeking that should be deconstructed. The second research
gap identified was a lack of research exploring help-seeking
differences between younger and older adolescents. This
would be of interest for future help-seeking interventions
due to differences in physical and emotional changes and
coping strategies between these age groups. Younger
adolescents may struggle with social, biological and
hormonal changes (Currie et al. 2001) and fear being infantilized
by mental health services
(Corry and Leavey 2017)
older adolescents may be challenged with school
(Currie et al. 2001)
and view help-seeking as a threat
to their newly-established sense of autonomy
et al. 2014)
. It would be beneficial to explore which stage
of adolescence is most receptive to the breaking down of
help-seeking barriers in order to maximize the success of
There is a growing policy interest in adolescent
mental health help-seeking due to its role in alleviating poor
mental wellbeing. However, the validity of evidence-based
adolescent help-seeking interventions may be hindered by
research conducted with age-inappropriate measures. A
review of adolescent help-seeking research was conducted
to identify all help-seeking measures used, assess their
psychometric properties, assess their linguistic appropriateness
for adolescent use and categorize identified measures for the
convenience of future researchers. This review uncovered
14 help-seeking measures used in adolescent help-seeking
research. These measures were categorized into one of four
help-seeking facets: attitudes toward help-seeking,
intentions to seek help, treatment fears regarding help-seeking,
and barriers to help-seeking. 13/14 measures were deemed
appropriate for adolescent use and 71% of adolescent
helpseeking studies reported at least one psychometric property,
but only 24% of adolescent help-seeking studies used one
of the validated measured identified in the review.
Adolescent help-seeking studies frequently use single-use scales
and vignettes, and lack information on any prior testing or
psychometric properties. Future adolescent help-seeking
research could benefit from using measures identified in the
review to explore under-researched areas such as cultural
barriers to help-seeking and differences in help-seeking
between younger and older adolescents.
Author Contributions GL conceived of the study and edited the
manuscript. ND searched databases for relevant articles, recorded their
findings and was responsible for writing the manuscript. PH and EC
searched databases for relevant articles and recorded their findings.
DC edited the manuscript. All authors read and approved the final
Funding This study did not receive funding.
Open Access This article is distributed under the terms of the Creative
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(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
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