Suicide and Life-Threatening Behavior 36(6) December 2006 601

 2006 The American Association of Suicidology

Teenagers’ Attitudes about Seeking Help

from Telephone Crisis Services (Hotlines)
Madelyn S. Gould, PhD, MPH, Ted Greenberg, MPH,
Jimmie Lou Harris Munfakh, BA, Marjorie Kleinman, MS, and Keri Lubell, PhD

The purpose of this study was to examine the attitudes toward the use of
telephone crisis services (hotlines) among 519 adolescents in 9th through 12th
grade mandatory health courses in six high schools in New York State. Few ado-
lescents (2.1%) used hotlines and negative attitudes were stronger toward hotlines
than they were toward other formal sources of help. The most common reasons
for hotline nonuse related to feelings of self-reliance and shame. Objections to
hotlines were strongest among students most in need of help by virtue of impaired
functioning or feelings of hopelessness. The results underscore needed outreach
efforts to youth.

Crisis/suicide hotlines have the potential to
serve vulnerable individuals in crisis. Al-
though evidence for their efficacy is sparse
(Leenaars & Lester, 2004; Lester, 1997;
Mishara & Daigle, 2000), hotlines enjoy a
justified reputation for their unique ability to
(a) offer some level of service at times when
other services are unavailable (Stein & Lam-
Dr. Gould is a Professor at Columbia
University in the Division of Child and Adoles-
cent Psychiatry (College of Physicians & Sur-
geons) and Department of Epidemiology (School
of Public Health), and a Research Scientist at the
New York State Psychiatric Institute. Ms. Mun-
fakh and Ms. Kleinman are in the Division of
Child and Adolescent Psychiatry and New York
State Psychiatric Institute, as was Mr. Greenberg
at the time of the study. Dr. Lubell is with the
Division of Violence Prevention National Center
for Injury Prevention and Control, Centers for
Disease Control and Prevention in Atlanta.
This research was supported by a coopera-
tive agreement from the Centers for Disease Con-
trol and Prevention, U81/CCU216089.
Address correspondence to Dr. Madelyn S.
Gould, Division of Child & Adolescent Psychia-
try, NYSPI, 1051 Riverside Drive, Unit 72, New
York, NY 10032; gouldm@childpsych.columbi-
a.edu
bert, 1984); (b) offer confidentiality and ano-
nymity to clients (McCord & Packwood,
1973); (c) provide information about other
treatment resources; and (d) provide a safe,
nonjudgmental environment enabling clients
to articulate complex feelings. Hotlines offer
the added benefit of allowing callers to freely
initiate and terminate contact (Slem & Cotler,
1973).
These practices would seem to hold
great appeal for adolescents, whose mental
health needs are addressed only partially
(Leaf et al., 1996; Offord et al., 1987; Wu et
al. 1999; Zahner, Pawelkiewicz, DeFranc-
esco, & Adnopoz, 1992). Moreover, recent
evidence indicates that youth who use hot-
lines are helped by them (King, Nurcombe,
Bickman, Hides, & Reid, 2003). Telephone
crisis counseling appears to yield significant
decreases in suicidality and significant im-
provements in the mental state of youth dur-
ing the course of the call, yet there is limited
evidence that adolescents call hotlines. Data
of usage patterns derive from two sources:
call volume reports from hotlines and surveys
of adolescents themselves.
The call volume report of an Ohio
hotline catering exclusively to teens indicates
602
calls in excess of 2,000 per year (Boehm &
Campbell, 1995); however, precise usage is
difficult to gauge because the number of sep-
arate (non-repeat) callers and originating
geographic location of calls is not known.
Hotlines catering to all ages allow a record-
ing of teen calls as a proportion of total calls,
but hotlines conventionally do not conduct
demographic intake and only one such U.S.
study is found. Wilkins (1969) reviewed char-
acteristics of 200 randomly selected callers to
a Chicago hotline between July 1966 and
June 1967. Of those callers from whom age
could be ascertained, 15% (26/169) were
aged 10 to 19. This age demographic repre-
sented 23% of the Cook’s county ten-and-
over population (U.S. Bureau of the Census,
1967), suggesting that hotlines were used
proportionately less often by adolescents
than by older age groups.
Service utilization surveys of adoles-
cents indicate that despite high awareness of
hotlines and high satisfaction ratings among
those who do contact hotlines, adolescents
access hotlines infrequently (King, 1977; Slem
& Colter, 1973) and less than they access
other help sources (Offer, Howard, Schonert,
& Ostrov, 1991; Vieland, Whittle, Garland,
Hicks, & Shaffer, 1991). In a sample of 1,763
high school students, Slem and Cotler (1973)
assessed the awareness and utilization of a
telephone crisis hotline in suburban Detroit.
Ninety-eight percent of adolescents had been
aware of the service, 5.6% had contacted the
hotline, and 68% of users had found it useful.
In a sample of 3,000 Alabama college stu-
dents, King (1977) identified 66 (2.2%) who
had called a limited-hour telephone counsel-
ing center. Over two-thirds of all callers rated
the hotline as somewhat effective to ex-
tremely effective. In a Midwest sample of 497
adolescents, Offer and colleagues (1991) as-
sessed the help-seeking tendencies of dis-
turbed adolescents. Thirty-seven percent of
disturbed adolescents were aware of hotline
services and 1.8% had called a crisis hotline
in the past year, significantly fewer than had
contacted guidance counselors, clergy mem-
bers, or mental health professionals. In a
population-based sample of 129 youth under
Gould et al.
25 years of age in New Zealand who made a
medically serious suicide attempt, 13.9% had
called a telephone counseling or crisis help-
line, in contrast to 72.1% who had “any psy-
chiatric contact” in the year preceding the at-
tempt (Beautrais, Joyce, & Mulder, 1998).
Significantly fewer youth in the community
who had not made a serious suicide attempt
used these services (2.0% hotlines; 7.8% psy-
chiatric services). In a case-control study of
153 13- to 34-year old suicide attempters
treated at emergency departments and 513
nonpatient members of the community (“con-
trols”) in Texas, hotlines were utilized less
frequently (4% of attempters and 0.2% of
controls) than any other resource (Barnes,
Ikeda, & Kresnow, 2001). Satisfaction ratings
were not reported in these population-based
studies (Barnes et al., 2001; Beautrais et al.,
1998; Offer et al., 1991). Vieland et al. (1991)
assessed changes in help-seeking behavior in
a sample of 1,300 New Jersey high school
students 18 months after implementation of
a suicide awareness program. The program
included the distribution of a hotline num-
ber. Use of hotlines after program exposure
was 2% and below all other help sources. A
satisfaction rating was not reported. Note-
worthy, however, was that at baseline assess-
ment 17% of self-identifying suicide attempt-
ers (n = 63) reported ever using a hotline
(Shaffer et al., 1990).
To date no studies have sought to de-
termine the reasons behind the infrequent
use of hotlines by teenagers. A direct exami-
nation of adolescent perceptions and atti-
tudes toward hotlines will help ascertain their
usefulness as a source of help to adolescents
and potentially aid the outreach efforts of
this resource.
The aim of this study was to determine
the attitudes that adolescents have toward the
use of crisis hotlines. The following questions
were addressed: (1) Are adolescents using hot-
lines significantly less than other formal
sources of help? (2) What are the reasons ado-
lescents state for not using hotlines? (3) Do
reasons for nonuse vary on demographics, im-
pairment, hopelessness, or a willingness to use
other formal sources of help? and (4) Are the
Teenagers and Crisis Hotlines
reasons for hotline nonuse different from the
reasons for nonuse of other formal sources?
METHODS
Sample
The sample was assessed as part of a
longitudinal study that examined patterns of
help-seeking behavior among high school
students (Gould, Munfakh, Lubell, Klein-
man, & Parker, 2002; Gould, Munfakh,
Kleinman, Lubell, & Provenzano, 2004).
The targeted population was adolescents
aged 13 through 19, enrolled in 9th through
12th grade mandatory health courses in six
high schools in Nassau, Suffolk, and West-
chester counties in New York State. Five of
the high schools were in suburban communi-
ties, while one was in a rural area. The
schools were socioeconomcally diverse: The
percentage of free or reduced lunches ranged
from <1% to 22.4% (M = 7.5%, SD = 8.5%).
In the fall/winter of 1999 we assessed 519 of
708 enrolled students (73% participation
rate). They were followed up using telephone
interviews in 2000, but the focus of the pres-
ent paper is on the baseline assessments. The
ethnic distribution of the participating base-
line sample was approximately 78% White,
3% African American, 13% Hispanic, 1%
Asian, and 4% other; approximately 50% of
the students were female. The mean age was
15.7 and 97% of the students were between
ages 14 and 17. There were no significant de-
mographic differences between participants
and nonparticipants, with the exception of
ethnicity (χ2 = 36.8, p < .0001). There was a
significantly lower participation rate among
Hispanics (55.7%) and a higher participation
rate among Whites (77.7%). Students were
recruited for the study using an “opt-out”
procedure for the parents and active written
assent for the youth. Two mailings (in En-
glish and Spanish), including an information
sheet describing the survey content and pro-
cedures, a response form, and stamped re-
sponse envelope, were sent to the parents
twice, 1 month and 2 weeks prior to the in-
603
school survey administration. Written assent
was obtained from participating students on
the day of the survey. The study procedures
were approved by the Institutional Review
Boards of the New York State Psychiatric In-
stitute/Columbia University Department of
Psychiatry and the Centers for Disease Con-
trol and Prevention.
Measures
A self-report questionnaire adminis-
tered in the health courses in school assessed
demographic characteristics, hopelessness,
functional impairment of the participants,
and use and perception of various treatment
services.
Demographic Questionnaire. The de-
mographic questionnaire elicited information
with regard to age, gender, racial/ethnic
background, household composition, geo-
graphic mobility, and parental marital status
and education.
Beck Hopelessness Scale (BHS). This
20-item questionnaire assessed the adoles-
cent’s degree of pessimism about the future
(Beck, Weissman, Lester, & Trexler, 1974).
The past week, including the day of the sur-
vey, was the time frame for the assessment. A
cutoff point of ≥9, reported to be predictive
of eventual suicide in a sample of depressed
inpatients with suicide ideation (Beck, Steer,
Kovacs, & Garrison, 1985), was used to di-
chotomize scores on the BHS.
Impairment. The Columbia Impair-
ment Scale (CIS) provided a measure of
overall severity of functional impairment
during the past year (Bird et al., 1993). The
CIS has demonstrated high interrater reli-
ability and both concurrent and discriminant
validity. The recommended cutoff point of
≥16 was used to dichotomize scores on the
CIS. While the CIS was originally designed
to be administered as an interview (Bird et
al., 1993), the present study employed it in a
self-report format.
Help-Seeking Utilization Questionnaire.
This 80-item questionnaire assessed the ado-
lescent’s use and perceptions of various kinds
of treatment services, both formal (e.g., alco-
604
hol/drug abuse centers, mental health profes-
sionals, other health professionals, school
counselors, clergy, Internet, crisis hotlines)
and informal (i.e., parents, friends, siblings,
teachers, coaches), during the past year. The
formal sources of help are the focus of the
present paper. The utilization questions for
each source of help were asked in the context
of when the youth felt “very upset, sad,
stressed or angry.” Students answering “no”
to an “ever use” question for a specific source
were instructed to skip to a subsequent ques-
tion detailing reasons for nonuse of that
source of help. The “reasons for nonuse”
question provided 16 nonexclusive explana-
tory responses. Three of the 16 responses
were worded to reflect the specific services.
For example, “I was ashamed to call”; “I did
not know where to call” and “I had problems
getting a private telephone” were responses
provided for hotline nonuse; whereas “I was
ashamed to go” and “I did not know where to
go” and “I had transportation problems” were
provided as responses for other services. In
addition, for the response item “I have never
heard of a crisis hotline,” there was no com-
parable item for other sources. The question-
naire was a modification of Offer’s Mental
Health Utilization Questionnaire (Offer et
al., 1991). Several items were added from the
Client Satisfaction Questionnaire (Attkisson
& Zwick, 1982), and questions assessing rea-
sons for seeking help were adapted from the
Methods for the Epidemiology of Child and
Adolescent Mental Disorders (MECA) Study
(Lahey et al., 1996). The total survey took
approximately 30 minutes to complete.
Data Analytic Strategy The primary
sampling unit of the study was school and the
secondary sampling unit was student within
school. Thus, we first examined the extent to
which within-school clustering existed in or-
der to determine whether this clustering vari-
able needed to be included in the analyses.
The sample clusters (school) had little impact
on the outcomes (usage of each help-seeking
source, gender, hopelessness, impairment), as
indicated by the intra-class coefficients (ICCs)
which were all close to zero (ICCs < .03).
Therefore, the employment of mixed linear
Gould et al.
models or Mantel-Haenszel methods to ac-
count for the clustering variable of school
was unnecessary.
The reasons for hotline nonuse were
consolidated by use of a principal compo-
nents factor analysis with varimax rotation.
In addition to continuous factor scores, the
proportion of students answering “yes” to
any item within each factor was calculated.
Significant differences between these propor-
tions were found by paired chi-square tests
(McNemar’s test with continuity correction;
Agresti, 1996). A series of McNemar’s chi-
square test with a continuity correction was
also conducted to compare the frequencies of
the individual reasons endorsed for hotline
nonuse and to determine whether adoles-
cents used hotlines significantly less than
other formal sources of help. Whether the
reasons for hotline nonuse varied by demo-
graphic characteristics (sex, age, race), im-
pairment, hopelessness, or a willingness to
use other formal sources of help was deter-
mined by a series of independent t tests and
multiple linear regression analyses. A for-
ward, stepwise, hierarchical block analysis
procedure was used for all regression analy-
ses. The dependent variables were the scale
scores on the derived “reasons for nonuse”
factors and the independent variables in-
cluded in the first block were design variables
for the six schools; in the second block, de-
mographic variables (age, sex, race); in the
third block, clinical variables (BHS and CIS);
and in the fourth block, indicator variables
for all formal sources of help (mental health
professionals [MHP], school counselors, other
health professionals [OHP], alcohol/drug
abuse centers [substance program], clergy,
and Internet). Age was dichotomized as un-
der 16 versus 16 and over; race was dichoto-
mized as White versus non-White. To deter-
mine whether the reasons for hotline nonuse
were different from the reasons for the non-
use of other formal help sources, the mean
scale scores on the nonuse factors for hot-
lines and the comparable factors for nonuse
of each other source were compared by using
paired t tests. For each t test, the sample was
comprised of nonuser respondents common
Teenagers and Crisis Hotlines 605

to both hotline and the alternative help
source of interest. Subjects who failed to re-
spond to the “ever use” question were ex-
cluded from analysis for that particular help
source. No more than 3% of subjects failed
to respond to “ever use” in any single section
(Hotline 0.7% [n = 4]; Counselor 1.5% [n =
8]; MHP 1.2% [n = 6]; Substance Program
1.5% [n = 8), OHP 1.9% [n = 10]; Clergy
2.1% [n = 11]; Internet 0.6% [n = 3]. Statisti-
cal analyses were conducted using SPSS sta-
tistical software, version 12 (SPSS Inc., Chi-
cago, IL).
least with respect to “ever” or “last year.”
The remaining analyses will focus on “ever”
having used a hotline or other service. Hot-
lines were used significantly less often than
MHPs (χ2 = 129.10, p < .001), school counse-
lors (χ2 = 127.81, p < .001), the Internet (χ2 =
72.30, p < .001), and clergy (χ2 = 5.60, p =
0.018). Hotlines were not used significantly
less often than OHPs (χ2 = 0.96, p = .32) and
alcohol/drug abuse centers (substance pro-
gram) (χ2 = 0.38, p = .54).
Reasons Adolescents State for Nonuse
of Hotlines

RESULTS The two reasons most often stated for

Use of Hotlines Compared to Other
Formal Sources
Nine (1.7%) students reported using a
hotline in the last year and 11 (2.1%) re-
ported having ever used a hotline (Table 1).
Ten of the “ever users” were female (91%).
All hotline users were between the ages of 16
and 18, and eight (72.7%) of the users were
White. Of the 11 hotline users, 73% had
used some other formal resource. If Internet
use is also considered, then 91% of hotline
users had used another source of help.
Nearly half of the hotline users had also seen
a mental health professional (5/11). Com-
pared to other options a hotline was used
not using a hotline (Table 2) were “I thought
the problem was not serious enough” and “I
wanted to solve the problem by myself”
(35.3% and 33.1%, respectively). Only 1.8%
of hotline nonusers had not heard of a hot-
line and 13% did not know where to call.
Thirty-eight subjects (7.5%) failed to en-
dorse any reason explaining nonuse of hot-
lines.
The factor analysis yielded an inter-
pretable three-factor model, which accounted
for 42.1% (24.8%, 10.0%, and 7.3%) of the
total variance (see Table 3). The reliability
estimates (Cronbach alpha coefficient) were
.67, .68, and .50 for the three factors, respec-
tively. The first factor, labeled “shame,” cor-
responded to a feeling of being ashamed and

TABLE 1
Prevalence of Use of Hotlines and Other Formal Help Sources

Ever Used Last Year Used

Help Source n† % χ2 p value‡ n % χ2 p value‡

Mental health professional 153 29.8% 129.10 <.001 108 21.1% 89.76 <.001
School counselor 151 29.5% 127.81 <.001 114 22.3% 94.72 <.001
Internet 95 18.4% 72.30 <.001 94 18.2% 76.54 <.001
Clergy 26 5.1% 5.60 0.018 21 4.1% 4.32 0.038
Other health professional 17 3.3% 0.96 0.327 16 3.1% 1.57 0.210
Substance program 15 2.9% 0.38 0.541 12 2.3% 0.21 0.648
Hotline 11 2.1% 9 1.7%

†Due to missing responses, the denominator of “ever used” ranges from 508 to 515.
‡McNemar chi-square tests compare each source to hotline.
606 Gould et al.

TABLE 2
Prevalence of Reasons for Nonuse of a Hotline
Reasons Rank % (N = 504) χ2 p value†

I thought the problem was not serious enough 1 35.3% 0.69 0.406
I wanted to solve the problem by myself 2 33.1% 12.75 <.001
I thought a family member or friend could help me 3 24.6% 0.06 0.800
I thought it probably would not have done any good 4 24.0% 0.33 0.560
I thought the problem would get better by itself 5 22.8% 12.57 <.001
The problem was too personal to tell anyone 6 15.1% 1.31 0.250
I did not know where to call (go) 7 13.1% 2.47 0.120
I was concerned what my family might think or say 8 10.9% 0.45 0.500
I would not have trusted the advice or help they would give me 9 9.7% 2.77 0.096
I was ashamed to call (use) 10 7.1% 2.00 0.157
I was concerned what my friends might think or say 11 5.6% 0.00 1.000
It would have taken too much time 12 5.6% 1.32 0.250
Services were too expensive 13 4.2% 6.00 0.014
I have never heard of a crisis hotline 14 1.8% 0.29 0.593
I had problems getting a private telephone‡ 15 1.4% 0.82 0.366
A family member objected 16 0.8%

†McNemar’s chi-square tests compared frequencies of contiguous items.

‡Where the hotline nonuse section had the item “I had problems getting a private telephone,”
the other help sources nonuse sections had the item “I had transportation problems.”

TABLE 3
Reasons for Nonuse of Hotlines: Factor Structure and Item Loadings†

Factor I Factor II Factor III

FACTOR 1: SHAME (4 items)

I was ashamed to call 0.76
I was concerned about what my family might think or say 0.75
I was concerned about what my friends might think or say 0.69
The problem was too personal to tell anyone 0.36
FACTOR 2: SELF-RELIANCE (6 items)
I wanted to solve the problem by myself 0.76
I thought the problem would get better by itself 0.61
I thought a family member or friend could help me 0.59
I thought it probably would not have done any good 0.59
I thought the problem was not serious enough 0.48
I would not have trusted the advice or help they would give me 0.38
FACTOR 3: STRUCTURE (5 items)
I have never heard of a crisis hotline 0.66
Services are too expensive 0.63
It would have taken too much time 0.52
I did not know where to call 0.44
I had problems getting a private telephone 0.43

†“A family member objected” did not load on any factor

Teenagers and Crisis Hotlines
was composed of four items. The second fac-
tor, labeled “self-reliance,” reflected self-reli-
ance either resulting from ones own re-
sourcefulness or a skepticism toward the
helping value of the source and was com-
prised of six items. The third factor, labeled
“structure,” indicated structural barriers that
would impede access, such as expense, time,
or unawareness of the source, and was com-
prised of five items. Students chose reasons
relating to “self-reliance” (62.5%) signifi-
cantly more often than “shame” (22.6%; χ2 =
182.65, p < .001). Reasons relating to “struc-
ture” were chosen least often (18.7%) and
significantly less often than “shame” (χ2 =
4.75, p = .029).
Reasons for Nonuse of Hotlines
by Demographic and Clinical
Characteristics
Mean scores on “shame” (Table 4)
were significantly higher for: females than for
males (0.53 vs. 0.24, t[502] = 3.98, p < .001);
students who were “hopeless” (i.e., scoring ≥
9 on the Beck Hopelessness Scale) than for
those not hopeless (0.73 vs. 0.34, t[495] =
3.19, p = .002); those who were “functionally
impaired” (i.e., scoring ≥ 16 on the CIS) than
for unimpaired students (0.71 vs. 0.29 , t[502]
= 4.82, p < .001); youth who had seen a MHP
compared to those who had not seen a MHP
(0.63 vs. 0.29, t[499] = 4.22, p < .001); and
teenagers who used the Internet as a source
of help compared to those who did not (0.74
vs. 0.31, t[501] = 4.42, p < .001). Gender (B =
0.27, 95% CI = 0.12, 0.47, p < .001), impair-
ment (B = 0.25, 95% CI = 0.06, 0.44, p = .009),
use of a MHP (B = 0.23, 95% CI = 0.06,
0.40, p = .007), and use of the Internet (B =
0.36, 95% CI = 0.17, 0.55, p < .001) contin-
ued to be independent predictors of “shame”
in the multiple regression analyses. Hope-
lessness was still a marginally statistically sig-
nificant predictor of “shame” after control-
ling for the effect of impairment (B = 0.25,
95% CI = 0.00, 0.51, p = .05), but was not
significant in the final model where all
sources of help were included (B = 0.22, 95%
CI = −0.03, 0.47, p = .08).
607
Females had significantly higher mean
scores on the “structure” factor (Table 4)
(0.32 vs. .20, t[502] = 2.03, p = .043), as did
youths scoring above the clinical thresholds
on the hopelessness and impairment mea-
sures (0.58 vs. 0.22, t[495] = 3.91, p < .001;
0.45 vs. 0.21, t[502] = 3.67, p < .001, respec-
tively), those who saw a MHP (0.43 vs. 0.19,
t[499] = 3.99, p < .001), youth who saw a
school counselor (0.36 vs. 0.22, t[497] = 2.28,
p < .023), and those who used the Internet
(0.42 vs. 0.23, t[501] = 2.64, p < .009). Signif-
icant independent predictors of “structure”
were hopelessness (B = 0.30, 95% CI = 0.11,
0.50, p = .002) and use of a MHP (B = 0.19,
95% CI = 0.06, 0.32, p = .004). Impairment
was still a statistically significant predictor of
“structure” after controlling for hopelessness
(B = 0.21, 95% CI = 0.07, 0.35, p = .004), but
was not significant in the final model (B =
0.14, 95% CI = −0.01, 0.28, p = .07).
“Self-reliance” mean scores were sig-
nificantly higher for females (1.77 vs. 1.23,
t[502] = 3.89, p < .001), teenagers reporting
impaired functioning (2.03 vs. 1.34, t[502] =
4.17, p < .001), those who saw a MHP (1.97
vs. 1.30, t[499] = 4.49, p < .001), youth who
saw a school counselor (1.88 vs. 1.35, t[497] =
3.45, p = .001), and teenagers who used the
Internet (1.86 vs. 1.42, t[501] = 2.41, p <
.016). Variables that were independently as-
sociated with “self-reliance” responses were
gender (B = 0.41, 95% CI = 0.13, 0.69, p =
.004), impairment (B = 0.51, 95% CI = 0.14,
0.87, p = .006), and use of MHPs (B = 0.43,
95% CI = 0.11, 0.75, p = .008).
Comparison of Reasons for the Nonuse
of Hotlines and Reasons for the Nonuse
of Other Sources
For these comparisons, the scale for
“structure” was deleted because the reasons
for nonuse response items across help
sources were not equivalent. The reliability
estimates (Cronbach alpha coefficient) for
the shame and self-reliance scales, respec-
tively, for each source were: MHP: .68, .53;
school counselors: .64, .48; Internet: .53, .63;
clergy: .60, .46; OHP: .68, .52; substance
608 Gould et al.

TABLE 4
Reasons for Hotline Nonuse by Demographic and Clinical Characteristics
SHAME STRUCTURE SELF-RELIANCE
(4 items) (5 items) (6 items)

n M (SD) t p M (SD) t p M (SD) t p

SEX
Female 249 0.53 (0.99) 3.98 <.001 0.32 (0.71) 2.03 0.04 1.77 (1.57) 3.89 <.001
Male 255 0.24 (0.62) 0.20 (0.53) 1.23 (1.52)
AGE
≥ 16 255 0.44 (0.86) 1.54 0.13 0.29 (0.73) 1.24 0.22 1.61 (1.59) 1.68 0.09
<16 249 0.33 (0.80) 0.22 (0.51) 1.38 (1.54)
RACE
White 393 0.38 (0.83) 0.27 (0.67) 0.83 0.41 1.52 (1.59) 0.55 0.58
Nonwhite 111 0.41 (0.86) 0.27 0.79 0.22 (0.47) 1.42 (1.50)
HOPELESSNESS
BHS ≥ 9 52 0.73 (1.14) 3.19 0.002 0.58 (0.91) 3.91 <.001 1.90 (1.73) 1.95 0.05
BHS < 9 445 0.34 (0.78) 0.22 (0.58) 1.46 (1.55)
IMPAIRMENT
CIS ≥ 16 144 0.71 (1.08) 4.82 <.001 0.45 (0.84) 3.67 <.001 2.03 (1.73) 4.17 <.001
CIS < 16 390 0.29 (0.72) 0.21 (0.54) 1.34 (1.48)
OTHER FORMAL
SOURCE
UTILIZATION
Mental Health
Professional
Yes 148 0.63 (1.02) 4.22 <.001 0.43 (0.83) 3.99 0.001 1.97 (1.61) 4.49 <.001
No 353 0.29 (0.72) 0.19 (0.51) 1.30 (1.51)
School Counselor
Yes 144 0.49 (0.82) 1.62 0.11 0.36 (0.70) 2.28 0.02 1.88 (1.59) 3.45 0.001
No 355 0.35 (0.84) 0.22 (0.60) 1.35 (1.54)
Internet
Yes 88 0.74 (1.15) 4.42 <.001 0.42 (0.88) 2.64 0.009 1.86 (1.55) 2.41 0.016
No 415 0.31 (0.73) 0.23 (0.56) 1.42 (1.56)
Clergy
Yes 25 0.56 (1.08) 1.02 0.31 0.48 (0.71) 1.77 0.08 1.60 (1.61) 0.28 0.78
No 471 0.38 (0.82) 0.25 (0.63) 1.51 (1.57)
Other health
professional
Yes 16 0.69 (1.01) 1.44 0.150 0.56 (0.73) 1.94 0.053 1.69 (1.57) 0.48 0.63
No 481 0.38 (0.83) 0.25 (0.63) 1.50 (1.57)
Substance program
Yes 14 0.79 (1.05) 1.82 0.07 0.36 (0.63) 0.57 0.57 2.00 (1.62) 1.19 0.23
No 484 0.38 (0.83) 0.26 (0.63) 1.49 (1.57)

BHS = Beck Hopelessness Scale; CIS = Columbia Impairment Scale.

program: .65, .69. Mean scores on “shame” DISCUSSION

and “self-reliance” were significantly higher
for hotline nonusers than for nonusers of The main findings of this study were
each of the other sources (Table 5). that few adolescents (2.1%) ever used hot-
Teenagers and Crisis Hotlines 609

TABLE 5
Comparison of Reasons for Nonuse of Hotlines and Nonuse of Other Sources
Shame Self-reliance
(4 items) (6 items)

n M t p M t p

Hotline 353 0.29 4.28 <.001 1.30 9.97 <.001

Mental health professional 0.14 0.57
Hotline 355 0.35 5.73 <.001 1.35 9.22 <.001
School counselor 0.13 0.69
Hotline 415 0.32 5.29 <.001 1.42 6.33 <.001
Internet 0.15 1.06
Hotline 471 0.38 7.36 <.001 1.51 13.26 <.001
Clergy 0.13 0.63
Hotline 480 0.38 7.77 <.001 1.49 13.34 <.001
Other Health Professional 0.10 0.58
Hotline 484 0.38 8.80 <.001 1.49 18.74 <.001
Substance program 0.04 0.16

lines and that negative attitudes among ado-
lescents were stronger toward hotlines than
they were toward other sources of help. Ado-
lescents who identified themselves as in need
of help by virtue of impaired functioning or
feelings of hopelessness and did not use hot-
lines had particularly negative attitudes to-
ward hotlines. Yet awareness of hotlines was
high. Over 98% had heard of a crisis hotline,
and 87% indicated they knew where to call.
This information is consistent with past re-
ports of high awareness but low usage (King,
1977; Slem & Cotler, 1973; Vieland et al.
1991).
Commonly cited reasons for not using
hotlines were thinking that the problem was
not serious enough (35%) and that the prob-
lem could be solved by oneself (33.1%).
These two reasons, along with four others (“I
thought the problem would get better by it-
self,” “I thought a family member or friend
could help me,” “I thought it probably would
not have done any good,” and “I would not
have trusted the advice or help they would
give me”), were categorized as a part of the
“self-reliance” factor. At least one item from
this category was endorsed by over 62% of
subjects not using hotlines, significantly more
often than the endorsement of the other cat-
egories (“shame” and “structure”). Items of
“self-reliance” were reported much more of-
ten in the context of hotline nonuse than
nonuse of any other help source. The relative
high endorsement of “self-reliance” suggests
that adolescents tend not to use a hotline be-
cause they want to solve their problems by
themselves; they perceive their problems as
not serious enough for a hotline; or they con-
sider the hotline as not useful enough for
their problems—in other words, a perceived
mismatch between need and service.
These findings show that objections to
hotlines were generally in line with usage
patterns: Adolescents used hotlines least and
objected to them most. However, adolescents
used substance abuse treatment centers and
saw other health professionals nearly as infre-
quently as hotlines, yet their negative re-
sponses to hotlines were significantly greater.
This finding may point to a perception among
adolescents that, unlike other rarely used
sources such as physicians and substance
abuse treatment centers, hotlines lack a spe-
cific function for any of their health needs.
Females were more likely than males
to call a hotline, consistent with the literature
on utilization of telephone crisis services
(Mishara & Daigle, 2001). Yet females en-
610
dorsed all three of the major reasons for non-
use more than males. It appears that males
do not require as negative an attitude as fe-
males to not use a hotline. This may reflect
the widespread reluctance among males to
ask for help, as reported in the literature on
help-seeking behavior among teenagers
(Boldero & Fallon, 1995; Gasquet, Ledoux,
Chavance, & Choquet, 1999; Rickwood &
Braithwaite, 1994).
Our findings also indicate that objec-
tions to hotlines are strongest among the in-
dividuals most in need of help. Youth who
reported impaired functioning were more
likely than the unimpaired youth to endorse
“self-reliance” in the context of not using a
hotline. This is consistent with findings that
depressed youth and those with serious sui-
cidal ideation and behavior are more likely
than their healthy counterparts to think that
people should be able to handle their own
problems without outside help (Gould, Velt-
ing, Kleinman, Lucas, Thomas, & Chung,
2004). Students with functional impairment
also reported being more ashamed to use
hotlines. Those who reported hopelessness
were more likely to endorse structural objec-
tions to hotline use than individuals who
were not hopeless. These structural objec-
tions included never having heard of a crisis
hotline, not knowing where to call, and hav-
ing problems getting a private telephone,
which may generally reflect the negative cog-
nitions and loss of motivation that underlie
hopelessness (Beck et al., 1974).
Objections to hotlines were consis-
tently stronger among those who had seen a
mental health professional, even when con-
trolling for impairment and hopelessness.
This may indicate that adolescents’ needs are
being addressed by this system of care and as
such, once they enter the mental health care
system, they do not feel favorably inclined to
call a hotline.
Limitations
First, this study was conducted using a
school-based sample and cannot be general-
ized to those adolescents not in school.
There is a distinct possibility that adolescents
Gould et al.
outside of a school system have less access to
mental health professionals and school coun-
selors and therefore the attitudes and utiliza-
tion rates reported in the present study may
not apply to other populations of youth. Sec-
ond, differential response rates for this sam-
ple may constitute a source of bias. A signifi-
cantly disproportionate number of eligible
Hispanic youths did not participate in the
study; however, non-White ethnicity was not
associated with any outcome, and thus this
difference was unlikely to have affected study
findings. Third, the schools were largely sub-
urban, with one rural school, and predomi-
nantly White, so the results cannot be gener-
alized to an urban or more ethnically diverse
setting. The six schools were, however, socio-
economically diverse. A fourth limitation was
the lack of a psychiatric assessment other
than impairment or hopelessness. While im-
pairment and hopelessness are correlated
with psychiatric problems, notably depres-
sion and suicidality (Asarnow, Carlson, &
Guthrie, 1987; Bird et al., 1996; Marcenko,
Fishman, & Friedman, 1999; Oversholser,
Adams, Lehnert, & Brinkman, 1995; Shaffer
et al., 1996; Spirito, Williams, Stark, & Hart,
1988), the present study cannot address how
specific diagnoses or symptoms may motivate
a teenager’s hotline usage, or how this re-
source impacts these problems. Lastly, this
study was conducted prior to the implemen-
tation of the national network of telephone
crisis services, funded by the Substance
Abuse and Mental Health Services Adminis-
tration (SAMHSA), and as such may not re-
flect any changes in attitudes or utilization
due to increased marketing strategies accom-
panying the network’s development. How-
ever, it appears that even school-based inter-
ventions specifically aimed at increasing
teenagers’ hotline usage yield little change in
hotline utilization (Gould, Munfakh et al.,
2004), and the results from the present study
are still useful in informing our efforts to de-
sign optimal helping resources for youth.
Conclusions
The low utilization of hotlines and the
negative attitudes toward them among youth
Teenagers and Crisis Hotlines
is particularly distressing in light of recent
evidence of the short-term efficacy of hot-
lines for youth who use this resource (King
et al., 2003). This potential source of help
appears to be inadequately tapped by adoles-
cents. The question remains of whether hot-
line use should be promoted as an indepen-
dent source of short-term relief, an entry to
accessing other more long-term resources of
help, and/or as an adjunct to other service
use. It appears that of the few adolescents in
our study who had ever used hotlines the vast
majority had used other services also.
Low utilization and negative attitudes
toward hotlines relative to other formal
sources may result from influences other
than help-seeking behavior on the part of the
adolescent. Adolescents are historically poor
initiators of their own help-finding (McGee,
Feehan, Williams, Partridge, Silva, & Kelly,
1990). Of all formal help sources, hotlines
may suffer most due to this disinclination. It
is unlikely that an adolescent would be intro-
duced to a hotline through school or family
in the manner that one might be introduced
to a school counselor. Nor can one imagine
hotline usage being compelled by a third
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Manuscript Received: October 28, 2005
Manuscript Accepted: December 28, 2005