Modes of entry into services for young children with disruptive behaviors

10.1177/1049732304268784QUALITATIVE HEALTH RESEARCH / November 2004Arcia et al. / MODES OF ENTRY

Modes of Entry Into Services for YoungChildren With Disruptive Behaviors

Emily ArciaMaría C. FernándezMarisela JáquezHéctor CastilloMaría Ruiz

The authors undertook this study to describe Latina mothers’ professional help seeking fortheir young children’s disruptive behaviors. They interviewed 62 Cuban, Puerto Rican, andDominican first-time help seekers and found four modes of entry: (a) coercion, (b) acceptanceof offered referral, (c) responsive and resourceful help seeking subsequent to school reports ofbehavior problems, and (d) a laborious and convoluted path that was characteristic of 52% ofthe sample. Schools, maternal and child characteristics, and social network forces played sig-nificant roles for all mothers, but the final determinants of service entry varied by the mode ofentry followed. Findings suggest that problem labeling is not a necessary precursor to ser-vice entry and that direct referrals might effectively shortcut the help-seeking process.Finally, the process that underlies service entry would be described more aptly as a Theory ofAffective Action than a Theory of Reasoned Action.

Keywords: service pathways; children; disruptive behaviors; Latino

Attention Deficit/Hyperactivity Disorder (ADHD) is one of the most prevalentmental health problems of children in the early elementary grades (American

Psychiatric Association, 1994), and, if left untreated, the prognosis is typically quitepoor (Hechtman & Weiss, 1983). Notwithstanding the importance of services, thispopulation is commonly underserved (Pavuluri, Luk, & McGee, 1996; Verhulst &van der Ende, 1997). It is difficult for parents to recognize that their children’sbehavior is atypical and in need of specialized services (Arcia & Fernández, 2003),and there is a dearth of appropriate and easily identified and accessed services(Hoagwood, Kelleher, Feil, & Comer, 2000). In addition, the ethnic minorities areparticularly likely to underuse mental health services (McMiller & Weisz, 1996).

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AUTHORS’NOTE: This study was supported by NIMH R03MH60462. It was also made possible by theassistance of numerous mental health care providers who referred mothers to the study and by the sup-port of Miami Behavioral Health Center and Miami-Dade County Public Schools. Most of all, we areindebted to the mothers who shared their stories with us and let us look into their hearts and minds. Acopy of the interview protocol is available. Correspondence concerning this article should be addressedto Emily Arcia, Ph.D., 5333 Collins Avenue, #1401, Miami Beach, FL 33140; telephone: 305-995-7585, fax:305-995-2047; e-mail: [email protected].

QUALITATIVE HEALTH RESEARCH, Vol. 14 No. 9, November 2004 1211-1226DOI: 10.1177/1049732304268784© 2004 Sage Publications

Thus, to understand how entry into needed services might be facilitated for fami-lies, we undertook this study to identify the pathways that led Latina mothers ofchildren with disruptive behaviors into service use and the factors that determinedthe approach through any given pathway.

Rogler and Cortes (1993) conceptualized a pathway as the “sequence of con-tacts with individuals and organizations prompted by the distressed person’sefforts . . . to seek help as well as the help that is supplied in response to such efforts”(p. 555). They described pathways as commencing with the onset of distress, pro-gressing to a stage in which individuals process and give meaning to the distressexperience, and terminate in contacts with the professional sector that eventuallylead to entry into services that are stable and appropriate. Models of help seekingfor physical health problems contribute to understanding of this process with fac-tors that are also likely determinants of entry into mental health services. TheHealth Belief Model, originally developed to explain participation in screening pro-grams, suggests that readiness to procure services is determined by perceived sus-ceptibility to disease, its potential severity, the perceived benefits of services, theperception of barriers, and cues to action (Mullen, Hersey, & Iverson, 1987; Poss,2001; Rosenstock, 1974). The Theory of Reasoned Action is based on the assumptionthat human beings are rational and weigh the costs and benefits of service use. Itsuggests that people’s attitudes toward services combine with their understandingof the social norm to determine their intentions to use services (Fishbein & Ajzen,1975). The Stages of Change Model recognizes a precontemplation stage, in whichthe individual might be unaware, uninvolved, or undecided about the merits of alifestyle change (Elder, Ayala, & Harris, 1999).

Other applications of service use models to the field of mental health also stressthe importance of the interpretations made at the onset of distress (Rogler & Cortes,1993), the need for problem recognition (Vera et al., 1998), and the role of the socialnetworks in shaping help seeking (Pescosolido, Gardner, & Lubell, 1998;Pescosolido, Wright, Alegría, & Vera, 1998; Vera et al., 1998). Together, these variouscontributions have led to the understanding of help seeking in the mental healthsector as a complex process between multiple factors that can vary substantiallyacross individuals. However, we do not know if models that apply to physicalhealth conditions, to mental health problems in adults, and even to adolescents areapt for young children with disruptive disorders. Key characteristics of behaviorproblems in young children might limit the appropriateness of general health oradult mental health help-seeking models.

Unlike most physical illnesses, with ADHD there is no clearly marked “dis-ease” or clear way of measuring severity or its consequences (Arcia & Fernández,2003). Neither is there an easily identifiable desired and well-known preventivehealth service, such as a vaccine that is readily available from a general practitioner.Second, psychopathology among parents of children with disruptive disorders ismore prevalent than among the general population (Epstein et al., 2000; Weiss,Hechtman, & Weiss, 2000), a fact that might cloud parent perception and ability toact effectively (Flisher et al., 1997; Verhulst & van der Ende, 1997). Third, help seek-ing in itself can be emotionally laden because of the implications it can hold for par-ents with respect to parenting competence or to the stigma associated with mentalhealth services use (Fernández & Arcia, in press). Fourth, feelings of self-efficacywith respect to parenting are particularly poor among parents of children with dis-ruptive disorders (Hoza et al., 2000; Johnston & Freeman, 1997), and this lowered

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sense of self-efficacy might affect negatively general feelings of competence toundertake a treatment option. Fifth, whereas some models of help seeking suggestthat a cue to action, such as a mailed-in reminder to seek the desired health service,is an important trigger for the health behavior, in the case of children with disrup-tive behaviors, there is no single salient cue. Instead, parents receive multiple andfrequent cues that might alert them or by their frequency might, in effect, desensi-tize them. Finally, it is important to note that mental health services, which haverelatively limited availability, might fail to alert parents as to its need.

Results of a prior study of Cuban mothers of children with disruptive behaviorsindicated that mothers portrayed themselves as readily seeking assistance oncethey realized that their children’s behavior constituted a problem (Arcia &Fernández, 1998). However, a subsequent study with a similar population of Latinamothers from the Caribbean found that the process of recognizing the need for ser-vices was quite lengthy for some mothers, that it required multiple inputs fromsocial networks and ultimately from schools, and that 18% of mothers had notarrived at a problem-labeling stage despite having sought services (Arcia &Fernández, 2003). Consequently, we undertook this study to understand anddescribe the pathway taken by the mothers.

METHOD

We used a cross-sectional multimethod design to collect both qualitative and quan-titative data on Latina mothers who were first-time help seekers for their children’sbehavior problems. Results presented below are from analyses of maternal narra-tives of their experiences.

Participants

Participants were 62 Latina mothers of children between the ages of 4 and 10 years(M = 7.12, SD = 1.7) who were seeking or had sought professional help for the firsttime for their children’s disruptive behaviors within the prior 12 months. All moth-ers accessed services from their provider of choice. We recruited them through pri-vate and public providers, a Spanish-language magazine, and word of mouth. Wedetermined the sample size by considerations of statistical power and of saturationon the key topics of interest.

The mothers were of Cuban (63%), Dominican (18%), and Puerto Rican (19%)descent. Residency in the United States of America ranged from 4 months to 37years, that is, the participant’s whole life, and 19% were first-generation Americans.Most of the mothers (71%) chose to be interviewed primarily in Spanish. Educa-tional attainment ranged from less than 6 years of schooling (n = 2) to medicaldegrees (n = 2) (M = 11.9 years, SD = 6.8). Fifty percent of the mothers were singleheads of households, and 68% were Medicaid eligible. Twelve of the children (19%)were girls, and 50 (81%) were boys. To be eligible for the study, maternal descrip-tions of the children’s behavior had to include at least two of the symptoms of Atten-tion Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, and/or Con-duct Disorder. Ahigher threshold was not set, because the primary aim of the studywas not the child per se but, rather, maternal perception of the need for services.

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Mothers of children with a diagnosis of a developmental delay or a chronic medicalcondition were not eligible. We established eligibility with a telephone screeningprotocol when mothers called requesting participation and/or information aboutthe study. All eligible mothers agreed to participate. However, 3 mothers whoagreed to participate could not be interviewed for reasons of moving, illness, anddisconnected telephone; we dropped a 4th participant from analyses, because thedegree of psychopathology apparent in the mother made the interview inappropri-ate and of questionable validity. We provided all participants with U.S.$30 inappreciation of their time, and we specified that the interview neither implied norwas associated with services.

Measures

We collected data through an interview that we designed and that lasted on averagebetween 1.5 to 2 hours and covered the following topics: (a) the composition of thesupport network, (b) the process that mothers followed from awareness to helpseeking, (c) service use, (d) interactions with schools and teachers, (e) impact ofchild behaviors on caregiver, (f) child behaviors at home, and (g) demographics. Itincluded open-ended questions, questions with set response categories, and ratingscales. The interview was structured with open-ended questions asked first to allowmothers to tell their stories in their own ways. With these questions, we used probesas necessary for the purpose of clarification and to ensure uniformity in the topicsand issues covered. Assuming that reports from schools would have a strongimpact on mothers, we asked all questions about interactions with schools aftermothers gave their narratives on their concern and help-seeking processes. Asmuch as possible, we collected data on each topic from several points of view, andboth qualitatively and quantitatively. Most of the data used for this study werequalitative.

Procedures

Mothers were interviewed in their location of choice, 57 in their homes and 5 at theuniversity, all by the first author. We obtained informed consent prior to each inter-view with procedures approved by the IRB. All interviews were audiotaped. Cate-gorical responses were coded during the interview and reviewed for accuracy whennarratives were transcribed. Immediately after each interview, the interviewerwrote a field note describing interactions that occurred before or after audiotaping,and visual information that could not be captured from the audiotape. A bilingualgraduate student in clinical psychology transcribed all the responses to open-endedquestions and any additional comments or narratives made by mothers whenresponding to categorical items. Transcriptions were made in the language of theinterview and included transcriber notes in English. The first author reviewed alltranscriptions and used Folio Views software to create and manage the database.This software program indexes all text and makes it possible to use multiple codesand labels of data, to link related text, and to make notations that are easilydistinguishable from the original text.

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Preliminary Analyses

Prior to targeted analyses, three of the five researchers involved in the study carriedout independent case reviews, summaries, and interpretations on a predeterminedset of topics. These topics included (a) description of the mother, (b) description ofpaternal figure, (c) maternal explanatory models for child behaviors, (d) symptomsnot noted as atypical, (e) help-seeking pathways, (f) social network, (g) other mod-els/themes, and (h) analysts’ observations/interpretations. These were discussed,and differences of opinions, which occurred rarely, were settled at the time. We usedthis procedural step to summarize data, identify emergent themes, provide anunderstanding of context, and facilitate and enhance the validity of interpretations.The five members of the research team included a special educator, a pediatrician, aclinical psychologist, a graduate student in clinical psychology, and a Cuban-trained psychiatrist working as a licensed mental health counselor in a communitymental health clinic who also provided clinical impressions on the mothers. Themembers’ countries of origin included Cuba and the Dominican Republic, and oneCuban-born member had lived and worked in Puerto Rico for 13 years. Finally, pre-liminary findings and emergent themes were reviewed with nonparticipatingLatina mothers, various Latino professionals, and a group of Latino mental healthproviders and case managers from the community mental health center thatprovided many of the referrals.

Targeted Analyses

Maternal narratives were complex stories of increasing concern prior to help seek-ing that spanned anywhere from a few months to several years. In every case,maternal characteristics, the severity of children’s symptoms, co-occurring lifeevents, schools, social networks, and prior or concurrent links to the service systemwere all significant players. But these multiple factors had varying effects and vary-ing degrees of salience across cases. Thus, we conducted analyses by case to identifyfor each the barriers faced and the final determinants of service entry: the events orfactors most immediate to entry that propelled or motivated mothers toward ser-vices. Next, we sorted cases by four modes of entry that we identified during analy-ses by case, and last, we conducted analyses of barriers and final determinants bymode of entry. Within- and across-case tables and matrices facilitated review of thedata.

RESULTS

Qualitatively, mothers portrayed themselves as active and decisive help seekers inthe professional sector for their children’s behavior problems. In response to beingasked why they sought assistance, only 10% of mothers gave adult-centered rea-sons, such as their own inabilities to manage or understand their children’s behav-iors, marital conflict, emotional trauma as a result of separation from a spouse, andbeing coerced into services. Subsequent analyses revealed a different portrait.Thirty-seven percent of mothers could not be labeled as active help seekers, and an

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additional 52% required a considerable amount of input from their networks to seekassistance. In effect, as described below, there were four modes of entry intoservices.

Four Modes of Entry Into Services

Entry Through Coercion

Four mothers readily admitted entering services because their own motherscoerced them into seeking help. Grandmothers made appointments and/or accom-panied daughters to the providers to ensure that concerns about the children’sbehaviors were discussed to their satisfaction. One grandmother threatened toexpel her daughter and granddaughter from the household if the mother did notconsult a provider. Forcefulness, to a lesser degree, was evident in many other sto-ries but was the final determinant in only these cases.

Entry Through Acceptance of Referral

Nineteen mothers accepted direct referrals for assessment and/or treatment ofbehavioral problems that were offered primarily by schools and less frequently byphysicians or by a social service. In the case of school referrals, the mothersdescribed disruptive behaviors at home, expressed caregiving burden, and men-tioned suggestions of help seeking from the social support network, but the schoolreferral was the final, most salient, and, sometimes, sole determinant of help seek-ing. Indeed, whereas almost all of the rest of the sample of mothers of school-agedchildren characterized their children’s behaviors as a problem, more than a third ofthe mothers who entered through referral had done so.

Mothers who accepted referrals from physicians and social service agencieshad turned to these sources for assistance with problems other than their children’sbehaviors, such as nonbehavioral health problems or financial, legal, or emotionalassistance subsequent to domestic violence, separation from a spouse, or other typeof family crisis. In all of these cases, the immediate determinant of services was areferring agent who became sensitive to the children’s needs and acted proactively.

Entry Through Responsive and Resourceful Action

Coercion and acceptance of referrals accounted for slightly more than a third of ser-vice entry. The remaining mothers could be considered actual help seekers. Amongthese, a small group of 6 mothers stood out from the rest as particularly responsiveand resourceful, seeking professional assistance promptly and independently inresponse to reports of children’s behavioral difficulties. All were mothers of school-aged children, and for this group the final determinant of service was school reportof behavioral difficulties.

The mothers in this group had mild-to-moderate concern prior to schoolreports of problem behavior and portrayed themselves as women who were incharge of their lives. Indeed, with an average educational attainment of 16.1 years,they clearly surpassed the whole group’s average of 11.9 years. These women

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differed from other help seekers, in that they were able to garner the resources nec-essary to overcome what for other mothers were barriers to services, including theirown reticence or stigma toward mental health services and toward the possibility ofmedication’s being prescribed, lack of information about appropriate and availableproviders, financial or insurance barriers, other needs that competed for their atten-tion, and system hurdles such as long waiting lists. In these cases, children wereevaluated within weeks of the school report that prompted help seeking.

The Norm: Entry Through a Laborious and Convoluted PathFollowing Multiple Indications of Problem Behaviors

Approximately half of the sample undertook a relatively more arduous path to helpseeking than that taken by the other mothers. Among these mothers, there was not asingle final determinant of service entry, and help seeking was not always active.Indeed, 2 mothers latched onto services almost by happenstance. In both cases, theydrove someone to a mental health center, and once there, it occurred to them to askabout services for their children. It is important to note that mild severity could notaccount for this mode of entry, because one of the two children had been expelledfrom a preschool for choking a child.

The factors that propelled mothers toward services or hindered their passageincluded the nature of school reports; the severity of children’s symptoms; the char-acteristics of the mothers social network; the sensitivity of the professional sector tomaternal and child needs; and maternal factors, such as educational level, personal-ity, mental health, personal norms for child behavior, ability to manage their chil-dren’s behaviors, co-occurring life events, and prior or concurrent links to the ser-vice system. Almost all of the factors were evident in almost all maternal narratives.They constituted a necessary backdrop against which a subset became magnifiedand gave the final impetus toward help seeking. These, along with the determinantsand barriers presented by the other three groups of mothers, are presented in Table1. Following is a description of the role that these factors played when they werefinal motivators for the average help seeker.

Final Motivators for the Average Help Seeker

Symptom severity, the input from schools, and the input from social networks werefinal motivators for all but one of the average help seekers. Symptom severity wasdeemed the sole final motivator in one third of these cases, and when symptoms,and the caregiving burden it represented, were insufficient in themselves to leadmothers to services, the additional input from schools or from the social networkwas necessary. None of the cases had all three factors as final motivators.

Symptom Severity

For 20 of 32 average seekers, the severity of children’s symptoms provided a neces-sary impetus toward service entry by affecting mothers cognitively, emotionally,and pragmatically. The symptoms violated maternal norms of normality, presagedfuture undesirable behavior that would have alarming consequences, and, in mostcases, represented a huge caregiving burden.

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Table 1: Motivators and Barriers to Seeking Treatment for Attention Deficit/HyperactivityDisorder (ADHD): All Participants

Motivators and Facilitators Barriers

Maternal characteristics and eventsReached a saturation point with children’s Had not reached a saturation point

behaviorsWas able to manage the child at homeDid not try to manage disruptive behaviorsHad a high tolerance for disruptive behaviorsHad alternative explanations for children’s

behaviors, such as “personality”Had a proactive personality/was a competent Lacked competence

problem solverWas incapable of overcoming logisticbarriersHad mental health problemsFelt overwhelmed by the number and

magnitude of personal/family problemsHad a service orientation Was reticent/in denial

Put faith in professionals and their Feared a diagnosis of mental health problemrecommendations

Sought assistance for domestic crises Considered use of mental health servicesSought consultation for health problems stigmatizingHad prior or current links to services Feared medication

Had idiosyncratic reasons Assumed services provided at school weresufficient

Went to a mental health center for other reasonsKnew ADHD symptomsDesired compensation for interviewDisagreed with school recommendations and

sought a second opinion

Social network strategiesEncouraged help seeking Disagreed with the need for services/specific

treatment optionsProvided instructions for accessing servicesProvided personal testimoniesSuggested medicationIdentified a service providerReframed help seeking in an acceptable mannerMade initial appointmentCoerced

Educational and service sector characteristics and strategiesNotified mothers of inappropriate behaviors Limited availability of mental health

professionals who accepted MedicaidSuggested help seeking and insisted until mothers Insurance did not cover psychological

reached a saturation point servicesProvided links to services Low provider receptivity

Identified appropriate providers Assumed child would outgrow behaviorsReferred children directly for services Considered psychostimulant

inappropriateOffered direct services Focused on other maternal problems

Awareness that their children’s behaviors were outside the norm developedover time, and for many of the mothers for whom symptoms were an impetus forhelp seeking, this occurred because the children’s behaviors crossed a personalthreshold. There were thresholds of acceptability, such as behavior that worsened orbehavior that included actions clearly outside maternal norms, such as stabbingoneself with a pencil or threatening a family member with a knife. Also, there weretime thresholds that mothers typically linked to a specific school grade. Theseranged from kindergarten to fourth grade, the academic grade of the oldest childrenin the sample. Actual thresholds varied, because they depended on mothers’ indi-vidual schemas. For instance, in one case, the threshold was school entry, becausethe mother assumed that public schools were more structured than privatepreschools and that this structured setting would curtail her child’s behaviors.

Typically, there were two scenarios represented when symptoms were alarm-ing, because they presaged possible undesirable behavior in the future. Some moth-ers feared that their children would grow up to be like a family member who wasviolent or had mental health problems; others, as exemplified by the quote that fol-lows, were concerned about how current symptoms would express themselves inan older child.

This is OK [now] but when my child is 15 years old and robs a car, I am not going totell the policeman, “Oh my child works on impulses. He doesn’t understand conse-quences. Please let him out.”

Last, but most common, were instances in which symptoms were of concern inand of themselves because of the substantial caregiving that they represented. Thequote that follows is an excellent example. This mother narrated how she felt whenher son’s school repeatedly called her to pick him up prior to dismissal. The quoteshows feelings of incomprehension, apprehension, defeat, guilt, exhaustion, andshame. The mother violates her own image of a good mother and faces the prag-matic and cognitive strain of running out of management strategies.

I was getting tired of the same thing, I mean, there were times that I would just beexhausted and I would just like, come home and be, “What else now?” You know,“What is going to happen tomorrow?” It was just being tired, complaints, andthings at home, and having to punish him, and having to be mean to him to maybeget my word across, constantly talking to him, “X be good, you have to be good, youare a good kid, come on!” I mean, sometimes I would cry, just because I would belike, “What do you want me to do, X?” I mean, I have to talk to these people [atschool] and they might think I am like, crazy or something, you know. They mustthink that he is living in this bad environment or something. And, having to dealwith explaining to everyone, don’t, you know, and having to deal with those calls atwork and everybody [at work] being concerned, and everybody saying thingsabout it. It becomes like a big ball and you are about to explode inside and it’s likesometimes I would get home and be like, “You know what? Forget it! Forget it! Youknow, there is nothing else I am going to do and I am just going to take it day by dayand do what I can. That’s it.” Sometimes you feel like you are just going to, the wordis like, kill him, but you don’t mean that, right. I am just like, “I don’t know what todo with him anymore.” It’s like, “Oh, my God.” It gets to a point that you are justpunishing him and it’s not even working, you know, and you feel so guilty. And Ijust come home and just lay there, and this is exhausting.

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Schools

Schools alerted mothers to children’s behaviors. When behaviors didn’t change,school communications became more frequent, insistent, and prescriptive, suchthat in some cases, mothers were called almost daily, and teachers or, less fre-quently, counselors or administrative staff suggested that mothers consult theirchildren’s pediatricians or that they consult a psychiatrist. In some cases, the spe-cific name of a provider was given to mothers. Expulsion from daycare or preschool,and, as exemplified in the quote above, having to pick up a child prior to dismissalfrom school repeatedly was a major motivator toward help seeking. Pressure fromschools was a final motivator in 11 of 32 mothers.

The Social Network

Pressure from the social network was a final motivator in 12 of the 32 average seek-ers. The influence of the social network was strong and quite evident. Indeed, one ofthe first, if not the first theme to emerge in preliminary case review, was TheGrandma Factor. Grandmothers were often the first to note and mention to mothersthat the children’s behaviors were atypical, the first to suggest that mothers consulta professional, and the player who was most insistent that mothers seek profes-sional assistance. As was the case with reports from teachers, suggestions and feed-back from the social network increased in frequency and in intensity, and becamemore prescriptive when mothers were slow to respond to children’s disruptiveness.Also, like schools, in some cases the pressure exerted by the social network bor-dered on coercion. In at least two cases, mothers’ friends made the initialappointment with a service provider.

One of the reasons why social networks were particularly strong influences onmothers was because mothers understood information as coming from people, notfrom institutions, written material, telephone information services, or the Internet.Also, the personal experiences, the testimonies that people provided were moreconvincing than expert opinion. Sometimes, mothers actively sought informationfrom their relatives, friends, neighbors, coworkers, acquaintances, and even pass-ing strangers, but most frequently, their information gathering was more passive.

The social network also influenced mothers by reframing issues in ways thatmade help seeking or the pursuit of a particular treatment option palatable to moth-ers. This reframing, which investigators labeled sugar coating, typically suggestedthat the child in question had great potential that would be wasted if he did notreceive assistance.

Fathers and stepfathers were either transparent or played a minimal role.Indeed, their absence was so marked in maternal narratives that after 6 interviews,we added an open-ended question toward the end of each interview on the role ofthe father and/or stepfather. Of the mothers asked, approximately one fifthreported that they consulted on decisions, made joint decisions, or received morethan minimal support, and slightly more than half reported receiving no support orbeing negatively affected by the father or stepfather. Mothers were either the sole orthe primary decision makers.

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Links to and Attitudes Toward Services

In the best of cases, mothers with a prior or current link to services had establishedrelationships, knew where to go for services, and did not have to overcome the hesi-tancy of undertaking a new experience. Apositive attitude toward services was alsoa facilitator for mothers who arrived recently from Cuba. These mothers demon-strated their respect of the service sector by the language that they used in their nar-ratives and by valuing the knowledge and opinion of school personnel and mentalhealth providers. For instance, in a few cases, mothers did not think that their chil-dren’s hyperactivity was a matter of concern, but they nonetheless followedthrough with teachers’ indications out of respect for the teachers’ expertise. In somecases, prior links to services fostered a negative or fearful attitude. Mothers fearedthat their children would have the mental health problems that they or anotherfamily member experienced.

Barriers to Services for the Average Help Seeker

The Interaction of Maternal Lack of Competenceand Service Characteristics

By far, the most significant barrier to service entry was the fact that it required per-sonal resources that many mothers did not have. Mothers had to identify an appro-priate source of care and had to have the determination, persistence, and personalcompetence to overcome the obstacles presented by fragmented, unfriendly, unre-sponsive, or inappropriate services. The presence of these maternal characteristicswas hampered by the fact that half of the average help seekers had mental healthproblems and/or levels of competence that clearly interfered with their ability tosecure services. They had been flagged by the mental health counselor as beinghighly likely to have mental health problems, as indicated by use of psychotropicmedication, self-report of current or prior psychiatric diagnoses, and substantialsymptomatology. Also, they reported not knowing and not being able to identify asource of care, failing to follow through with referrals, or failing to attend scheduledappointments. Most of these mothers presented themselves as overwhelmed by themismatch between the problems in their lives and their abilities to manage them.

Also, 13 of 31 mothers had clear evidence of being poorly served by the healthsector. Five mothers who solicited referrals or treatment were turned away by pedi-atricians, and 8 had experienced various other setbacks. These included changes ininsurance that resulted in aborted attempts to access services, with mothers receiv-ing services for themselves from providers who either dismissed or failed to notechildren’s needs, or lacked adequate case management to set up services beforemothers’ felt need for services ebbed. This lack in the service system was high-lighted by the contrast presented by one community mental health service that hadexcellent case management and by the narratives of mothers who were identifiedproperly and referred by the school system or government agencies (the acceptorsdescribed above). For these mothers, hampering factors did not slow their entryinto services once they were identified.

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Schools as Barriers

School services for children with disruptive behaviors are limited to serving theireducational needs such that they provide behavior management in the classroombut do not address wider needs outside of the school context. Consequently, chil-dren served solely by the school system were underserved relative to their needs,and not knowing the limitations that schools have in the services that they provide,the mothers of these children were unaware that additional services might be desir-able. This effect was evident among average seekers, half of whom at a later pointsought services from health or mental health providers. Thus, schools were facilita-tors when they identified children, met their educational needs, and referred themto mental health services but constituted a barrier if they did not refer for additionalservices. Schools also proved to be a barrier by the length of time they took to evalu-ate children. Some children were on waiting lists for 1 or 2 years.

Social Networks as a Barrier

Evident in maternal narratives were instances in which social networks delayedhelp seeking by asserting that the child did not need services, that a particular pro-vider would prescribe medication, or that medication was harmful. These instanceswere not as salient as the instances in which social networks motivated help seek-ing, but that finding could be the result of the study’s design, which selected partici-pants who were recent help seekers.

Reticence

One third of the mothers in this group were reticent to seek services for reasons thatranged from not being totally convinced that the children’s behaviors constituted aproblem to denial. Six mothers expressed concerns over medication, 1 clearlyrejected seeking services in the mental health sector because she feared that it wouldimply a mental health problem, and 2 considered mental health servicesstigmatizing.

DISCUSSION

We undertook this study to describe pathways into services taken by Latina moth-ers of children with disruptive behaviors. In an earlier study, we described the pro-cess followed by mothers of children with disruptive behaviors as they traversedfrom awareness to acknowledgment (Arcia & Fernández, 2003), and in these analy-ses, we noted that an important aspect of mothers’ pathway into services was thepresence of four distinct modes of entry that are significant by being distinct. Over-all, analyses indicated that mothers sought assistance for their children and not forthemselves, saw themselves as active seekers subsequent to determining that theirchildren’s behaviors constituted a problem, and followed one of four modes intoservices: coercion, acceptance of offered services, responsive and resourceful seek-ing, or a laborious and convoluted path following multiple indications of problembehaviors. Schools, maternal and child characteristics, and social network forces

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played a role in all mothers’ stories about what led to their help seeking. The finaldeterminants of service entry varied, however, by the mode of entry followed.

Results of the study should be interpreted with caution. Data were collected in asingle interview, and their validity is limited by maternal recollections, by maternalintrospective and metacognitive abilities, and, as such, by researcher ability to iden-tify and describe the processes that underlie surface representations. Mothersunderstood themselves to be more proactive, more decisive in their actions, and lessinfluenced by their networks than was evident from the events they narrated. Evenmothers who were coerced into services or were referred by an agency such as theWork and Gain Economic Self-Sufficiency (WAGES) framed their narratives interms of when, how, and why they sought services for their children. Similarly,mothers recognized and were quick to express the burden that their children’sbehaviors represented for them and their need for relief from this burden. Almostunanimously, however, they represented their help seeking as motivated by theirchildren’s needs and did not portray it as motivated by the need to find relief forthemselves. Thus, the various factors described in the study might be, in reality,more or less significant than portrayed.

Another limitation of the study’s design is that it cannot be assumed that factorsthat were significant in determining a specific mode of entry for some mothers wereabsent from others who followed a different mode. For instance, the average motherwho undertook the laborious or convoluted path might have rejected offers of refer-ral or might have successfully resisted attempts at coercion and overlooked theseevents in her narrative because they were not consistent with her reconstructions ofherself as an active and decisive agent. Similarly, mothers might have been exposedto multiple personal testimonies or reframing attempts from their social networksthat did not influence them. Thus, the narratives provide data on factors that werepresent and active but cannot provide data on factors that were absent or ineffec-tual. Neither can it be assumed that the mode of entry followed was immutable. Aturn of events might have propelled a mother through a different mode than the oneshe took. Last, it must be remembered that the generalizability and specificity offindings are unknown. We can assume neither that findings are applicable to allLatinos nor that they are limited to Latinos.

The study does provide a firsthand look at a complex process that, to ourknowledge, has not been examined previously in this manner and a set of findingsthat merit further study. Overall, the final determinants of service entry identified inthis study parallel the factors proposed by models of help seeking, but these wererealized in ways that might be specific to young children. For instance, the factor ofperceived susceptibility to disease posited by the Health Belief Model (Mullen et al.,1987; Poss, 2001; Rosenstock, 1974) has a parallel in maternal concern over possiblefuture delinquent behavior or mental illness, and the factor of the perceived benefitsof services was realized through the personal testimonies offered by the social net-work. Similarly, cues to action, which in physical conditions typically originatefrom the service sector, in these cases arose from social networks. On the other hand,whereas the perceived costs and benefits of services might have affected maternalattitudes toward help seeking, qualitatively, mothers appeared to process andrespond to these in a much more affective manner than would be proposed by thecognitively framed Theory of Reasoned Action (Fishbein & Ajzen, 1975). Amore aptterm for the process followed by the mothers would be a Theory of Affective Action.Major interpretations of findings were as follows.

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First, the offer of referral to mental health services made by schools, pediatri-cians, and government agencies appeared to provide a shortcut to services, and thisshortcut explains why a percentage of mothers had entered services without prob-lem labeling (Arcia & Fernández, 2003). It suggests that problem labeling as a deter-minant might be replaced by other factors, such as deferral to the expertise orauthority of schools or a particularly strong service orientation. Through directreferral, schools and families were saved the painful and frustrating series of con-frontations that occurred as teachers repeatedly reported negative child behaviorand suggested that parents address them. To the extent that this finding is valid andgeneralizable, it indicates that the service sector should be proactive in providingdirect referrals. An experimental design in which parents are offered direct referralwould test the extent to which this is a more efficient pathway than currentprocedures.

Second, consistent with results of other studies (Woodward, Dowdney, & Tay-lor, 1997), schools were an integral part of almost every mother’s story whose childwas in kindergarten or a higher grade and served multiple prominent roles. Schoolsidentified problems for mothers who did not have prior concerns, confirmed exist-ing concerns for others, built maternal concern to the point that mothers determinedto seek assistance, were a source of stress, made indirect and direct referrals, andprovided services. Indeed, all the children of mothers who were particularlyresponsive and resourceful in seeking assistance were of school age. As such,schools had power lacked by preschools and day care providers. It is an issue forfuture research the extent to which this power rests on maternal recognition ofschools’ expertise with regards to children, cultural acceptance of schools as anauthority figure, or schools’ ability to disrupt mothers’ lives through suspensionand by calling for her presence and intervention.

In addition, findings were consistent with the concept that a substantial percentageof help seekers “muddle” their way into services (Pescosolido, Gardner, et al., 1998). Inthis study, 52% of mothers found their way into services through a laborious path thatrequired that schools, social networks, and the children’s care giving difficulties pro-pel them to overcome the barriers posed by their own reticence and by the servicesystem, which for children in the preschool years included a notable lack of treat-ment options.

Several factors, such as acceptability thresholds, time thresholds, personal testi-monies, and reframing offered by the social network, featured prominently in manymothers’ narratives. This finding extends prior research results on the importanceof social networks (Pescosolido, Wright, et al., 1998) by portraying the ways inwhich these affect the decision process. Future research should elucidate furtherwhen and how these operate, because they were evident in some, but not all, narra-tives. Similarly, reticence due to the stigma of mental health services and the wish todeny a problem was evident in mothers across modes of entry, but it was a signifi-cant barrier only for some, not all, mothers. Identification of what allowed mothersin the entry modes to overcome their reticence would help relevant professionals tofacilitate mothers’ service entry.

In analyses, the research team noted a theme that could not be tested because ofthe cross-sectional design of the study but merits mention because of its possiblesignificance in the interpretation of maternal narratives. The availability of servicesappeared to provide mothers with an a posteriori awareness and justification for itsneed. For instance, the children whose mothers were referred had long-standing

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behavioral problems that the mothers had previously noted but not acknowledged,and it appeared as though having a source of service facilitated acknowledgment. Alongitudinal study would allow clarification of these processes.

Possibly, the most significant finding of this study is the one that is most diffi-cult to synthesize and convey. Except for a few decisive mothers who knew how toseek appropriate services for their children in an effective manner, most narrativeswere marked by a series of happenstance events that made the mothers’ searchresemble the course followed by a pinball. This finding, more than any other, high-lights the need for continued research and for the designing of information andreferral systems that will straighten the course for the average service user. Key tothese might be direct referral by children’s schools.

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Emily Arcia, Ph.D., was a research associate in the Department of Research, Mount Sinai MedicalCenter, Miami Beach, Florida, at the time this research was conducted. She is currently affiliated withMiami-Dade County Public Schools.

María C. Fernández, Ph.D., N.C.S.P., is an assistant professor of clinical pediatrics at the MailmanCenter for Child Development, University of Miami, Florida.

Marisela Jáquez, M.D., is an assistant professor of clinical pediatrics at the University of Miami,Florida.

Héctor Castillo, L.M.H.C., is Director of Case Management Services, Children and Families, MiamiBehavioral Health Center, Florida.

María Ruiz, B.A., was a student at Barry University, Florida, at the time this research was performed.She is currently affiliated with Jackson Memorial Hospital.

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