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A Systematic Review of Help-Seeking Interventions for Parents of Adolescents

Open AccessPublished:August 27, 2021DOI:https://doi.org/10.1016/j.jadohealth.2021.07.004

      Abstract

      Purpose

      Parents do not always seek timely help for adolescents when the need arises. Although interventions to increase parental help-seeking have been evaluated and published, no systematic review of these interventions has been conducted. The aim of this systematic review is to collate, synthesise, and evaluate research on help-seeking interventions for parents of adolescents.

      Methods

      Six electronic databases were searched from inception to May 2020 using terms related to the concepts of “parent” and “help-seeking” and focusing on parents of adolescents (aged 10–19 years). Methodological quality was assessed using the Quality Assessment Tool for Quantitative Studies; the Behavioural Change Taxonomy was used to code behavioral change techniques, and “promising interventions” were identified using pre-established criteria.

      Results

      Eighteen studies met inclusion criteria, with six rated strong for design and methodology. The most frequently identified Behavioural Change Taxonomies included a credible source delivering the intervention, supporting parents, and providing prompts/cues regarding services/appointments. Four interventions were identified as “promising” because of strong methodology, significant positive outcomes, and strong evidence-base.

      Conclusions

      More high-quality, theory-driven parental help-seeking interventions using common outcome measures are needed to advance the literature in this area. Future research should replicate the promising interventions identified to develop best practice guidelines.

      Keywords

      Implications and Contribution
      This systematic review synthesises evidence of value to those seeking to develop interventions to increase help-seeking among parents of adolescents. The review identifies common behavioral change techniques that could be implemented by other researchers and also highlights promising interventions to serve as models for others to replicate.
      See Related Editorial on p.5
      Family, particularly parents, plays a key role in helping adolescents cope with problems they experience/encounter [
      • Logan D.E.
      • King C.A.
      Parental facilitation of adolescent mental health service utilization: A Conceptual and Empirical review.
      ]. Research demonstrates that receiving help from a formal or informal source is a protective factor for adolescent health, well-being, and overall satisfaction with life [
      • Dooley B.A.
      • O’Connor C.
      • Fitzgerald A.
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      ,
      • DeVore E.R.
      • Ginsburg K.R.
      The protective effects of good parenting on adolescents.
      ,
      • van Wel F.
      • Linssen H.
      • Abma R.
      The parental bond and the well-being of adolescents and young adults.
      ]. However, adolescents have been found to underutilise formal sources such as health-care professionals who have a legitimate and recognized professional role in providing relevant advice and are often best equipped to provide the type of help needed [
      • Rickwood D.
      • Deane F.P.
      • Wilson C.J.
      • Ciarrochi J.
      Young people’s help-seeking for mental health problems.
      ]. Because of this reluctance to seek professional help, the task of help-seeking frequently depends on parental actions [
      • Logan D.E.
      • King C.A.
      Parental facilitation of adolescent mental health service utilization: A Conceptual and Empirical review.
      ,
      • Rothi D.M.
      • Leavey G.
      Mental health help-seeking and young people: A review.
      ,
      • Boulter E.
      • Rickwood D.
      Parents’ experience of seeking help for children with mental health problems.
      ]. However, while parents are typically willing to offer support to their adolescent, studies have shown that due to individual and systemic factors, they may delay seeking professional help [
      • Reardon T.
      • Harvey K.
      • Baranowska M.
      • et al.
      What do parents perceive are the barriers and facilitators to accessing psychological treatment for mental health problems in children and adolescents? A systematic review of qualitative and quantitative studies.
      ,
      • Sayal K.
      • Tischler V.
      • Coope C.
      • et al.
      Parental help-seeking in primary care for child and adolescent mental health concens: Qualitative study.
      ].
      Adolescents generally have good physical health; therefore, the majority of the research on parental help-seeking is focused on mental health difficulties, which have their peak onset during adolescence [
      • Patel V.
      • Flisher A.J.
      • Hetrick S.
      • McGorry P.
      Mental health of young people: A global public-health challenge.
      ] yet can be difficult for parents to recognise [
      • Dang-Tan T.
      • Franco E.L.
      Diagnosis delays in childhood cancer: A review.
      ,
      • Stewart L.
      • Chapple J.
      • Hughes A.R.
      • et al.
      Parents’ journey through treatment for their child’s obesity: A qualitative study.
      ,
      • Teagle S.E.
      Parental problem recognition and child mental health service use.
      ]. Parents report difficulties distinguishing between behavior of concern and typical adolescent behavior as adolescence is often perceived as a time of emotional turmoil [
      • Logan D.E.
      • King C.A.
      Parental facilitation of adolescent mental health service utilization: A Conceptual and Empirical review.
      ,
      • Sayal K.
      • Tischler V.
      • Coope C.
      • et al.
      Parental help-seeking in primary care for child and adolescent mental health concens: Qualitative study.
      ]. In turn, when help is required, parents are often unfamiliar and unaware of the mental health system, who to turn to for advice, or where help is available [
      • Frauenholtz S.
      • Conrad-Hiebner A.
      • Mendenhall A.N.
      Children’s mental health Providers’ perceptions of mental health literacy among parents and caregivers.
      ,
      • Hurley D.
      • Swann C.
      • Allen M.S.
      • et al.
      A systematic review of parent and caregiver mental health literacy.
      ]. In addition, self-blame and stigma can influence parents' willingness to seeking help [
      • Villatoro A.P.
      • DuPont-Reyes M.J.
      • Phelan J.C.
      • et al.
      Parental recognition of preadolescent mental health problems: Does stigma matter?.
      ]. While the majority of research on help-seeking has focused on the mental health context, parents can also experience shame and stigma when seeking help for adolescents with a higher Body Mass Index (i.e., BMI ≥ 25) [
      • Robinson E.
      • Sutin A.R.
      Parents’ perceptions of their children as overweight and children’s weight concerns and weight gain.
      ,
      • Kelleher E.
      • Davoren M.P.
      • Harrington J.M.
      • et al.
      Barriers and facilitators to initial and continued attendance at community-based lifestyle programmes among families of overweight and obese children: A systematic review.
      ]. Edmunds [
      • Edmunds L.
      Parents’ perceptions of health professionals’ responses when seeking help for their overweight children.
      ], for example, found that while parents were aware that their adolescent had a higher body weight, when they discussed these concerns with a health-care professional, their concerns were sometimes dismissed or they experienced blame for their adolescent's weight issues, thus negatively impacting willingness to seek further help.
      Although adolescence is seen as a time for growing autonomy and for taking more responsibility for personal health, in many jurisdictions, adolescents are legally required to have a parent's permission to seek treatment from health services. In Europe, for example, some countries allow an adolescent to seek help from medical/mental health services by themselves from the ages of 14 or 16 years. However, in many other European countries and in the United States, an adolescent cannot make a decision without their parent's permission until the age of eighteen [,
      • McNary A.
      Consent to treatment of minors.
      ], thus emphasising the role of parents. However, even in jurisdictions where adolescents could seek help independently, many studies have shown that adolescent rely on parents for help and support when seeking health services, and this extends even beyond the adolescent years [
      • Rickwood D.J.
      • Mazzer K.R.
      • Telford N.R.
      Social influences on seeking help from mental health services, in-person and online, during adolescence and young adulthood.
      ,
      • Wray-Lake L.
      • Crouter A.C.
      • McHale S.M.
      Developmental patterns in decision-making autonomy across middle childhood and adolescence: European american parents’ perspectives.
      ]. Therefore, regardless of legal requirements related to professional help-seeking, parents play a key role in their adolescents' lives and are important intervention targets to increase timely access to services [
      • Logan D.E.
      • King C.A.
      Parental facilitation of adolescent mental health service utilization: A Conceptual and Empirical review.
      ]. Parents require information and support to enable them to determine if their adolescent requires help, where such help is available, and how to sensitively encourage the young person to accept such help [
      • Rickwood D.
      • Deane F.P.
      • Wilson C.J.
      • Ciarrochi J.
      Young people’s help-seeking for mental health problems.
      ,
      • Rickwood D.J.
      • Mazzer K.R.
      • Telford N.R.
      Social influences on seeking help from mental health services, in-person and online, during adolescence and young adulthood.
      ].
      Help-seeking interventions are planned actions which target attitudes, intentions, or behaviors toward seeking services [
      • Rickwood D.
      • Thomas K.
      • Bradford S.
      Help-seeking measures in mental health: A Rapid review.
      ]. Help-seeking interventions have been shown to be effective in increasing the help-seeking attitudes of the general population [
      • Gulliver A.
      • Griffiths K.M.
      • Christensen H.
      • Brewer J.L.
      A systematic review of help-seeking interventions for depression, anxiety and general psychological distress.
      ,
      • Xu Z.
      • Huang F.
      • Kösters M.
      • et al.
      Effectiveness of interventions to promote help-seeking for mental health problems: Systematic review and meta-analysis.
      ] and in increasing at-risk children's access to care [
      • Werlen L.
      • Gjukaj D.
      • Mohler-Kuo M.
      • Puhan M.A.
      Interventions to improve children’s access to mental health care: A systematic review and meta-analysis.
      ]. A number of help-seeking interventions have been designed to increase adolescent help-seeking, but parents are often not included [
      • Werlen L.
      • Gjukaj D.
      • Mohler-Kuo M.
      • Puhan M.A.
      Interventions to improve children’s access to mental health care: A systematic review and meta-analysis.
      ]. While some parental help-seeking interventions have been published [
      • Chu J.T.W.
      • Wadham A.
      • Jiang Y.
      • et al.
      Effect of MyTeen SMS-based Mobile intervention for parents of adolescents: A Randomized clinical trial.
      ,
      • Beals-Erickson S.E.
      • Roberts M.C.
      Youth development program participation and changes in help-seeking intentions.
      ], to date, there has been no systematic review of such interventions. A substantial gap exists in the parenting literature regarding what interventions exist, which are effective, and, in particular, what components of the intervention are effective in changing help-seeking behavior [
      • Logan D.E.
      • King C.A.
      Parental facilitation of adolescent mental health service utilization: A Conceptual and Empirical review.
      ,
      • Boldero J.
      • Fallon B.
      Adolescent help-seeking: What do they get help for and from whom?.
      ].
      Therefore, the aim of this systematic review is to identify, collate, synthesise, and evaluate the available research on parental help-seeking interventions and to use the Behaviour Change Technique Taxonomy (v1) to identify the behavioral change techniques used in those interventions [
      • Michie S.
      • Richardson M.S.
      • Johnston M.
      • et al.
      The behavior change technique Taxonomy (v1) of 93 Hierarchically Clustered techniques: Building an International Consensus for the reporting of behavior change interventions.
      ]. The findings of the review will facilitate researchers, practitioners, and policy-makers to develop and deliver high-quality parent help-seeking interventions.
      Specifically, the review aims to address the following questions:
      • 1.
        What are the characteristics of interventions that are designed to increase help-seeking knowledge, attitudes, intentions, and behaviors among the parents of adolescents?
      • 2.
        To establish the qualities of both effective and ineffective parental help-seeking interventions. However, it was noted apriori that previous systematic reviews looking at the effectiveness of general help-seeking interventions had been unable to conduct a meta-analysis because of the heterogeneity of the interventions and measures used in the studies [
        • Gulliver A.
        • Griffiths K.M.
        • Christensen H.
        • Brewer J.L.
        A systematic review of help-seeking interventions for depression, anxiety and general psychological distress.
        ,
        • Werlen L.
        • Gjukaj D.
        • Mohler-Kuo M.
        • Puhan M.A.
        Interventions to improve children’s access to mental health care: A systematic review and meta-analysis.
        ]. An alternative question was planned for this eventuality:
        • a.
          Are there any “promising interventions” [
          • Fazal N.
          • Jackson S.F.
          • Wong K.
          • et al.
          Between worst and best: Developing criteria to identify promising practices in health promotion and disease prevention for the Canadian best practices portal.
          ] that should be replicated to develop best practice guidelines for parental help-seeking interventions?
      • 3.
        What are the behavioral change techniques [
        • Michie S.
        • Richardson M.S.
        • Johnston M.
        • et al.
        The behavior change technique Taxonomy (v1) of 93 Hierarchically Clustered techniques: Building an International Consensus for the reporting of behavior change interventions.
        ] used by researchers designing interventions to increase parental help-seeking behavior?

      Method

      The systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standardized reporting guidelines [
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      Preferred reporting Items for systematic reviews and meta-Analyses: The PRISMA Statement.
      ].

       Search strategy

      Key words were selected through identification of terms used in reviews of a similar nature [
      • Reardon T.
      • Harvey K.
      • Baranowska M.
      • et al.
      What do parents perceive are the barriers and facilitators to accessing psychological treatment for mental health problems in children and adolescents? A systematic review of qualitative and quantitative studies.
      ,
      • Gulliver A.
      • Griffiths K.M.
      • Christensen H.
      • Brewer J.L.
      A systematic review of help-seeking interventions for depression, anxiety and general psychological distress.
      ,
      • Gulliver A.
      • Griffiths K.M.
      • Christensen H.
      Perceived barriers and facilitators to mental health help-seeking in young people: A systematic review.
      ] and through consultation with a specialist librarian. The final search terms were as follows (see Appendix A for the full search strategy): (“help-seeking OR "seek∗ help" OR "Seek∗ treatment" OR "service use" OR "help-seeking behaviours" OR "help-seeking intentions” OR “help-seeking attitudes”) AND (parent∗ OR caregiver∗ OR ‘care giver’ OR mother OR father OR paternal OR maternal OR guardian). The following six databases were searched on the 21st of January 2019, and the search was updated on the 13th of May 2020: CINAHL, PsycINFO, ERIC, Scopus, PubMed, and ASSIA. Forward and backward reference screening was also completed on all retrieved full-text articles.

       Eligibility criteria

       Population

      To be included in the review, studies had to include an intervention that was targeting parental help-seeking for a specified problem involving an adolescent. Adolescence was defined as aged 10–19 years as per the World Health Organisation Guidelines [
      World Health Organisation
      Health for the world’s adolescents: A second chance in the second decade.
      ].

       Intervention

      An intervention was defined as a planned action that was intended to increase parental help-seeking [
      • Hodges L.J.
      • Walker J.
      • Kleiboer A.M.
      • et al.
      What is a psychological intervention? A metareview and practical proposal.
      ]. Help-seeking in this context refers to a change in parents' knowledge, attitudes, intentions, or behaviors toward seeking either formal or informal services for a problem related to their adolescent [
      • Rickwood D.
      • Thomas K.
      Conceptual measurement framework for help-seeking for mental health problems.
      ]. No constraints were placed on the type of problem for which help was sought. This was to provide insights into help-seeking from a number of fields and to draw attention to different approaches [
      • Featherstone B.
      • Broadhurst K.
      Engaging parents and carers with family support services: What can be learned from research on help-seeking.
      ].

       Outcome

      The outcome was any measure of parental help-seeking knowledge, attitudes, intentions, or behaviors.

       Study Design

      All study types were included in the review (randomized controlled trials [RCT], controlled trials, cohort and quasi-experimental), and this was accounted for in both the quality assessment and narrative synthesis. Qualitative studies were excluded because the aim of the review was to identify the characteristics of effective interventions and as such required research that had measured and quantified help-seeking. Studies must have been published in a peer-reviewed journal, and there was no restriction based on the language of the article or date of publication.

       Study selection

      Articles retrieved through searches of the six databases were imported to the COVIDENCE software, and duplicates were removed. Titles and abstracts of studies were screened by two independent reviewers (E.H. and D.M.). Studies selected for full-text review were again screened by the independent reviewers (E.H. and D.M.). Disagreements were resolved through discussion, and a third reviewer (C.H.) was consulted where necessary. Forward and backward reference searching was conducted on all full-text articles by one of the study authors (D.M.), any potentially relevant articles were added to COVIDENCE, and the process was followed through again.

       Data extraction

      Data were extracted by two of the study authors (D.M. and M.D.O’R.) using a prepiloted data-extraction form. The data included author details, country where the study was conducted, recruitment method/site, study design, presenting problem that was the focus of the intervention, sample characteristics, help-seeking outcome measure (knowledge, attitudes, intentions, or behavior), and main findings. Intervention characteristics were extracted based on the criteria outlined in the Template for Intervention Description and Replication (TIDieR) reporting guidelines [
      • Hoffmann T.C.
      • Glasziou P.P.
      • Boutron I.
      • et al.
      Better reporting of interventions: Template for intervention description and replication (TIDieR) checklist and guide.
      ].

       Quality assessment

      The methodological quality of included studies was assessed using the Quality Assessment Tool for Quantitative Studies developed by the Effective Public Health Practice Project [
      • Thomas B.H.
      • Ciliska D.
      • Dobbins M.
      • Micucci S.
      A process for systematically reviewing the literature: Providing the research evidence for public health nursing interventions.
      ]. This tool was chosen as it can be adapted to different types of study designs (RCT, CT, cohort and quasi-experimental designs) and has been judged to be a suitable quality assessment tool for systematic reviews including both randomized and nonrandomized intervention studies [
      • Deeks J.
      • Dinnes J.
      • D’Amico R.
      • et al.
      Evaluating non-randomised intervention studies.
      ]. The quality of the included studies was evaluated based on selection bias, study design, confounders, blinding, data collection methods, and withdrawal/dropout. A global quality rating of “weak”, “moderate”, or “strong” was assigned by two independent reviewers (D.M. and M.D.O’R.). Reviewer differences were resolved by discussion and reference to a third reviewer (E.H.).

       Behavioural Change Taxonomy

      The Behaviour Change Taxonomy (Version 1) developed by Michie et al. [
      • Michie S.
      • Richardson M.S.
      • Johnston M.
      • et al.
      The behavior change technique Taxonomy (v1) of 93 Hierarchically Clustered techniques: Building an International Consensus for the reporting of behavior change interventions.
      ] was used to synthesise the key features of the intervention arms designed to increase parental help-seeking behavior. This framework categorizes the smallest identifiable components (active ingredients) of interventions that are designed to change behavior. Intervention descriptions from each relevant article were coded independently by two coders (D.M. and M.H.). All articles and Supplementary Files (e.g., intervention protocols) were coded to ensure that all content related to the intervention was coded. Both coders had completed the training in recognizing and coding Behavioural Change Taxonomy (BCTs) (https://www.bct-taxonomy.com/). The coders indicated where a technique was used and which technique was used. Coding differences were resolved through discussion, and if agreement was not reached, a third reviewer was consulted (C.H.).

       Promising interventions

      “Promising intervention” refers to interventions whose content has a strong evidence-base, which are evaluated as having a strong methodology, and with an outcome which includes a significant positive change in help-seeking. The term has been used in the literature to describe an intervention that shows potential for development into best practice [
      • Fazal N.
      • Jackson S.F.
      • Wong K.
      • et al.
      Between worst and best: Developing criteria to identify promising practices in health promotion and disease prevention for the Canadian best practices portal.
      ]. Based on adapted criteria set out by Fazal et al. [
      • Fazal N.
      • Jackson S.F.
      • Wong K.
      • et al.
      Between worst and best: Developing criteria to identify promising practices in health promotion and disease prevention for the Canadian best practices portal.
      ], a study was classified as a promising intervention when (1) the intervention was based on evidence-based guidelines, models, theory, or research; (2) the quality of the methodology was evaluated as moderate or strong; and (3) a statistically significant difference was noted in help-seeking knowledge, attitudes, intentions, or behaviors over time between the intervention group and the control group.

      Results

      Searches of the six electronic databases yielded 8,461 articles. After duplicate removal, 4,577 were identified for title and abstract screening against the inclusion/exclusion criteria. An additional 26 articles (for abstract screening) were found through forward and backward reference screening. Ninety-two articles were screened for full-text review. Eighteen articles were subsequently identified for inclusion in the review. The most common reason for exclusion was that help-seeking was not a measured outcome (N = 20), the review was focused on parents of children and adolescents not solely adolescents (aged 10–19 years) (N = 27), or it was not an intervention study (N = 13). For an overview of the screening process, see the PRISMA diagram in Figure 1.
      Figure thumbnail gr1
      Figure 1PRISMA diagram of database search and record screening.

       General overview

      The 18 included studies were published between 1988 and 2019. The majority were conducted in the United States [
      • Beals-Erickson S.E.
      • Roberts M.C.
      Youth development program participation and changes in help-seeking intentions.
      ,
      • Asarnow J.R.
      • Baraff L.J.
      • Berk M.
      • et al.
      An emergency department intervention for linking pediatric suicidal patients to follow-up mental health treatment.
      ,
      • Spirito A.
      • Boergers J.
      • Donaldson D.
      • et al.
      An intervention trial to improve adherence to community treatment by adolescents after a suicide attempt.
      ,
      • Szapocznik J.
      • Perez-Vidai A.
      • Brickman A.L.
      • et al.
      Engaging adolescent drug abusers and their families in treatment: A strategic structural systems approach.
      ,
      • Cheng T.L.
      • Wright J.L.
      • Markakis D.
      • et al.
      Randomized trial of a Case management program for Assault-Injured Youth.
      ,
      • Donohue B.
      • Azrin N.H.
      • Lawson H.
      • et al.
      Improving initial session attendance of substance abusing and conduct disordered adolescents: A controlled study.
      ,
      • Gould M.S.
      • Marrocco F.A.
      • Hoagwood K.
      • et al.
      Service Use by at-risk Youths after school-based suicide screening.
      ,
      • Grupp-Phelan J.
      • McGuire L.
      • Husky M.M.
      • Olfson M.
      A Randomized controlled trial to engage in care of adolescent emergency department patients with mental health problems that increase suicide risk.
      ,
      • Jonovich S.J.
      • Alpert-Gillis L.J.
      Impact of pediatric mental health screening on clinical discussion and referral for services.
      ,
      • Kutash K.
      • Duchnowski A.J.
      • Green A.L.
      • Ferron J.
      Effectiveness of the parent Connectors program: Results from a Randomized controlled trial.
      ,
      • Rotheram-Borus M.J.
      • Piacentini J.
      • Van Rossem R.
      • et al.
      Enhancing treatment adherence with a specialized emergency room program for adolescent suicide attempters.
      ,
      • Schoenfelder E.
      • McCabe C.
      • Fife A.
      • et al.
      Research brief: The teen ADHD Workshop to improve adolescent ADHD treatment engagement.
      ], and the rest were conducted across a variety of countries, including Australia [
      • Hurley D.
      • Allen M.S.
      • Swann C.
      • et al.
      The development, Pilot, and process evaluation of a parent mental health literacy intervention through community sports clubs.
      ,
      • Morgan A.J.
      • Fischer J.A.A.
      • Hart L.M.
      • et al.
      Does mental health first aid training improve the mental health of aid recipients? The training for parents of teenagers randomised controlled trial.
      ], New Zealand [
      • Chu J.T.W.
      • Wadham A.
      • Jiang Y.
      • et al.
      Effect of MyTeen SMS-based Mobile intervention for parents of adolescents: A Randomized clinical trial.
      ], Japan [
      • Yoshii H.
      • Watanabe Y.
      • Kitamura H.
      • et al.
      Effect of an education program on improving help-seeking among parents of junior and senior high school students in Japan.
      ], Canada [
      • Spettigue W.
      • Maras D.
      • Obeid N.
      • Henderson K.A.
      A Psycho-education intervention for parents of adolescents with eating disorders: A Randomized controlled trial.
      ], and England [
      • Sallis A.
      • Porter L.
      • Tan K.
      • et al.
      Improving child weight management uptake through enhanced National child measurement Programme parental feedback letters: A randomised controlled trial.
      ]. Three of the studies were cohort studies, four were quasi-experimental, and 11 were RCTs. Five of the studies [
      • Chu J.T.W.
      • Wadham A.
      • Jiang Y.
      • et al.
      Effect of MyTeen SMS-based Mobile intervention for parents of adolescents: A Randomized clinical trial.
      ,
      • Jonovich S.J.
      • Alpert-Gillis L.J.
      Impact of pediatric mental health screening on clinical discussion and referral for services.
      ,
      • Hurley D.
      • Allen M.S.
      • Swann C.
      • et al.
      The development, Pilot, and process evaluation of a parent mental health literacy intervention through community sports clubs.
      ,
      • Morgan A.J.
      • Fischer J.A.A.
      • Hart L.M.
      • et al.
      Does mental health first aid training improve the mental health of aid recipients? The training for parents of teenagers randomised controlled trial.
      ,
      • Yoshii H.
      • Watanabe Y.
      • Kitamura H.
      • et al.
      Effect of an education program on improving help-seeking among parents of junior and senior high school students in Japan.
      ] were a universal parent intervention study, and the focus of all was emotional or behavioral issues. The rest [
      • Beals-Erickson S.E.
      • Roberts M.C.
      Youth development program participation and changes in help-seeking intentions.
      ,
      • Asarnow J.R.
      • Baraff L.J.
      • Berk M.
      • et al.
      An emergency department intervention for linking pediatric suicidal patients to follow-up mental health treatment.
      ,
      • Spirito A.
      • Boergers J.
      • Donaldson D.
      • et al.
      An intervention trial to improve adherence to community treatment by adolescents after a suicide attempt.
      ,
      • Szapocznik J.
      • Perez-Vidai A.
      • Brickman A.L.
      • et al.
      Engaging adolescent drug abusers and their families in treatment: A strategic structural systems approach.
      ,
      • Cheng T.L.
      • Wright J.L.
      • Markakis D.
      • et al.
      Randomized trial of a Case management program for Assault-Injured Youth.
      ,
      • Donohue B.
      • Azrin N.H.
      • Lawson H.
      • et al.
      Improving initial session attendance of substance abusing and conduct disordered adolescents: A controlled study.
      ,
      • Gould M.S.
      • Marrocco F.A.
      • Hoagwood K.
      • et al.
      Service Use by at-risk Youths after school-based suicide screening.
      ,
      • Grupp-Phelan J.
      • McGuire L.
      • Husky M.M.
      • Olfson M.
      A Randomized controlled trial to engage in care of adolescent emergency department patients with mental health problems that increase suicide risk.
      ,
      • Kutash K.
      • Duchnowski A.J.
      • Green A.L.
      • Ferron J.
      Effectiveness of the parent Connectors program: Results from a Randomized controlled trial.
      ,
      • Rotheram-Borus M.J.
      • Piacentini J.
      • Van Rossem R.
      • et al.
      Enhancing treatment adherence with a specialized emergency room program for adolescent suicide attempters.
      ,
      • Schoenfelder E.
      • McCabe C.
      • Fife A.
      • et al.
      Research brief: The teen ADHD Workshop to improve adolescent ADHD treatment engagement.
      ,
      • Spettigue W.
      • Maras D.
      • Obeid N.
      • Henderson K.A.
      A Psycho-education intervention for parents of adolescents with eating disorders: A Randomized controlled trial.
      ,
      • Sallis A.
      • Porter L.
      • Tan K.
      • et al.
      Improving child weight management uptake through enhanced National child measurement Programme parental feedback letters: A randomised controlled trial.
      ] were indicated interventions targeting parents of adolescents who are currently experiencing or at risk of experiencing a problem. These included an emotional or behavioral issue, eating disorder, a BMI ≥ 25, and involvement in a violent assault. Three of the interventions focused solely on parents, and 11 involved both the parent and the adolescent. All studies involved parents of adolescents aged from 10 to 19
      A decision was made to include one study that had an age range from 12 to 21 years, and this was because majority of the participants, 82%, were of the age range from 14 to 18 years.
      years (A decision was made to include one study that had an age range from 12 to 21 years, and this was because majority of the participants, 82%, were of the age range from 14 to 18 years.), and the sample size varied from 20 to 2,690. Of the studies that provided information about which parent participated [
      • Chu J.T.W.
      • Wadham A.
      • Jiang Y.
      • et al.
      Effect of MyTeen SMS-based Mobile intervention for parents of adolescents: A Randomized clinical trial.
      ,
      • Beals-Erickson S.E.
      • Roberts M.C.
      Youth development program participation and changes in help-seeking intentions.
      ,
      • Donohue B.
      • Azrin N.H.
      • Lawson H.
      • et al.
      Improving initial session attendance of substance abusing and conduct disordered adolescents: A controlled study.
      ,
      • Kutash K.
      • Duchnowski A.J.
      • Green A.L.
      • Ferron J.
      Effectiveness of the parent Connectors program: Results from a Randomized controlled trial.
      ,
      • Rotheram-Borus M.J.
      • Piacentini J.
      • Van Rossem R.
      • et al.
      Enhancing treatment adherence with a specialized emergency room program for adolescent suicide attempters.
      ,
      • Hurley D.
      • Allen M.S.
      • Swann C.
      • et al.
      The development, Pilot, and process evaluation of a parent mental health literacy intervention through community sports clubs.
      ,
      • Morgan A.J.
      • Fischer J.A.A.
      • Hart L.M.
      • et al.
      Does mental health first aid training improve the mental health of aid recipients? The training for parents of teenagers randomised controlled trial.
      ,
      • Yoshii H.
      • Watanabe Y.
      • Kitamura H.
      • et al.
      Effect of an education program on improving help-seeking among parents of junior and senior high school students in Japan.
      ,
      • Spettigue W.
      • Maras D.
      • Obeid N.
      • Henderson K.A.
      A Psycho-education intervention for parents of adolescents with eating disorders: A Randomized controlled trial.
      ], only one had an equal number of mothers and fathers [
      • Yoshii H.
      • Watanabe Y.
      • Kitamura H.
      • et al.
      Effect of an education program on improving help-seeking among parents of junior and senior high school students in Japan.
      ], and in most studies, most participating parents were mothers (64%–100%). The focus of interventions was on changing parents' help-seeking behavior [
      • Asarnow J.R.
      • Baraff L.J.
      • Berk M.
      • et al.
      An emergency department intervention for linking pediatric suicidal patients to follow-up mental health treatment.
      ,
      • Spirito A.
      • Boergers J.
      • Donaldson D.
      • et al.
      An intervention trial to improve adherence to community treatment by adolescents after a suicide attempt.
      ,
      • Szapocznik J.
      • Perez-Vidai A.
      • Brickman A.L.
      • et al.
      Engaging adolescent drug abusers and their families in treatment: A strategic structural systems approach.
      ,
      • Cheng T.L.
      • Wright J.L.
      • Markakis D.
      • et al.
      Randomized trial of a Case management program for Assault-Injured Youth.
      ,
      • Donohue B.
      • Azrin N.H.
      • Lawson H.
      • et al.
      Improving initial session attendance of substance abusing and conduct disordered adolescents: A controlled study.
      ,
      • Gould M.S.
      • Marrocco F.A.
      • Hoagwood K.
      • et al.
      Service Use by at-risk Youths after school-based suicide screening.
      ,
      • Grupp-Phelan J.
      • McGuire L.
      • Husky M.M.
      • Olfson M.
      A Randomized controlled trial to engage in care of adolescent emergency department patients with mental health problems that increase suicide risk.
      ,
      • Jonovich S.J.
      • Alpert-Gillis L.J.
      Impact of pediatric mental health screening on clinical discussion and referral for services.
      ,
      • Yoshii H.
      • Watanabe Y.
      • Kitamura H.
      • et al.
      Effect of an education program on improving help-seeking among parents of junior and senior high school students in Japan.
      ,
      • Spettigue W.
      • Maras D.
      • Obeid N.
      • Henderson K.A.
      A Psycho-education intervention for parents of adolescents with eating disorders: A Randomized controlled trial.
      ,
      • Sallis A.
      • Porter L.
      • Tan K.
      • et al.
      Improving child weight management uptake through enhanced National child measurement Programme parental feedback letters: A randomised controlled trial.
      ], help-seeking intentions [
      • Beals-Erickson S.E.
      • Roberts M.C.
      Youth development program participation and changes in help-seeking intentions.
      ,
      • Morgan A.J.
      • Fischer J.A.A.
      • Hart L.M.
      • et al.
      Does mental health first aid training improve the mental health of aid recipients? The training for parents of teenagers randomised controlled trial.
      ], knowledge of help-seeking options [
      • Chu J.T.W.
      • Wadham A.
      • Jiang Y.
      • et al.
      Effect of MyTeen SMS-based Mobile intervention for parents of adolescents: A Randomized clinical trial.
      ], attitudes toward seeking help and help-seeking behaviors [
      • Kutash K.
      • Duchnowski A.J.
      • Green A.L.
      • Ferron J.
      Effectiveness of the parent Connectors program: Results from a Randomized controlled trial.
      ,
      • Rotheram-Borus M.J.
      • Piacentini J.
      • Van Rossem R.
      • et al.
      Enhancing treatment adherence with a specialized emergency room program for adolescent suicide attempters.
      ], knowledge of help-seeking options and attitudes toward seeking help [
      • Hurley D.
      • Allen M.S.
      • Swann C.
      • et al.
      The development, Pilot, and process evaluation of a parent mental health literacy intervention through community sports clubs.
      ], and attitudes and intentions toward seeking help [
      • Schoenfelder E.
      • McCabe C.
      • Fife A.
      • et al.
      Research brief: The teen ADHD Workshop to improve adolescent ADHD treatment engagement.
      ]. Of the studies, nine found a significant increase in help-seeking [
      • Chu J.T.W.
      • Wadham A.
      • Jiang Y.
      • et al.
      Effect of MyTeen SMS-based Mobile intervention for parents of adolescents: A Randomized clinical trial.
      ,
      • Asarnow J.R.
      • Baraff L.J.
      • Berk M.
      • et al.
      An emergency department intervention for linking pediatric suicidal patients to follow-up mental health treatment.
      ,
      • Szapocznik J.
      • Perez-Vidai A.
      • Brickman A.L.
      • et al.
      Engaging adolescent drug abusers and their families in treatment: A strategic structural systems approach.
      ,
      • Donohue B.
      • Azrin N.H.
      • Lawson H.
      • et al.
      Improving initial session attendance of substance abusing and conduct disordered adolescents: A controlled study.
      ,
      • Gould M.S.
      • Marrocco F.A.
      • Hoagwood K.
      • et al.
      Service Use by at-risk Youths after school-based suicide screening.
      ,
      • Grupp-Phelan J.
      • McGuire L.
      • Husky M.M.
      • Olfson M.
      A Randomized controlled trial to engage in care of adolescent emergency department patients with mental health problems that increase suicide risk.
      ,
      • Jonovich S.J.
      • Alpert-Gillis L.J.
      Impact of pediatric mental health screening on clinical discussion and referral for services.
      ,
      • Rotheram-Borus M.J.
      • Piacentini J.
      • Van Rossem R.
      • et al.
      Enhancing treatment adherence with a specialized emergency room program for adolescent suicide attempters.
      ,
      • Yoshii H.
      • Watanabe Y.
      • Kitamura H.
      • et al.
      Effect of an education program on improving help-seeking among parents of junior and senior high school students in Japan.
      ], five found no significant increase [
      • Beals-Erickson S.E.
      • Roberts M.C.
      Youth development program participation and changes in help-seeking intentions.
      ,
      • Spirito A.
      • Boergers J.
      • Donaldson D.
      • et al.
      An intervention trial to improve adherence to community treatment by adolescents after a suicide attempt.
      ,
      • Cheng T.L.
      • Wright J.L.
      • Markakis D.
      • et al.
      Randomized trial of a Case management program for Assault-Injured Youth.
      ,
      • Schoenfelder E.
      • McCabe C.
      • Fife A.
      • et al.
      Research brief: The teen ADHD Workshop to improve adolescent ADHD treatment engagement.
      ,
      • Morgan A.J.
      • Fischer J.A.A.
      • Hart L.M.
      • et al.
      Does mental health first aid training improve the mental health of aid recipients? The training for parents of teenagers randomised controlled trial.
      ], and four studies [
      • Kutash K.
      • Duchnowski A.J.
      • Green A.L.
      • Ferron J.
      Effectiveness of the parent Connectors program: Results from a Randomized controlled trial.
      ,
      • Hurley D.
      • Allen M.S.
      • Swann C.
      • et al.
      The development, Pilot, and process evaluation of a parent mental health literacy intervention through community sports clubs.
      ,
      • Spettigue W.
      • Maras D.
      • Obeid N.
      • Henderson K.A.
      A Psycho-education intervention for parents of adolescents with eating disorders: A Randomized controlled trial.
      ,
      • Sallis A.
      • Porter L.
      • Tan K.
      • et al.
      Improving child weight management uptake through enhanced National child measurement Programme parental feedback letters: A randomised controlled trial.
      ] found mixed results. Seven studies found an increase in help-seeking behavior, and two found no significant effect. The study that looked at help-seeking knowledge found a significant effect, while the two studies that looked at help-seeking intentions found no significant effect (Table 1).
      Table 1Characteristics of studies included in the review
      NameIntervention designCountryRecruitment locationFocus for helpSample demographicsIntervention componentMeasure of help-seekingFindings
      Asarnow et al. [
      • Asarnow J.R.
      • Baraff L.J.
      • Berk M.
      • et al.
      An emergency department intervention for linking pediatric suicidal patients to follow-up mental health treatment.
      ]
      Randomized control trial

      Quality rating: Strong
      USAEmergency departmentSuicide attempt/suicidal ideation181 families of adolescents aged 10-18 enrolled in study, and 160 completed follow-up. PGNS.FISP: Family-based cognitive behavioral therapy to increase motivation for outpatient treatment.Attendance at outpatient servicesFISP patients were significantly more likely than those in the control to attend outpatient treatments (92% vs. 76%)
      Beals-Erickson & Roberts [
      • Beals-Erickson S.E.
      • Roberts M.C.
      Youth development program participation and changes in help-seeking intentions.
      ]
      Cohort study

      Quality rating: Weak
      USACommunity: AileyCampEmotional problem, behavioral problem, or drug use135 caregivers (82% mothers) and 124 adolescents aged 11-14AileyCamp: Program increase parental exposure to services through orientation night, community resource fairs, & family night eventsHelp-seeking intentionsNo statistically significant changes in caregiver's willingness to seek help for youth problems
      Cheng et al. [
      • Cheng T.L.
      • Wright J.L.
      • Markakis D.
      • et al.
      Randomized trial of a Case management program for Assault-Injured Youth.
      ]
      Randomized control trial

      Quality rating: Weak
      USAEmergency departmentViolence-related behavior88 parents and their adolescents aged 12-17 enrolled in the study, 50 completed follow-up. PGNS.Families received case management from counselor who assessed family needs and facilitated service useService access-14 specific mental health and social servicesNo significant program effect on service utilization per parent and youth report
      Chu et al. [
      • Chu J.T.W.
      • Wadham A.
      • Jiang Y.
      • et al.
      Effect of MyTeen SMS-based Mobile intervention for parents of adolescents: A Randomized clinical trial.
      ]
      Randomized control trial

      Quality rating:

      Strong
      New ZealandCommunity Outreach & Social MediaMental health221 parents enrolled in study (94.2% mothers) of adolescents aged 10–15 years and 201 completed studyText messaging program providing information to parents on how to recognise depressive symptoms and understand treatment optionsKnowledge of where to seek informationSignificant increase in knowledge of where to seek help noted in parents who received intervention (Int M = 17.6 vs. Cont M = 16.7)
      Donohue et al. [
      • Donohue B.
      • Azrin N.H.
      • Lawson H.
      • et al.
      Improving initial session attendance of substance abusing and conduct disordered adolescents: A controlled study.
      ]
      Randomized controlled trial

      Quality quality: Strong
      USAReferred via justice system or by parentConduct problem and substance misuse39 parents (77% mothers) and their adolescents (M = 15.4)Parent and youth received a motivational telephone call 2–3 days before their first session to encourage attendanceService attendanceSignificantly more parents and youth in the intervention kept their first appointment (89% compared to 60%).
      Gould et al. [
      • Gould M.S.
      • Marrocco F.A.
      • Hoagwood K.
      • et al.
      Service Use by at-risk Youths after school-based suicide screening.
      ]
      Quasi-experimental

      Quality rating: Weak
      USASchoolRisk of suicide317 parents and their adolescents aged 13 to 19 enrolled in intervention and 223 completed follow-up. PGNS.Results of screener discussed with parent. At-risk students given referral or list of mental health service providers.Service accessIn those that were not receiving any mental health services at the time of screening, there were differences in who received services depending on if they received a referral, provider list, or no referral (69.2%, 42.3%, and 31.9%).
      Grupp-Phelan et al. [
      • Grupp-Phelan J.
      • McGuire L.
      • Husky M.M.
      • Olfson M.
      A Randomized controlled trial to engage in care of adolescent emergency department patients with mental health problems that increase suicide risk.
      ]
      Randomized controlled trial

      Quality rating: Moderate
      USAEmergency departmentMental health24 parents and their adolescents aged 12-17. PGNS.Social worker discussed the screening results and clinical recommendations with the adolescent and their parentsService attendanceThose in intervention were more likely to schedule a mental health appointment (73% vs. 54%) and attend appointment (64% vs. 15%) in comparison to control.
      Hurley et al. [
      • Hurley D.
      • Allen M.S.
      • Swann C.
      • et al.
      The development, Pilot, and process evaluation of a parent mental health literacy intervention through community sports clubs.
      ]
      Quasi-experimental

      Quality rating: Strong
      AustraliaSports clubsMental health66 parents of adolescents enrolled in study and 55 completed follow-up (77% mothers)A brief 1-hour mental health workshop to educate parents on how to recognize the development of a mental health disorder in their adolescent and how to seek helpKnowledge of help-seeking options

      Attitudes toward seeking help
      Significant difference noted between groups on knowledge of help-seeking options (Int M = 18.44 vs. Cont M = 17.23). No difference on attitudes toward seeking help
      Jonovich & Alpert-Gillis [
      • Jonovich S.J.
      • Alpert-Gillis L.J.
      Impact of pediatric mental health screening on clinical discussion and referral for services.
      ]
      Quasi-experimental

      Quality rating: Weak
      USAPaediatric clinicMental health289 parents and adolescence aged 11 & 12 years. PGNS.Parents and adolescent completed a mental health screener and were provided with follow-up call/letter discussing the resultsService attendanceThose who received the screener were more likely to be referred and attend col-located (10% vs. .5%) and community mental health services (18% vs. 2%)
      Kutash et al. [
      • Kutash K.
      • Duchnowski A.J.
      • Green A.L.
      • Ferron J.
      Effectiveness of the parent Connectors program: Results from a Randomized controlled trial.
      ]
      Randomized control trial

      Quality rating: Strong
      USASchoolsEmotional and behavioral disturbances128 parents and their adolescents (M = 14 years) enrolled and 112 completed (64.3% biological mother)Parent connectors: peer-to-peer program to provide informational, emotional, instrumental support and the promotion of the perceived benefit of treatmentPerceived benefit of engagement in education and mental health

      Parent engagement in education and mental health services

      Child mental health service use
      Parents in intervention, reported greater expected benefit of involvement in child mental health services.

      Parents were found to be more involved in child's mental health services. Child received more school-based counseling services.

      No impact on perceived benefit of engagement in child's education or engagement in child's school activities.
      Morgan et al. [
      • Morgan A.J.
      • Fischer J.A.A.
      • Hart L.M.
      • et al.
      Does mental health first aid training improve the mental health of aid recipients? The training for parents of teenagers randomised controlled trial.
      ]
      Randomized control trial

      Quality rating: Moderate
      AustraliaCommunity (newsletter, community groups, ads on radio)Mental health209 parents of adolescents aged 12-15, 178 parents completed follow-up and 150 adolescents. Mostly mothers (88.1%).Mental Health First Aid Training: information on recognizing and identifying potential mental health problem and how to get appropriate professional supportConfidence and intentions to help a person with a mental health problem and appropriate help-seekingSmall improvements in confidence to help a young person with a mental health problem and intentions to provide effective support. These effects were no longer significant at year 2.
      Rotheram-Borus et al. [
      • Rotheram-Borus M.J.
      • Piacentini J.
      • Van Rossem R.
      • et al.
      Enhancing treatment adherence with a specialized emergency room program for adolescent suicide attempters.
      ]
      Quasi-experimental

      Quality rating: Weak
      USAEmergency departmentSuicide attempt140 mothers of adolescents aged 12-18 (M = 15)Specialized emergency room program: training workshop for staff, videotape aimed at modifying families' treatment expectations & family therapy sessionAttitudes to treatment

      Treatment adherence: attendance at least 1 treatment session
      Mothers in the intervention group had more positive attitudes toward treatment (Int M = 8.46 vs. Cont M = 6.0).

      Adolescents receiving the specialized program were significantly more likely to return to the clinic for any outpatient treatment (95.4% vs. 82.7%).
      Sallis et al. [
      • Sallis A.
      • Porter L.
      • Tan K.
      • et al.
      Improving child weight management uptake through enhanced National child measurement Programme parental feedback letters: A randomised controlled trial.
      ]
      Randomized control trial

      Quality rating: Moderate
      UKSchoolsWeight268 parents of very overweight or overweight adolescents aged 10-11. PGNS.All received: Letters with weight-feedback information and also a visual tool to help weight status recognition (MeMap), social norms statement

      For very overweight children: a prepopulated booking form for weight management services
      Three measures of weight management uptake: enrolment, contact made, and attendanceSignificantly more children contacted (4.8% vs. 2.4%) and enrolled (4.3% vs. 2.2%) in weight management in the intervention group than the control group. No difference in attendance (except for those who were very over weight).
      Schoenfelder et al. [
      • Schoenfelder E.
      • McCabe C.
      • Fife A.
      • et al.
      Research brief: The teen ADHD Workshop to improve adolescent ADHD treatment engagement.
      ]
      Cohort study

      Quality rating: Moderate
      USAOutpatient clinic & primary careADHD20 parents and 15 adolescents aged 13–17 years. PGNS.3-hour workshop on ADHD including psychoeducation, individual/family goal setting, and motivational interviewingTreatment intent

      Attitudes toward ADHD treatments
      No difference in relation to intention to seek treatment.

      No difference in attitudes toward individual therapy, school-based accommodations or parent training
      Spettigue et al. [
      • Spettigue W.
      • Maras D.
      • Obeid N.
      • Henderson K.A.
      A Psycho-education intervention for parents of adolescents with eating disorders: A Randomized controlled trial.
      ]
      Randomized control trial

      Quality rating: Moderate
      CanadaHospital clinicEating disorder51 parents of adolescents (M = 15.66) enrolled in study, 37 completed follow-up (92.2% mothers)2-hour psychoeducation session followed by bi-weekly phone calls to support parentsHelp-seeking behaviorsParents in the intervention accessed significantly more books and websites to learn about the eating disorder (94.4% vs. 60%) while on the wait list but did not access other forms of support in community or services (e.g., general practitioner)
      Spirito et al. [
      • Spirito A.
      • Boergers J.
      • Donaldson D.
      • et al.
      An intervention trial to improve adherence to community treatment by adolescents after a suicide attempt.
      ]
      Randomized control trial

      Quality rating: Strong
      USAEmergency departmentSuicide attempt76 parents and their adolescents aged 12-18 received intervention and 63 completed follow-up. PGNS.1-hour compliance enhancement intervention using a problem-solving formatNumber of psychotherapy sessions attended (reported by parent and therapist)No significant difference between groups on number of sessions attended.
      Szapocznik et al. [
      • Szapocznik J.
      • Perez-Vidai A.
      • Brickman A.L.
      • et al.
      Engaging adolescent drug abusers and their families in treatment: A strategic structural systems approach.
      ]
      Randomized control trial

      Quality rating: Weak
      USAMental health serviceDrug use108 families of adolescents aged 12-21, (82% were aged 14–18) enrolled, 74 completed study PGNS.Strategic structural-systems engagement: Identified and restructured patterns of interactions that interfere with entry into treatmentAttendance at treatment57.7% of control intake as usual failed to come to the centre for treatment. In comparison, only 7.1% of families in the intervention were lost
      Yoshii et al. [
      • Yoshii H.
      • Watanabe Y.
      • Kitamura H.
      • et al.
      Effect of an education program on improving help-seeking among parents of junior and senior high school students in Japan.
      ]
      Cohort study

      Quality rating: Weak
      JapanResearch companySchizophrenia2,565 parents of junior and high school students (12–16 years of age) (51.3% fathers)Web-based education programTypes of consultations they sought from 15 choices of formal/informal sourcesIncrease in help-seeking after intervention for all symptoms of schizophrenia expect sleepiness (31.4% vs. 27.4%).
      ADHD = attention deficit hyperactivity disorder; FISP = Family Intervention for Suicide Prevention; PGNS = parents gender not specified.

       Characteristics of the interventions

      Participants were recruited to the studies from a variety of settings including hospital emergency departments [
      • Asarnow J.R.
      • Baraff L.J.
      • Berk M.
      • et al.
      An emergency department intervention for linking pediatric suicidal patients to follow-up mental health treatment.
      ,
      • Spirito A.
      • Boergers J.
      • Donaldson D.
      • et al.
      An intervention trial to improve adherence to community treatment by adolescents after a suicide attempt.
      ,
      • Cheng T.L.
      • Wright J.L.
      • Markakis D.
      • et al.
      Randomized trial of a Case management program for Assault-Injured Youth.
      ,
      • Grupp-Phelan J.
      • McGuire L.
      • Husky M.M.
      • Olfson M.
      A Randomized controlled trial to engage in care of adolescent emergency department patients with mental health problems that increase suicide risk.
      ,
      • Rotheram-Borus M.J.
      • Piacentini J.
      • Van Rossem R.
      • et al.
      Enhancing treatment adherence with a specialized emergency room program for adolescent suicide attempters.
      ], schools [
      • Gould M.S.
      • Marrocco F.A.
      • Hoagwood K.
      • et al.
      Service Use by at-risk Youths after school-based suicide screening.
      ,
      • Kutash K.
      • Duchnowski A.J.
      • Green A.L.
      • Ferron J.
      Effectiveness of the parent Connectors program: Results from a Randomized controlled trial.
      ,
      • Sallis A.
      • Porter L.
      • Tan K.
      • et al.
      Improving child weight management uptake through enhanced National child measurement Programme parental feedback letters: A randomised controlled trial.
      ], community [
      • Chu J.T.W.
      • Wadham A.
      • Jiang Y.
      • et al.
      Effect of MyTeen SMS-based Mobile intervention for parents of adolescents: A Randomized clinical trial.
      ,
      • Beals-Erickson S.E.
      • Roberts M.C.
      Youth development program participation and changes in help-seeking intentions.
      ,
      • Hurley D.
      • Allen M.S.
      • Swann C.
      • et al.
      The development, Pilot, and process evaluation of a parent mental health literacy intervention through community sports clubs.
      ,
      • Morgan A.J.
      • Fischer J.A.A.
      • Hart L.M.
      • et al.
      Does mental health first aid training improve the mental health of aid recipients? The training for parents of teenagers randomised controlled trial.
      ,
      • Yoshii H.
      • Watanabe Y.
      • Kitamura H.
      • et al.
      Effect of an education program on improving help-seeking among parents of junior and senior high school students in Japan.
      ] (through social media, local radio, community organisation, research company), and hospital clinics, outpatient clinics, and mental health services [
      • Szapocznik J.
      • Perez-Vidai A.
      • Brickman A.L.
      • et al.
      Engaging adolescent drug abusers and their families in treatment: A strategic structural systems approach.
      ,
      • Donohue B.
      • Azrin N.H.
      • Lawson H.
      • et al.
      Improving initial session attendance of substance abusing and conduct disordered adolescents: A controlled study.
      ,
      • Jonovich S.J.
      • Alpert-Gillis L.J.
      Impact of pediatric mental health screening on clinical discussion and referral for services.
      ,
      • Schoenfelder E.
      • McCabe C.
      • Fife A.
      • et al.
      Research brief: The teen ADHD Workshop to improve adolescent ADHD treatment engagement.
      ,
      • Spettigue W.
      • Maras D.
      • Obeid N.
      • Henderson K.A.
      A Psycho-education intervention for parents of adolescents with eating disorders: A Randomized controlled trial.
      ]. The interventions subsequently took place in an emergency department [
      • Asarnow J.R.
      • Baraff L.J.
      • Berk M.
      • et al.
      An emergency department intervention for linking pediatric suicidal patients to follow-up mental health treatment.
      ,
      • Spirito A.
      • Boergers J.
      • Donaldson D.
      • et al.
      An intervention trial to improve adherence to community treatment by adolescents after a suicide attempt.
      ,
      • Grupp-Phelan J.
      • McGuire L.
      • Husky M.M.
      • Olfson M.
      A Randomized controlled trial to engage in care of adolescent emergency department patients with mental health problems that increase suicide risk.
      ,
      • Rotheram-Borus M.J.
      • Piacentini J.
      • Van Rossem R.
      • et al.
      Enhancing treatment adherence with a specialized emergency room program for adolescent suicide attempters.
      ], over the phone [
      • Chu J.T.W.
      • Wadham A.
      • Jiang Y.
      • et al.
      Effect of MyTeen SMS-based Mobile intervention for parents of adolescents: A Randomized clinical trial.
      ,
      • Gould M.S.
      • Marrocco F.A.
      • Hoagwood K.
      • et al.
      Service Use by at-risk Youths after school-based suicide screening.
      ,
      • Kutash K.
      • Duchnowski A.J.
      • Green A.L.
      • Ferron J.
      Effectiveness of the parent Connectors program: Results from a Randomized controlled trial.
      ], letter [
      • Sallis A.
      • Porter L.
      • Tan K.
      • et al.
      Improving child weight management uptake through enhanced National child measurement Programme parental feedback letters: A randomised controlled trial.
      ], online [
      • Yoshii H.
      • Watanabe Y.
      • Kitamura H.
      • et al.
      Effect of an education program on improving help-seeking among parents of junior and senior high school students in Japan.
      ], in the community (sports club or school hall) [
      • Beals-Erickson S.E.
      • Roberts M.C.
      Youth development program participation and changes in help-seeking intentions.
      ,
      • Hurley D.
      • Allen M.S.
      • Swann C.
      • et al.
      The development, Pilot, and process evaluation of a parent mental health literacy intervention through community sports clubs.
      ,
      • Morgan A.J.
      • Fischer J.A.A.
      • Hart L.M.
      • et al.
      Does mental health first aid training improve the mental health of aid recipients? The training for parents of teenagers randomised controlled trial.
      ], over the phone and/or in person (hospital clinic or mental health service) [
      • Cheng T.L.
      • Wright J.L.
      • Markakis D.
      • et al.
      Randomized trial of a Case management program for Assault-Injured Youth.
      ,
      • Donohue B.
      • Azrin N.H.
      • Lawson H.
      • et al.
      Improving initial session attendance of substance abusing and conduct disordered adolescents: A controlled study.
      ], and in hospital clinics, outpatient clinics, or mental health services [
      • Szapocznik J.
      • Perez-Vidai A.
      • Brickman A.L.
      • et al.
      Engaging adolescent drug abusers and their families in treatment: A strategic structural systems approach.
      ,
      • Jonovich S.J.
      • Alpert-Gillis L.J.
      Impact of pediatric mental health screening on clinical discussion and referral for services.
      ,
      • Schoenfelder E.
      • McCabe C.
      • Fife A.
      • et al.
      Research brief: The teen ADHD Workshop to improve adolescent ADHD treatment engagement.
      ,
      • Spettigue W.
      • Maras D.
      • Obeid N.
      • Henderson K.A.
      A Psycho-education intervention for parents of adolescents with eating disorders: A Randomized controlled trial.
      ]. Three of the interventions were delivered by health-care professionals (including nurses and doctors), four of the interventions were delivered by a clinical psychologist or a therapist, two were delivered by a social worker, six were delivered by the research team, two were delivered by unspecified clinicians, and one was delivered by parents with lived experience. The duration of the intervention varied: Seven of the interventions were a once-off session, five were a once-off session with follow-up phone calls, and the rest of the interventions varied in duration (longest lasted one school year). Follow-up time for outcome assessment varied greatly from the same day to 2 years, and for most studies, it was three months or less (61%). Nine of the interventions identified a theory informing the design of the intervention such as family therapy, mental health first aid, theory of planned behavior, or motivational interviewing [
      • Asarnow J.R.
      • Baraff L.J.
      • Berk M.
      • et al.
      An emergency department intervention for linking pediatric suicidal patients to follow-up mental health treatment.
      ,
      • Szapocznik J.
      • Perez-Vidai A.
      • Brickman A.L.
      • et al.
      Engaging adolescent drug abusers and their families in treatment: A strategic structural systems approach.
      ,
      • Kutash K.
      • Duchnowski A.J.
      • Green A.L.
      • Ferron J.
      Effectiveness of the parent Connectors program: Results from a Randomized controlled trial.
      ,
      • Schoenfelder E.
      • McCabe C.
      • Fife A.
      • et al.
      Research brief: The teen ADHD Workshop to improve adolescent ADHD treatment engagement.
      ,
      • Hurley D.
      • Allen M.S.
      • Swann C.
      • et al.
      The development, Pilot, and process evaluation of a parent mental health literacy intervention through community sports clubs.
      ,
      • Morgan A.J.
      • Fischer J.A.A.
      • Hart L.M.
      • et al.
      Does mental health first aid training improve the mental health of aid recipients? The training for parents of teenagers randomised controlled trial.
      ,
      • Spettigue W.
      • Maras D.
      • Obeid N.
      • Henderson K.A.
      A Psycho-education intervention for parents of adolescents with eating disorders: A Randomized controlled trial.
      ,
      • Sallis A.
      • Porter L.
      • Tan K.
      • et al.
      Improving child weight management uptake through enhanced National child measurement Programme parental feedback letters: A randomised controlled trial.
      ].

       Quality appraisal

      Six of the 18 studies were rated strong for their design and methodology [
      • Chu J.T.W.
      • Wadham A.
      • Jiang Y.
      • et al.
      Effect of MyTeen SMS-based Mobile intervention for parents of adolescents: A Randomized clinical trial.
      ,
      • Asarnow J.R.
      • Baraff L.J.
      • Berk M.
      • et al.
      An emergency department intervention for linking pediatric suicidal patients to follow-up mental health treatment.
      ,
      • Spirito A.
      • Boergers J.
      • Donaldson D.
      • et al.
      An intervention trial to improve adherence to community treatment by adolescents after a suicide attempt.
      ,
      • Donohue B.
      • Azrin N.H.
      • Lawson H.
      • et al.
      Improving initial session attendance of substance abusing and conduct disordered adolescents: A controlled study.
      ,
      • Kutash K.
      • Duchnowski A.J.
      • Green A.L.
      • Ferron J.
      Effectiveness of the parent Connectors program: Results from a Randomized controlled trial.
      ,
      • Hurley D.
      • Allen M.S.
      • Swann C.
      • et al.
      The development, Pilot, and process evaluation of a parent mental health literacy intervention through community sports clubs.
      ], five were rated as moderate [
      • Grupp-Phelan J.
      • McGuire L.
      • Husky M.M.
      • Olfson M.
      A Randomized controlled trial to engage in care of adolescent emergency department patients with mental health problems that increase suicide risk.
      ,
      • Schoenfelder E.
      • McCabe C.
      • Fife A.
      • et al.
      Research brief: The teen ADHD Workshop to improve adolescent ADHD treatment engagement.
      ,
      • Morgan A.J.
      • Fischer J.A.A.
      • Hart L.M.
      • et al.
      Does mental health first aid training improve the mental health of aid recipients? The training for parents of teenagers randomised controlled trial.
      ,
      • Spettigue W.
      • Maras D.
      • Obeid N.
      • Henderson K.A.
      A Psycho-education intervention for parents of adolescents with eating disorders: A Randomized controlled trial.
      ,
      • Sallis A.
      • Porter L.
      • Tan K.
      • et al.
      Improving child weight management uptake through enhanced National child measurement Programme parental feedback letters: A randomised controlled trial.
      ], and seven were rated as weak [
      • Beals-Erickson S.E.
      • Roberts M.C.
      Youth development program participation and changes in help-seeking intentions.
      ,
      • Szapocznik J.
      • Perez-Vidai A.
      • Brickman A.L.
      • et al.
      Engaging adolescent drug abusers and their families in treatment: A strategic structural systems approach.
      ,
      • Cheng T.L.
      • Wright J.L.
      • Markakis D.
      • et al.
      Randomized trial of a Case management program for Assault-Injured Youth.
      ,
      • Gould M.S.
      • Marrocco F.A.
      • Hoagwood K.
      • et al.
      Service Use by at-risk Youths after school-based suicide screening.
      ,
      • Jonovich S.J.
      • Alpert-Gillis L.J.
      Impact of pediatric mental health screening on clinical discussion and referral for services.
      ,
      • Rotheram-Borus M.J.
      • Piacentini J.
      • Van Rossem R.
      • et al.
      Enhancing treatment adherence with a specialized emergency room program for adolescent suicide attempters.
      ,
      • Yoshii H.
      • Watanabe Y.
      • Kitamura H.
      • et al.
      Effect of an education program on improving help-seeking among parents of junior and senior high school students in Japan.
      ]. The main reasons for the weak quality rating were lack of control group, lack of control for possible confounding variables, and selection bias as many of the studies had a high refusal rate or did not have a representative sample. The majority of the studies failed to mention whether the researcher or participant was blind to the study aims. See Supplementary Materials for quality rating of all studies.

       Behavioral change techniques

      The intervention arm of 13 studies designed to increase parental help-seeking behaviors were coded for BCTs (N = 13). The number of BCTs in interventions ranged from three to 9 with an average of 5.1 BCTs per intervention. The most common BCTs used included credible source (92.3%), social support (unspecified) (69.2%), prompts and cues (46.2%), information about the social and environmental consequences (46.2%), information about the health consequences (38.5%), framing/reframing (38.5%), social support (practical) (38.5%), and feedback on the behavior (23.1%). See Table 2 for examples based on the BCT description. One study that was designed to increase parental help-seeking behavior could not be coded for BCTs as the intervention description was too vague [
      • Yoshii H.
      • Watanabe Y.
      • Kitamura H.
      • et al.
      Effect of an education program on improving help-seeking among parents of junior and senior high school students in Japan.
      ].
      Table 2The commonly used behavioral change techniques with examples from the interventions
      BCTDescriptionExample of coded text
      2.2 Feedback on the behaviorMonitor and provide informative or evaluative feedback on performance of the behavior (e.g., form, frequency, duration, intensity)“All families that completed the screener were provided a follow-up call and/or letter discussing if the results of the screening were negative or positive” (p365) [
      • Jonovich S.J.
      • Alpert-Gillis L.J.
      Impact of pediatric mental health screening on clinical discussion and referral for services.
      ]
      3.1 Social support unspecifiedAdvise on, arrange, or provide social support or noncontingent praise or reward for performance of the behavior“our project social workers recommended either a specific referral, provided lists of mental health resources in the area, or merely discussed the screening

      findings with the parents” (p4) [
      • Gould M.S.
      • Marrocco F.A.
      • Hoagwood K.
      • et al.
      Service Use by at-risk Youths after school-based suicide screening.
      ]
      3.2 Social support practicalAdvise on, arrange, or provide practical help (e.g., from friends, relatives, colleagues, ‘buddies’, or staff) for performance of the behavior“The case manager made follow-up telephone calls on a weekly to monthly basis as part of an ongoing needs assessment; assisted in the identification of community services for the family; and facilitated service use including providing service information and application forms, making appointments, assisting with transportation” (p132) [
      • Cheng T.L.
      • Wright J.L.
      • Markakis D.
      • et al.
      Randomized trial of a Case management program for Assault-Injured Youth.
      ]
      5.1 Information about the health consequencesProvide information (e.g., written, verbal, visual) about health consequences of performing the behavior“The psychoeducation session was delivered face-to-face by s psychiatrist and adolescent health physician who specialize in the treatment of pediatric eating disorders. Topic addressed included:… definition of symptoms, risk factors for developing an eating disorder, and medical and psychiatric complications” (p63-64) [
      • Spettigue W.
      • Maras D.
      • Obeid N.
      • Henderson K.A.
      A Psycho-education intervention for parents of adolescents with eating disorders: A Randomized controlled trial.
      ]
      5.3 Information about the social and environmental consequencesProvide information about social and environmental consequences of performing the behavior“A 20-minute videotape portraying the emergency room experiences of two adolescent attempters was developed. The video used a soap opera format to provide a strong rationale for follow-up treatment” (p5) [
      • Rotheram-Borus M.J.
      • Piacentini J.
      • Van Rossem R.
      • et al.
      Enhancing treatment adherence with a specialized emergency room program for adolescent suicide attempters.
      ]
      7.1 Prompts and cuesIntroduce or define environmental or social stimulus with the purpose of prompting or cueing the behavior.“The social worker assisted families with securing a mental health evaluation…. provided telephone reminders before the scheduled appointment” (p1264) [
      • Grupp-Phelan J.
      • McGuire L.
      • Husky M.M.
      • Olfson M.
      A Randomized controlled trial to engage in care of adolescent emergency department patients with mental health problems that increase suicide risk.
      ]
      9.1 Credible sourcePresent verbal or visual communication from a credible source in favor of or against the behavior“The study was begun with two therapists. However early in the study one of the therapists became seriously ill…. The remaining therapist had a doctoral degree in clinical psychology and over 15 years of experience as a therapist” (p554) [
      • Szapocznik J.
      • Perez-Vidai A.
      • Brickman A.L.
      • et al.
      Engaging adolescent drug abusers and their families in treatment: A strategic structural systems approach.
      ]
      13.2 Framing/ReframingSuggest the deliberate adoption of a perspective or new perspective on behavior (e.g., its purpose) to change cognitions or emotions about performing the behavior“It was theorised that the MapMe tool and the social norms message would help parents recognise excess weight in their children and reset perceptions of child weight norms” (p134) [
      • Sallis A.
      • Porter L.
      • Tan K.
      • et al.
      Improving child weight management uptake through enhanced National child measurement Programme parental feedback letters: A randomised controlled trial.
      ]
      Table 3Description of promising interventions
      Article nameQuality ratingEvidence base underpinning interventionPositive outcome measure
      Hurley et al. [
      • Hurley D.
      • Allen M.S.
      • Swann C.
      • et al.
      The development, Pilot, and process evaluation of a parent mental health literacy intervention through community sports clubs.
      ]
      StrongMental health literacy frameworkSignificant difference noted between intervention and control in help-seeking knowledge
      Chu et al. [
      • Chu J.T.W.
      • Wadham A.
      • Jiang Y.
      • et al.
      Effect of MyTeen SMS-based Mobile intervention for parents of adolescents: A Randomized clinical trial.
      ]
      StrongParenting strategies programSignificant increase in knowledge of where to seek help between intervention and control
      Asarnow et al. [
      • Asarnow J.R.
      • Baraff L.J.
      • Berk M.
      • et al.
      An emergency department intervention for linking pediatric suicidal patients to follow-up mental health treatment.
      ]
      StrongFamily-based cognitive behavioral therapyThose who received the intervention were significantly more likely to attend outpatient services
      Kutash et al. [
      • Kutash K.
      • Duchnowski A.J.
      • Green A.L.
      • Ferron J.
      Effectiveness of the parent Connectors program: Results from a Randomized controlled trial.
      ]
      StrongABCX model and the theory of planned vehaviorParents in the intervention reported greater expected benefit of engagement in their child's mental health treatment, parents were more involved in their child's mental health services, and their child received more school-based counseling services.

       Promising interventions

      Four interventions were identified as promising (see Table 3). Two of these were universal interventions identified as promising in increasing parental help-seeking knowledge. Hurley et al. [
      • Hurley D.
      • Allen M.S.
      • Swann C.
      • et al.
      The development, Pilot, and process evaluation of a parent mental health literacy intervention through community sports clubs.
      ] developed a mental health literacy intervention based on the mental health literacy framework [
      • Jorm A.F.
      • Korten A.E.
      • Jacomb P.A.
      • et al.
      “Mental health literacy”: A survey of the public’s ability to recognise mental disorders and their beliefs about the effectiveness of treatment.
      ] and consultations with parents. The intervention was a once-off session used to educate parents on how to recognise the development of a mental health disorder in their adolescent and how to go about seeking help. A significant difference in help-seeking knowledge was found between the intervention and control groups at one-month follow-up. Chu et al. [
      • Chu J.T.W.
      • Wadham A.
      • Jiang Y.
      • et al.
      Effect of MyTeen SMS-based Mobile intervention for parents of adolescents: A Randomized clinical trial.
      ] developed a four-week text messaging intervention to deliver a series of evidence-based tips adapted from the Parenting Strategies Program [
      Parenting Strategies: Protecting your child’s mental health.
      ]. The tips provided parents with information on how to recognize depressive symptoms in adolescents and understanding treatment options. A significant increase in knowledge of where to seek help was found in parents who received the intervention at 3-month follow-up.
      Two indicated interventions targeting parents of adolescents who were experiencing emotional/behavioral difficulties were identified as promising in increasing parents' help-seeking behaviors. The intervention developed by Asarnow et al. [
      • Asarnow J.R.
      • Baraff L.J.
      • Berk M.
      • et al.
      An emergency department intervention for linking pediatric suicidal patients to follow-up mental health treatment.
      ] involved a family-based cognitive behavioral therapy (CBT) session which was designed to increase attendance at outpatient appointments. Those who received the family-based CBT intervention were more likely than those in the control group to attend outpatient treatments. This intervention had nine BCTs, and these included social support (emotional), social support (unspecified), credible source, information about the emotional consequences and health consequences, action planning, problem solving, framing/reframing, and prompts/cues. The intervention of Kutash et al. [
      • Kutash K.
      • Duchnowski A.J.
      • Green A.L.
      • Ferron J.
      Effectiveness of the parent Connectors program: Results from a Randomized controlled trial.
      ] was based on the ABCX model and the theory of planned behavior. The intervention involved Parent Connects (parents with lived experience), calling participants once a week offering support, and helped the parent to see the benefit of engagement with services. Parents who received the intervention were more likely to see the benefit of involvement in their child's mental health services, and their children received more school-based counseling services. The intervention had four BCTs: social support (unspecified), information about the social and environmental consequences, framing/reframing, and credible source.

      Discussion

      A number of interventions have been designed to increase parental help-seeking; however, to date, no review has been conducted to collate and synthesis the research on parental help-seeking interventions. The aim of this review was to provide researchers, policy-makers, and practitioners with an overview of the current research on parental help-seeking interventions so that they can make evidence-informed choices when designing and implementing interventions in the future.
      Question 1: What are the characteristics of interventions designed to increase parental help-seeking knowledge, attitudes, intentions, and behaviors?
      The majority of the interventions were designed to increase parental help-seeking for emotional and behavioral issues. This is not surprising as mental health problems account for a large proportion of the disease burden in young people [
      • Patel V.
      • Flisher A.J.
      • Hetrick S.
      • McGorry P.
      Mental health of young people: A global public-health challenge.
      ]. The majority of the included interventions were a single-session intervention for parents, and the follow-up time of studies was quite short. Studies have shown that while a once-off intervention is the favored approach for parents, higher duration and intensity leads to better outcomes [
      • Sanders M.R.
      • Haslam D.M.
      • Calam R.
      • et al.
      Designing effective interventions for working parents: A web-based survey of parents in the UK workforce.
      ]. Furthermore, the longer the follow-up time, the better the indication of the long-term impact of the intervention [
      • Rickwood D.
      • Thomas K.
      Conceptual measurement framework for help-seeking for mental health problems.
      ]. Half of the studies found a significant improvement in help-seeking knowledge and behavior. However, the findings were contradictory, for example, while some studies found an effect for help-seeking behavior, others did not. As it was not possible to conduct a meta-analysis, conclusions about the effectiveness of the interventions should be interpreted with extreme caution.
      The majority of the studies had a moderate to weak rating for their methodological quality. This was, in part, due to the design of the studies, as nine were cohort or quasi-experimental studies. Many of the studies were also rated weak for the recruitment of their sample because of a high refusal rate or a nonrepresentative sample. This is not surprising as one of the biggest challenges when designing an intervention is engaging parents. More needs to be done in the initial recruitment phase to attract parents to intervention studies [
      • Axford N.
      • Lehtonen M.
      • Kaoukji D.
      • et al.
      Engaging parents in parenting programs: Lessons from research and practice.
      ]. It was also noted that in most studies (that described the parent sample), the sample were predominantly mothers. One study had an equal mix of mothers and fathers; however, participants were recruited via a private company that specialised in survey research. Both parents share equal responsibility in the upbringing of their children. It is important when designing an intervention for parents to adapt the intervention so that the promotion, content, and activities is appealing to both mothers and fathers [
      • Panter-Brick C.
      • Burgess A.
      • Eggerman M.
      • et al.
      Practitioner review: Engaging fathers - Recommendations for a game change in parenting interventions based on a systematic review of the global evidence.
      ]. MacFayden et al. [
      • MacFayden A.
      • Swallow V.
      • Lambert H.
      Involving fathers in research.
      ] outline a number of ways researchers can try to recruit fathers including incorporating fathers in the early stages of the research through testing intervention materials and survey questions to ensure they are meaningful to men, targeting fathers directly when recruiting, emphasising the importance of fathers' contribution to the research study, and ensuring that fathers' voices are accurately reflected in the results.
      Question 2: Are any of the interventions identified “promising interventions” that could be replicated to develop best practice guidelines for parental help-seeking interventions?
      As outlined in this review, parents are an important avenue for intervention, but to date, the evidence has been limited regarding what types of interventions are effective and should be implemented with parents. Based on the criteria outlined by Fazal et al. [
      • Fazal N.
      • Jackson S.F.
      • Wong K.
      • et al.
      Between worst and best: Developing criteria to identify promising practices in health promotion and disease prevention for the Canadian best practices portal.
      ], we have identified four promising interventions [
      • Chu J.T.W.
      • Wadham A.
      • Jiang Y.
      • et al.
      Effect of MyTeen SMS-based Mobile intervention for parents of adolescents: A Randomized clinical trial.
      ,
      • Asarnow J.R.
      • Baraff L.J.
      • Berk M.
      • et al.
      An emergency department intervention for linking pediatric suicidal patients to follow-up mental health treatment.
      ,
      • Kutash K.
      • Duchnowski A.J.
      • Green A.L.
      • Ferron J.
      Effectiveness of the parent Connectors program: Results from a Randomized controlled trial.
      ,
      • Hurley D.
      • Allen M.S.
      • Swann C.
      • et al.
      The development, Pilot, and process evaluation of a parent mental health literacy intervention through community sports clubs.
      ], all of which relate to aspects of adolescent mental health. Hurley et al. [
      • Hurley D.
      • Allen M.S.
      • Swann C.
      • et al.
      The development, Pilot, and process evaluation of a parent mental health literacy intervention through community sports clubs.
      ] demonstrated that a once-off mental health literacy intervention could increase parental mental health help-seeking knowledge. Chu et al. [
      • Chu J.T.W.
      • Wadham A.
      • Jiang Y.
      • et al.
      Effect of MyTeen SMS-based Mobile intervention for parents of adolescents: A Randomized clinical trial.
      ] reported that a four-week text messaging intervention “My Teen”, which provided parents with information about recognizing depressive symptoms and where to seek help, was effective in increasing help-seeking knowledge. Neither study explored the effects of their interventions on help-seeking behavior. However, we identified two interventions that are promising in their impact on behavior [
      • Asarnow J.R.
      • Baraff L.J.
      • Berk M.
      • et al.
      An emergency department intervention for linking pediatric suicidal patients to follow-up mental health treatment.
      ,
      • Kutash K.
      • Duchnowski A.J.
      • Green A.L.
      • Ferron J.
      Effectiveness of the parent Connectors program: Results from a Randomized controlled trial.
      ]. Asarnow et al. [
      • Asarnow J.R.
      • Baraff L.J.
      • Berk M.
      • et al.
      An emergency department intervention for linking pediatric suicidal patients to follow-up mental health treatment.
      ] found that a brief family-based CBT session (Family Intervention for Suicide Prevention), followed by a structured telephone contact significantly increased subsequent attendance at outpatient appointments after an adolescents' attempted suicide. Kutash et al. [
      • Kutash K.
      • Duchnowski A.J.
      • Green A.L.
      • Ferron J.
      Effectiveness of the parent Connectors program: Results from a Randomized controlled trial.
      ] used their “Parent Connectors” intervention (parents with lived experience who supported parents) to effectively increase attendance at school counseling services. Although differing in delivery and design, both the interventions helped parents to see the benefit of seeking help and in turn supported the parent and provided guidance in obtaining such help.
      Replication of the aforementioned studies with different samples in different contexts is needed to determine if the results of such intervention studies generalize to other populations and situations [
      • Fazal N.
      • Jackson S.F.
      • Wong K.
      • et al.
      Between worst and best: Developing criteria to identify promising practices in health promotion and disease prevention for the Canadian best practices portal.
      ]. Fazal et al. [
      • Fazal N.
      • Jackson S.F.
      • Wong K.
      • et al.
      Between worst and best: Developing criteria to identify promising practices in health promotion and disease prevention for the Canadian best practices portal.
      ] indicates that if a promising intervention repeatedly shows it has a positive impact overtime on the desired outcome, it can be deemed best practice.
      Question 3: What are the “active ingredients” of the interventions designed to increase parental help-seeking behavior?
      This is one of the first studies to apply the BCT to help-seeking interventions. BCTs common to many of the interventions and also identified in the promising interventions included credible source, social support (unspecified), prompt/cue, framing/reframing, and information about the social and environmental/health consequences. A credible source, usually a health-care professional, delivered the majority of the interventions. A credible source is important as parents need to trust the individual who is providing them advice and support for seeking help [
      • Sayal K.
      • Tischler V.
      • Coope C.
      • et al.
      Parental help-seeking in primary care for child and adolescent mental health concens: Qualitative study.
      ]. Providing parents with social support and prompts and cues were frequently used in the study interventions to remind and encourage parents to seek help. Studies have shown that providing parents with support to help their adolescent when seeking help is important to motivate the parent to feel empowered to help their child [
      • Hoagwood K.E.
      • Cavaleri M.A.
      • Olin S.S.
      • et al.
      Family support in children’s mental health: A review and synthesis.
      ]. A common technique in the interventions was to frame the problem as requiring action and provide information related to the health and social or environmental consequences. This was usually information to educate parents and provide a rationale for why seeking help is important. Studies have previously shown that it is not enough for parents to be aware of help that is available but that they need to be persuaded and motivated to see the benefit of seeking help [
      • Morrissey-Kane E.
      • Prinz R.J.
      Engagement in child and adolescent treatment: The role of parental cognitions and attributions.
      ]. A credible source and providing information related to the health and social or environmental consequences were commonly used strategies identified in a systematic review that applied the framework to identify behavior change techniques to increase mental health service utilization among men [
      • Sagar-Ouriaghli I.
      • Godfrey E.
      • Bridge L.
      • et al.
      Improving mental health service utilization among men: A systematic review and synthesis of behavior change techniques within interventions targeting help-seeking.
      ].
      This systematic review addresses a gap in the literature and focuses specifically on interventions to increase parental help-seeking. The review used reliable and rigorous methodologies while searching the literature; no limitations were placed based on language or year of publication. The search string was very broad, and forward and backward reference screening was conducted on all full-text article to ensure no study was missed. However, there has been dispute among researchers regarding what defines help-seeking, and it is possible some studies may have been missed because of articles not referring to the intervention as a help-seeking intervention in the title, abstract, or keywords [
      • Rickwood D.
      • Thomas K.
      Conceptual measurement framework for help-seeking for mental health problems.
      ]. To the authors' knowledge, this is one of the first studies to apply the Behavioural Change Technique Taxonomy to help-seeking interventions. The tool provides a useful framework for greater replicability and interpretation of specific elements that lead to help-seeking behaviors [
      • Cane J.
      • Richardson M.
      • Johnston M.
      • et al.
      From lists of behaviour change techniques (BCTs) to structured hierarchies: Comparison of two methods of developing a hierarchy of BCTs.
      ]. In order for a BCT to be coded as present, the description should be explicit to indicate that the technique is being applied to change the target behavior. As some of the intervention descriptions were not detailed, it was difficult in some articles to determine if a BCT was present or not [
      • Lorencatto F.
      • West R.
      • Stavri Z.
      • Michie S.
      How well is intervention content described in published reports of Smoking Cessation interventions?.
      ].
      The results of this systematic review outline important points for researchers to consider when designing future parental help-seeking interventions. Researchers should place more emphasis on designing interventions that have a strong methodology, in particular, focus should be placed on identifying ways to recruit parents to the intervention to ensure a representative sample, and the recruitment of fathers should also not be overlooked. More emphasis needs to be placed on designing universal parent help-seeking interventions. Early intervention is key to better outcomes, and evidence has shown that it is more advantageous to equip parents with the skills to help their adolescent before an issue arises rather than when an issue arises [
      • Kieling C.
      • Baker-Henningham H.
      • Belfer M.
      • et al.
      Child and adolescent mental health worldwide: Evidence for action.
      ]. As the intervention design and outcome measures were heterogenous, it was not possible to conduct a meta-analysis. Future help-seeking intervention studies should attempt to coordinate and standardize the outcomes assessed so that quantitative comparison among studies via meta-analysis can be completed [
      • Werlen L.
      • Gjukaj D.
      • Mohler-Kuo M.
      • Puhan M.A.
      Interventions to improve children’s access to mental health care: A systematic review and meta-analysis.
      ]. Interventions should be designed based on a pre-established model or theory [
      • Michie S.
      • Prestwich A.
      Are interventions theory-based? Development of a theory coding scheme.
      ]. In this study, we identified whether a theory was present or not, and future research should go one step further and use a tool, such as the theory coding scheme, to identify the extent to which the theory informed the design and outcomes of the intervention [
      • Michie S.
      • Prestwich A.
      Are interventions theory-based? Development of a theory coding scheme.
      ]. Researchers should use the BCT Framework [
      • Michie S.
      • Richardson M.S.
      • Johnston M.
      • et al.
      The behavior change technique Taxonomy (v1) of 93 Hierarchically Clustered techniques: Building an International Consensus for the reporting of behavior change interventions.
      ] to assist in the development and to enhance the description of an intervention. If common behavioral change techniques are used in help-seeking interventions, over time, it will be possible to identify effective/ineffective behavior change techniques [
      • Michie S.
      • Richardson M.S.
      • Johnston M.
      • et al.
      The behavior change technique Taxonomy (v1) of 93 Hierarchically Clustered techniques: Building an International Consensus for the reporting of behavior change interventions.
      ]. As the study was focusing on help-seeking as an outcome measure, only quantitative studies were included in the review. Future reviews could explore parents' experiences of engaging in help-seeking interventions to gain more rounded understanding of parents' experiences.
      To conclude, this review has identified the potential value of help-seeking interventions for parents of adolescents. Given the importance of parents in supporting adolescents at times of physical and mental health challenges, the findings may be of value to researchers, policy-makers, and practitioners who seek guidelines on developing high-quality interventions.

      Funding Sources

      This research was supported by a grant from the Health Research Board Ireland ( CDA-FA-2018-001 ).

      Acknowledgments

      The authors acknowledge Rachel Niland and specialist librarian Marta Bustillo for their contributions to the literature search process. A poster presentation on the progress of this research was made at the European Association for Research on Adolescence conference (online September 2020) and again in the Society for Research on Adolescence conference (online, March 2021).

      Supplementary Data

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