Barriers to Accessing Mental Health Services for Children Exposed to Domestic Violence

PURPOSE:This qualitative study interviewed mothers(N=19) in domestic violence (DV) shelters to obtain a comprehensive picture of experiences seeking mental health (MH) services for their children. Studies indicate that 40-60% of children in DV shelters meet diagnostic criteria for internalizing or externalizing disorders and 13-50% meet PTSD criteria (Chemtob & Carlson,2004; Grych et al.,2000; Hughes et al.,2001; Wolfe, et al.,2003). Although promising MH interventions are emerging (Feerick & Silverman,2006), factors influencing access to MH services for DV-exposed children have not been studied. Using an ecological-resilience framework, research questions were: Which individual and environmental factors help or hinder efforts of mothers in DV shelters to address their children’s MH needs? What types of help have mothers considered, sought and received for children’s MH needs?

METHODS: Mothers of school-age children in urban and rural DV shelters were recruited using purposive and maximum variation sampling. Participants were 23-50 years old (mean=37) with 1-7 children (mean=3.7). They were Latina(47.4%), White(26.3%), African American(21.1%) and Asian(5.3%).  A semi-structured interview guide elicited descriptions of children’s behavioral and emotional needs and context-rich narratives of help-seeking, focusing on a child the mother perceived as having the greatest challenges. Qualitative data were augmented by measures of maternal DV experiences (Abusive Behavior Inventory, Shepard & Campbell,1992) and child psychological adjustment (Strengths and Difficulties Questionnaire--SDQ, Goodman,2001; Parent Report of Post-traumatic Symptoms--PROPS, Greenwald & Rubin,1999). Study documents were professionally translated into Spanish for language preference. Every participant received a $20 store card.

Interview audiotapes were transcribed verbatim. Two compatible analytic methods were used: thematic (Braun & Clark,2006) and categorical-content (Lieblich et al.,1998). Both begin with inductive, iterative codebook development. Transcripts were coded independently by two coders using consensus to resolve differences and refine themes. Fluent Spanish speakers coded Spanish transcripts.

RESULTS:Focus children of 14(68.4%) participants had one or more indicators of poor MH: maternal report of MH diagnosis or PROPS/SDQ scores above clinical cutoff. Some mothers of those without MH indicators had sought counseling for their child. Their help-seeking experiences were included in analyses.

Barriers to accessing child MH services were found at multiple levels: individual (e.g.,lack of awareness of resources, fear), family (e.g.,DV influence), organizational (e.g.,professionals minimizing maternal concerns), community (e.g.,lack of transportation), and policy (e.g., lack of insurance). Schools helped with service access, but services often interrupted because of DV-related residential instability. Mothers reported greater understanding of children’s needs and services since shelter arrival and recommended increasing public awareness about children’s MH issues and community services.

IMPLICATIONS: This study gained in-depth information on barriers to accessing MH services for DV-exposed children, which is needed by practitioners, policy makers and researchers. Practitioners must be aware of DV as a barrier to child services and school practitioners interacting with families should educate them on community services early in their relationship. Mothers’ accounts suggest that access could be facilitated by policy initiatives aiming to increase awareness of child MH services. Findings identified variables for future quantitative studies on this population’s help-seeking with established models of health service use (Andersen & Newman,1973).