Journal of Intellectual Disability Research 939 volume 53 part 11 pp 939948 november 2009

doi: 10.1111/j.1365-2788.2009.01214.x

Ethnic variation in service utilisation among children with intellectual disability

jir_1214 939..948

G. Dur-Vil & M. Hodes

Division of Neuroscience and Mental Health, Imperial College London, London, UK

Abstract Background This study examined whether service utilisation among children with intellectual disability (ID) varied by ethnic cultural group. Method Survey carried out in four special schools in London. Information was provided by school teachers using case les, and 242 children aged 7 to 17 years with mild and moderate ID were identied. Ethnic categories were derived from selfreported main categories. Service utilisation categorised as use of: child and adolescent mental health services (CAMHS), social services, physical health and education services. Results Child and adolescent mental health services uptake was lower for South Asians than for White British (P = 0.0487). There were statistically signicant differences among ethnic groups for community-based social services uptake (being the highest for the Black groups and the lowest for South Asians, P = 0.015) and respite care uptake (being the highest for the Black and White European groups and the lowest for South Asians, P = 0.009). In regression analysis family structure predicted CAMHS service utilisation and social service community support. Ethnicity predicted use of respite care.
Correspondence: Dr Matthew Hodes, Academic Unit of Child and Adolescent Psychiatry, Imperial College London, St Marys Campus, Norfolk Place, London W2 1PG, UK (e-mail: m.hodes@ imperial.ac.uk).

Conclusions Signicant ethnic differences in service utilisation among children with ID were found for both CAMHS and social service contact. There was particularly low service use for the South Asian group. These differences might arise because of differences in family organisation, as more South Asian children lived in two-parent families, which may have been better able to provide care than single-parent families. Other factors such as variation in parental belief systems and variation in psychopathology may be relevant. Implications are discussed. Keywords children, culture, ethnicity, intellectual disability, mental health, parents, service utilisation

Introduction
The impact of having a child with intellectual disability (ID) is inuenced by the socio-cultural context in which the individual lives (OHara & Bouras 2007). This arises because of cultural variation in beliefs about the learning disability, and different living and care arrangements, alongside economic factors. Furthermore, the frequently associated physical health problems are also subject to similar inuences (Helman 2007). In spite of children and adolescents with ID having higher rates of mental health problems and behavioural difculties than those with normal

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intellectual ability (Emerson & Hatton 2007), in many areas of the UK psychiatric services for these children with ID and their families may be poorly provided (McCarthy & Boyd 2002). Deinstitutionalisation and normalisation of young people with ID have challenged professionals to manage this special needs group in a community-based setting (Dossetor et al. 2005). Within a multicultural society professionals need to ensure their services and practice are sensitive to the family organisation, culture and religion of the communities they serve (Hassiotis 1996). Nevertheless, concerns regarding the scarcity of culturally appropriate services have long been documented (National Association of Health Authorities 1988; Department of Health 2003). There may be a need to develop cultural competence in the delivery of care to this population who may be doubly disadvantaged by the ID and, culturally inappropriate forms of care and service provision (OHara 2003). However, whether there actually is ethnic variation in service utilisation for people with ID and especially children has not been adequately investigated. Within the UK context, it has been claimed that South Asian families caring for individuals with ID may under-use services (Baxter et al. 1990). A cross-sectional study compared the rates of psychological morbidity and service use among South Asian and White adults with ID in Leicestershire (UK) (McGrother et al. 2002). Although South Asians showed similar levels of psychological morbidity, they made signicantly lower use than Whites of psychiatric services, residential care and respite care. Nearly twice as many South Asian adults with ID lived at home with their families compared with White adults. South Asians seemed to prefer community services as they used these as extensively as Whites, but felt that they had a substantially greater unmet need, particularly with regard to social services. South Asians may make less use of residential care than White British (Fatimilehin & Nadirshaw 1994). Data are entirely lacking with regard to children with ID. Differences in family structure existing among ethnic groups may contribute to variation in service utilisation (two-parent families may be better able to provide care). In the UK, all South Asian ethnic groups (Indian, Pakistani and Bangladeshi) have higher proportions of multi-adult and fewer single

households than Whites. BlackWhite mixed heritage, African Caribbean and Black African ethnic groups have higher proportions of lone parent and single households than other ethnic groups (about half of African Caribbean children are living with only one parent, compared with a sixth of children nationally) (Modood 2005; Markkanen et al. 2008). The main aim of the current study was to investigate possible ethnic variation in uptake across child and adolescent mental health and social services. Subsidiary aims were to investigate variation of provision in physical and education services. We formulated the following two hypotheses taking into account the impact that family composition and support may have on service uptake: 1 South Asians will have lower service uptake than White British; and 2 Black groups (African Caribbean and Black African) will have higher service uptake than White British.

Method Ethical considerations

Imperial College Research Ethics Committee were contacted about the study and were able to conrm the authors views that the study did not require full ethical review. The reasons were: 1 That the study was a service evaluation and audit, as a quality standard was being sought, that children with ID from all ethnic groups would have similar access to the services; 2 Only routine school-based service data were used; and 3 There were no breaches of condentiality as the researchers did not look in any of the les or have access to any person-identifying information.

Procedures
A survey was carried out in special schools in London to determine whether service utilisation varied by ethnic cultural group. Four out of 12 special schools approached agreed to participate in the survey. The main reasons for not taking part in the study were: pressure of time and the study not being conducted by a governmental organisation.

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Sample
Data were provided by school teachers and administration staff using case les. In order for the pupils to be included in the survey, they needed to have mild or moderate ID as recorded in the school les, and those with severe and profound ID were excluded. Information on 242 children, aged 7 to 17 years, attending four special schools was collected.

Results Recruitment bias of special schools

Four out of 12 special schools approached agreed to participate in the survey. Fishers exact test showed no statistically signicant differences between the eight schools that refused to participate and those that did participate for the following characteristics: age of pupils, school size, location (urban vs. suburban), and range of ID and other difculties.

Measures
Basic demographic details, household composition (two-parent and single-parent/foster carer) was recorded as well as known information regarding childrens diagnosis and difculties as stated in their school les. Ethnic categories were derived from self-reported main categories. The following six ethnic categories were used: South Asians (Indian, Bangladeshi and Pakistani), Black groups (African Caribbean and Black African), White British, White European, Middle East/Arab, mixed ethnic group/ other ethnic groups. Service utilisation was categorised as use of: child and adolescent mental health services (CAMHS), social service disability teams (community-based, and respite care), youth offending teams, physical health services [speech and language therapy (SALT), physiotherapy, occupational health therapy, visual and hearing impairment teams] and education services (behavioural and emotional support teams, educational welfare services, numeracy and literacy support).

Sample characteristics
The sample characteristics according to ethnic group have been provided in Table 1. There were no statistically signicant differences in the childrens gender and age among ethnic groups. Of the total 242 children attending special schools, the majority were boys 163/242 (67.3%) and were within the age range 1317 years 168/242 (66.9%). Most of the pupils had moderate ID rather than mild ID (215/242, 89.3%, vs. 26/242, 10.7%). Among the sample, in addition to the ID many developmental and psychiatric difculties were reported. Autistic spectrum disorder (ASD) was reported in 34/242 (14%), speech and language difculties 38/242 (15.7%), attention decit hyperactivity disorder (ADHD) in 9/242 (3.7%). Physical abnormalities reported were: visual/hearing impairment in 13/242 (5.4%) and epilepsy among 6/242 (2.5%). These difculties did not differ in prevalence across the ethnic groups. Regarding household composition, statistically signicant differences were found among ethnic groups (c2 = 32.641, 10 d.f., P < 0.001). It was found that more South Asian children live in twoparent families 25/32 (78.1%) compared with White British 29/74 (39.2%) (c2 = 12.04, 1 d.f., P = 0.0005), Black groups (African Caribbean and Black African) 25/48 (52.0%) (c2 = 4.5, 1 d.f., P = 0.034) and mixed ethnic group/other ethnic groups 9/27 (33.3%) (c2 = 10.27, 1 d.f., P = 0.0014).

Analysis
Pearson chi-square and Fishers exact tests with 95% condence intervals were used, depending on the size of the cells, in the analyses to compare the data collected among the six ethnic groups (6 2 table). Chi-squared tests with Yates correction were applied (2 2 or contingency tables) to test the study hypotheses. Two failed tests were used. Binary logistic regression was also undertaken to identify for variables which may predict service uptake. Statistical signicance was set at the 0.05 level. The data were analysed using the Statistical Package for Social Sciences (SPSS 15.0 2003).

Child and adolescent mental health service use

There were no signicant differences in CAMHS use across the six ethnic groups. However, chisquared tests with Yates correction conrmed our

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Table 1 Characteristics of the children

Journal of Intellectual Disability Research

Characteristics

White British (n = 75) South Asian (n = 36) Black group (n = 49) Mixed/Other (n = 27)

Middle East/Arab (n = 33)

White European (n = 22)

Chi-square (value, d.f.) or Fisher Ex. (value)

P-value

15 (20%) 60 (80%) 20 (55.6%) 16 (44.4%) 29 (59.2%) 20 (40.8%) 23 (69.7%) 10 (30.3%) 17 (77.3%) 5 (22.7%)

14 (38.9%) 22 (61.1%)

15 (30.6%) 34 (69.4%)

14 (42.4%) 19 (57.6%)

14 (63.6%) 8 (36.4%)

8 (29.6%) 19 (70.4%) 21 (77.8%) 6 (22.2%)

7.66, 5

0.176

2009 The Authors. Journal Compilation 2009 Blackwell Publishing Ltd 6.54, 5 0.257 (14.7%) (85.3%) (10.7%) (6.7%) (14.7%) (21.3%) (4.0%) (5.3%) 25 (78.1%) 7 (21.9%) 4 25 (52.0%) 23 (47.9%) 1 21 (63.6%) 12 (36.4%) 0 3 33 3 0 5 3 0 3 (8.3%) (91.7%) (8.3%) (0%) (13.9%) (8.3%) (0%) (8.3%) 4 45 5 2 6 6 1 4 (8.2%) (91.8%) (10.2%) (4.1%) (12.2%) (12.2%) (2.0%) (8.2%) 4 29 8 1 7 3 0 0 (12.1%) (87.9%) (24.2%) (3.0%) (21.2%) (9.1%) (0%) (0%) 2 20 5 0 5 3 2 2 (9.1%) (90.9%) (22.7%) (0%) (22.7%) (13.6%0 (9.1%) (9.1%) 13 (59.1%) 9 (40.9%) 0 2 25 5 1 4 5 0 0 (7.4%) (92.6%) (18.5%) (3.7%) (14.8%) (18.5%) (0%) (0%) 9 (33.3%) 18 (66.7%) 0 1.90 3.016 6.79 3.11 2.36 5.45 4.91 8.62 24.5, 10 0.882 0.698 0.223 0.695 0.809 0.354 0.280 0.376 0.006

53 (70.7%) 22 (29.3%)

G. Dur-Vil & M. Hodes Ethnic variation in service utilisation among children

Age in years 712 1317 Gender Male Female Diagnosis/difculties ID Mild Moderate ASD ADHD Speech & language Beh, emotion & soc Epilepsy Visual/hearing imp Household composition Two-parent Single-parent/foster Non-available data

11 64 8 5 11 16 3 4

29 (39.2%) 45 (60.8%) 1

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n, total number of children in each ethnic group; ID, intellectual disability; ASD, autistic spectrum disorder; ADHD, attention decit hyperactivity disorder; speech & language, speech and language difculties; beh, emotion & soc, behavioural, emotional and social difculties; visual/hearing imp, visual/hearing impairment. Statistically signicant differences shown in bold.

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Social services use

There were statistically signicant differences among ethnic groups (6 2 table) for the uptake of community-based social services (c2 = 14.12, 5 d.f., P = 0.015) and respite care (c2 = 31.34, 10 d.f., P = 0.001). Children belonging to the Black groups (African Caribbean and Black African) were statistically signicantly more likely to be receiving communitybased social services 23/49 (46.9%) than White British 19/75 (25.3%) (c2 = 5.250, 1 d.f., P = 0.0220), conrming our second hypothesis. Their uptake was also statistically signicantly higher than for South Asians 6/36 (16.7%) (c2 = 7.168, 1 d.f., P = 0.0074), and White Europeans 4/22 (18.2%) (c2 = 4.177, 1 d.f., P = 0.0410). Regarding uptake of respite care, statistically signicant differences were found among the ethnic groups (F = 12.40, P = 0.009): White European 4/22 (18.2%) was the ethnic group that had the highest use of these facilities while South Asian group 0/36 (0%) presented the lowest use.

Speech and language therapy

Access to SALT varied across the six ethnic groups (c2 = 18.59, 5 d.f., P = 0.002). Children from the Middle East/Arab group had the highest levels of SALT use 24/33 (72.7%), followed by White European 15/22 (68.2%) and mixed ethnic group/other ethnic groups 15/27 (55.5%). The lowest use of this service was for the Black groups 18/49 (36.7%). Nevertheless, no signicant differences were found in the levels of speech and language difculties and ASD among ethnic groups to account for this difference in service uptake.
South Asian (n = 36) 14 (38.9%) 2 (5.6%) 10 (27.8%) 3 (4.2%) 6 (16.7%) 0 (0%) 0 (0%) 2 (5.6%) 0 (0%) 1 (1.4%) 1 (2.8%) 2 (2.7%) 9 (6.0%) 8 (10.7%)

Table 2 Service utilisation according to ethnic group

Family composition and service use

The association between family composition (regardless of ethnic group) and service use was

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Services

n, total number of children in each ethnic group; SALT, speech and language therapy; OT, occupational therapy; visual/hearing, visual/hearing impairment teams; BEST, behavioural and emotional support team; numeracy/literacy, numeracy and literacy support teams; YOT/YPDP, youth offending team, young peoples development programme. Statistically signicant differences shown in bold.

Chi-square (value, d.f.) or Fisher Ex. (value)

14.12, 5 12.40 8.30 11 (40.7%) 2 (7.4%) 0 (0%) 4 (18.2%) 4 (18.2%) 1 (4.5%) 8 (24.2%) 1 (3.0%) 1 (3.0%) 23 (46.9%) 5 (10.2%) 3 (6.1%) 19 (25.3%) 1 (1.3%) 5 (6.7%)

18.59, 5 5.56 8.86 8.62

rst hypothesis: showing that South Asians service uptake of CAMHS was statistically signicantly lower than for White British (2/36, 5.6%, vs. 17/75, 22.7%) (c2 = 3.886, 1 d.f., P = 0.0487). There was also a trend for lower CAMHS use comparing the South Asian group with the Black group 11/49 (22.4%) (c2 = 3.361, 1 d.f., P = 0.0668) (Table 2).

P-value

0.002 0.291 0.106 0.376

0.015 0.009 0.734

0.275

6.245

Mixed/Other (n = 27)

4 (14.8%)

15 (55.5%) 0 (0%) 5 (18.5%) 0 (0%)

White European (n = 22)

15 (68.2%) 3 (13.6%) 7 (31.8%) 2 (4.5%)

4 (18.2%)

Middle East/Arab (n = 33)

5 (15.2%)

24 (72.7%) 2 (6.1%) 3 (9.1%) 0 (0%)

Black group (n = 49)

18 (36.7%) 1 (2.04%) 6 (12.2%) 4 (8.2%)

11 (22.4%)

White British (n = 75)

17 (22.7%)

Mental health Physical health SALT Physiotherapy OT Visual/hearing Social services Community-based Respite care YOT/YPDP Education services BEST Numeracy/literacy Education welfare

29 (38.7%) 6 (8%) 10 (13.3%) 3 (2%)

2 (4.1%) 3 (6.1%) 3 (6.1%)

1 (3.0%) 3 (4.5%) 1 (3.0%)

1 (4.5%) 1 (2.2%) 1 (4.5%)

0 (0%) 2 (7.4%) 0 (0%)

2.65 8.17 2.81

0.781 0.510 0.742

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investigated. Regarding CAMHS uptake, 14/122 (11.5%) of two-parent families used this service compared with 28/114 (24.6%) of single-parent/ foster families (c2 = 6.91, 2 d.f., P = 0.032). For social services (community-based) uptake was 26/122 (21.3%) among two-parent families compared with 43/114 (37.7%) of single-parent/foster families (c2 = 7.70, 2 d.f., P = 0.021). There were no statistically signicant differences observed between two-parent families and single-parent/foster families in their use of the other services examined in the study.

service; this variable was loaded on step 4 reaching a statistically signicant level [step 4, B (SE) = -3.051 (1.081), OR = 0.047, 95% CI for OR = 0.0060.393, P = 0.005] (Table 3). Respite care. Contrary to the above services, the ethnicity variable was the only variable to reach a statistically signicant level for the use of respite care facilities [step 2, B (SE) = 0.219 (0.095), OR = 1.245, 95% CI for OR = 1.0341.499, P = 0.021]. This variable remained statistically signicant when family composition, ASD, ADHD, age and gender variables were added to the analysis. Speech and language therapy In addition to household composition and ethnicity, ASD and speech and language difculties were added to the analysis of predictors for SALT use. The ethnicity variable and as expected ASD and speech and language difculties variables were statistically signicant predictors of SALT use [ethnicity (step 2, B (SE) = -0.142 (0.245), OR = 1.217, 95% CI for OR = 1.1041.342, P < 0.001]; ASD [step 3, B (SE) = -3.132 (0.750), OR = 0.044, 95% CI for OR = 0.0100.190, P < 0.001]; speech and language difculties [step 4, B (SE) = -1.761 (0.434), OR = 0.174, 95% CI for OR = 0.0730.402, P < 0.001]. The addition of gender, age and family composition variables did not alter the results (Table 4).

Predictors of service utilisation

Finally, binary logistic regression was carried out to investigate which variables might predict service uptake. This was carried out as stepwise forward regression, by adding single predictors. They were identied on the basis of the strength of the association with the specied outcome variable (Field 2009). The rst predictor was family composition and the second one ethnicity, followed by ASD and ADHD as there were theoretical reasons to believe that they would inuence CAMHS and social services uptake. Child and adolescent mental health services Family composition (two-parent vs. single-parent/ foster carer) was the only variable to reach a statistically signicant level for CAMHS use [step 1, B (SE) = -0.707 (0.307), OR = 0.493, 95% CI for OR = 0.2700.900, P = 0.021]. When other variables ethnicity, ASD, ADHD and gender were entered on subsequent steps, no differences occurred in the results (the family composition variable remained statistically signicant). Social services Community-based. As for CAMHS uptake, family composition was the main predictor of service uptake for social service (community-based) use [step 1, B (SE) = -0.666 (0.261), OR = 0.514, 95% CI for OR = 0.3080.856, P = 0.011]. When ethnicity, ASD, ADHD, age and gender variables were added to the analysis, the family composition variable remained statistically signicant. The presence of ADHD might also predict the uptake of this

Discussion Ethnic variation in child and adolescent mental health and social service utilisation
Results showed signicant ethnic differences in service utilisation among children with ID. Our rst hypothesis was conrmed with regard to CAMHS uptake, with South Asians having lower uptake than White British. Our second hypothesis (Black groups would have higher service uptake than White British) was found for the statistically signicant difference for social services uptake. These differences might arise because of differences in family organisation: more South Asian children lived in two-parent families than any of the other ethnic groups, and this may help them to be better able to

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Table 3 Binary logistic regression analysis for variables predicting service utilisation of social services (community-based)

B (SE) Step 1 Constant Household Step 2 Constant Household Ethnicity Step 3 Constant Household Ethnicity ASD Step 4 Constant Household Ethnicity ASD ADHD

OR

95% CI for OR

P-value

composition

0.080 (0.392) -0.666 (0.261) 0.098 (0.415) -0.661 (0.263) -0.007 (0.052) -0.101 -0.659 -0.005 0.02 6.051 -0.656 0.007 -0.012 -3.051 (0.937) (0.263) (0.053) (0.429) (2.373) (0.271) (0.054) (0.432) (1.081)

0.514

0.3080.856

0.011

composition

0.516 0.993

0.3080.864 0.8961.100

0.012 0.891

composition

0.517 0.995 1.107

0.3090.866 0.8971.103 0.4782.566

0.012 0.922 0.812

composition

0.519 1.008 0.988 0.047

0.3050.882 0.9061.121 0.4242.302 0.0060.393

0.015 0.890 0.977 0.005

R2 = 0.027 (Cox & Snell), 0.039 (Nagelkerke), Model c2 = 6.66, 1 d.f., P = 0.010 (step 1); R2 = 0.027 (Cox & Snell), 0.039 (Nagelkerke), Model c2 = 6.68, 2 d.f., P = 0.35 (step 2); R2 = 0.027 (Cox & Snell), 0.039 (Nagelkerke), Model c2 = 6.74, 3 d.f., P = 0.081 (step 3); R2 = 0.082 (Cox & Snell), 0.117 (Nagelkerke), Model c2 = 20.649, 4 d.f., P < 0.001 (step 4). ASD, autistic spectrum disorder; ADHD, attention decit hyperactivity disorder; SE, standard error; OR, odds ratio; 95% CI for OR, 95% condence interval for the odds ratio, lowerupper. Statistically signicant differences shown in bold.

provide care for their children and, therefore, in less need of services. The percentage of single-parent units for the Black groups was more than double that of South Asians. There is growing research in ID showing that differences in family composition inuence family functioning and help-seeking. An association was found between being a lone-parent family and poor family functioning in families with children with ID (Emerson & Hatton 2007). Marital quality and the parenting partnership (ability to work together in the parenting role), together with child behaviour problems, accounted for 23% to 53% of the variance in parenting condence and in aversive parentchild exchanges for parents of school-age children with mild and moderate ID (as well as for parents of typically developing children) (Floyd & Zmich 1991). Less family support, e.g. in single-parent families, may result in higher parental stress (Avison 1997; Upadhyay & Havalappanavar 2007). Parental stress may play an important role in inuencing access to

services: service use is more likely when parents have higher stress (Thomas et al. 2007) with respite care in particular having been linked with underlying distress in the carer (Hoare et al. 1998). There are other possible explanations for the ethnic variation in service utilisation. First, South Asian children may have a lower level of psychopathology, especially disruptive behaviour disorders (Hackett et al. 1991; Meltzer et al. 2000) and this could be true for South Asian children with ID. This would result in lower need for service uptake. Second, there may be barriers to access and cultural inappropriateness of the services. Language barriers may make it more difcult for carers from minority ethnic groups to gain information about their childrens ID (Fatimilehin & Nadirshaw 1994) as well as services and supports (Bailey et al. 1999; McGrother et al. 2002). Failure to provide appropriate diet and facilities for washing has been given by South Asian parents as reasons for their reluctance to use respite and residential care (Fatimilehin & Nadirshaw 1994) as well as their preference

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Table 4 Binary logistic regression analysis for variables predicting service utilisation of speech and language therapy

B (SE) Step 1 Constant Household composition Step 2 Constant Household composition Ethnicity Step 3 Constant Household composition Ethnicity ASD Step 4 Constant Household composition Ethnicity ASD Speech & language difc

OR

95% CI for OR

P-value

-0.089 (0.371) -0.007 (0.235) -0.586 (0.400) 0.196 (0.050) -0.142 (0.245) 5.573 -0.245 0.184 -3.132 5.574 -0.377 0.170 -3.305 -1.761 (1.551) (0.266) (0.053) (0.750) (2.994) (0.283) (0.056) (0.758) (0.434)

0.993

0.6261.575

0.977

0.868 1.217

0.5371.403 1.1041.342

0.563 <0.001

0.783 1.202 0.044

0.4651.318 1.0831.335 0.0100.190

0.357 0.001 <0.001

0.710 1.188 0.035 0.174

0.4091.231 1.0651.325 0.0080.155 0.0750.405

0.183 0.002 <0.001 <0.001

R2 = 0.000 (Cox & Snell), 0.000 (Nagelkerke), Model c2 = 0.001, 1 d.f., P = 0.977 (step 1); R2 = 0.067 (Cox & Snell), 0.089 (Nagelkerke), Model c2 = 16.76, 2 d.f., P < 0.001 (step 2); R2 = 0.195 (Cox & Snell), 0.260 (Nagelkerke), Model c2 = 52.53, 3 d.f., P < 0.001 (step 3); R2 = 0.255 (Cox & Snell), 0.341 (Nagelkerke), Model c2 = 7111.36, 4 d.f., P < 0.001 (step 4). ASD, autistic spectrum disorder; SE, standard error; OR, odds ratio; 95% CI for OR, 95% condence interval for the odds ratio, lower upper; speech & language difc, speech and language difculties. Statistically signicant differences shown in bold.

for community services to support the family rather than respite and residential care (Fatimilehin & Nadirshaw 1994; McGrother et al. 2002; Kandel et al. 2004). A further barrier may be the perception of stigma with service access. Third, specic cultural inuences such as parental belief systems may vary. For example, if the cause of ID is considered reversible, many carers may live in the hope that their disabled offspring will get better or be cured (Fatimilehin & Nadirshaw 1994; Katbamna et al. 2000). This may partly explain why families from some ethnic minority communities seem not to be interested in educational or habilitative programmes (OHara & Bouras 2007).

frequently spoken at home among the Middle East/ Arab group than in the homes of the children from the other communities. Alternatively, child professionals, e.g. teachers, health visitors, may more rapidly refer the children to SALT.

Study limitations
The study relied on case note information, so there may be lack of reliability of the data regarding service access. However, while reporting of service access may underestimate service contact overall, it is unclear why this should contribute bias with regard to the particular differences identied. The data reported here do not include the frequency or duration of service contact. It is accepted that it would have been preferable to verify actual service contact with review of the relevant agencies les, but the resources needed for this were not available (substantial resources would be needed to check child and adolescent mental health and social service records in departments in many areas of London). The characteristics of the children,

Ethnic variation in speech and language therapy

The analysis also revealed statistically signicant differences in the uptake of SALT among ethnic groups with children from the Middle East/Arab group having the highest levels of use. This interesting nding may relate to delayed acquisition of English, as this language would be signicantly less

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including level of ID, and the rates of recognition of mental health problems (such as ADHD and ASD which were considerably lower than that expected) were not independently assessed with standardised tests or by reports from any other external agencies; but again it is unclear why this should bias the results regarding service contact. Case note data would not have recorded the parental beliefs about the childs ID, so the extent to which they contributed to the ndings could not be explored. Nevertheless, the relatively large sample obtained here and the strong support for the study hypotheses, which are consistent with the available literature from the UK, give credence to the ndings.

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Clinical and research implications

Systematic investigation is required into the links between cultural beliefs, family constitution and service uptake for parents with a child with ID among ethnic groups. The extent of variation of parental beliefs across communities in multi-ethnic societies and their impact in help-seeking behaviour and service uptake remains unclear. There are signicant practical implications for professionals in both health and social services, who need to be aware of the cultural differences to ensure that their practice is sensitive to the religion, ethnicity and languages of the different communities to which they provide services (Hassiotis 1996; Skinner & Weisner 2007).

Acknowledgements
Thanks to Olivia Meyrick and other school staff for contributing to this study. Thanks also to Elena Garralda for support.

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Accepted 3 August 2009

2009 The Authors. Journal Compilation 2009 Blackwell Publishing Ltd