The use of telephone help-lines by lonely children and adolescents

Loneliness is a subjective distressing feeling of being disconnected from a desired group or intimate relationship. Most children and adolescents experience loneliness at some time but for 10-20% of young people it can be severe and chronic. While there are many avenues for help for distressed young people, such as friends and family as well as the professional help of counselors and psychologists, lonely young people often do not seek help. Telephone help-lines are one way to assist young people in difficulty which is cost effective, accessible and anonymous. Many countries provide this free or low cost help with specific services for youth either by telephone or online. From the call records of help-lines however, it would seem that lonely young people do not often utilize these services. The reasons for this apparent reluctance are discussed.

Another distinction that has been made is between experiencing social and emotional loneliness [11]. Social loneliness is said to occur when the individual lacks relationships with groups of friends and feels bored and aimless. Emotional loneliness on the other hand, is when an individual has no close and intimate attachment to another person producing feelings of emptiness and anxiety [12]. Thus, loneliness has been found to be a multi-dimensional construct with emotional, motivational, cognitive, and behavioral dimensions [9].
Almost all young people experience loneliness at some time in their lives. In adolescents 66-79% of young people have reported some feelings of loneliness [13].
For most, this distressing, subjective experience is short-lived. It can be occasioned by situational factors such as changing schools, parental separation or conflict with peers.
For some children and adolescents however, loneliness is long lasting and severe. The prevalence rate of chronic loneliness in children and adolescents has been estimated to be about 10-20% [14]. Adolescents report more feelings of loneliness when they are forming important relationships to establish their identity. Although generally no gender differences have been found with chronic loneliness in childhood [15], if differences have been found, boys report more loneliness than girls [16][17][18]. However, most prevalence studies of chronic loneliness in this population are now dated and might not indicate the extent of the problem at present [19].
Loneliness is a significant problem that needs to be addressed because it can lead to poor psychological, physical and social outcomes. The developmental trajectory for young people who experience chronic loneliness is associated with numerous difficulties such as depression [20]; anxiety [21]; psychosocial difficulties [22]; school refusal [23]; poor academic performance [17] and suicidal ideation and behavior [24]. Loneliness has been associated with increased feelings of anger and shyness and decreased optimism and self-esteem leading to poor quality of life [25,26]. It is associated with mental and physical health problems such as headaches and nausea due to the disruption of eating and sleeping patterns [27]. Loneliness in childhood has also been shown to be a significant risk factor for cardiovascular disease in later life [28].
The purpose of this paper is to present an integrative review on the use of help-lines by children and adolescents who experience loneliness.

Help-seeking for loneliness
As well as being associated with poor mental health, loneliness is an unpleasant, aversive feeling state which causes distress to the individual. Not surprisingly, children and adolescents who experience these feelings want to alleviate their loneliness. In fact, loneliness is an aversive signal that motivates individuals to renew social connections and to seek meaning that is essential for survival [25]. One way young people can overcome their loneliness is to seek help.
Help-seeking is defined as a "behaviour of actively seeking help from other people" [29, p. 4]. It is regarded as a productive coping strategy that has a positive influence on an individual across the lifespan and can help alleviate distressing psychological symptoms when under stress [30]. There are two forms of help-seeking, informal and formal. Informal help-seeking refers to seeking help from informal relationships such as friends and family. Sixty percent of young Australians with a mental health illness report they are comfortable accessing help from friends and the internet more than from professional services [31]. Unfortunately, the contextual conditions in which lonely young people find themselves in their peer relationships and family often mitigates against them help-seeking for their loneliness in an informal way. For example, lonely children and adolescents often have poor social skills which limit their help-seeking from friends [32] as well as having negative communication beliefs and poor communication abilities [33]. In addition, they are often part of families where they are not securely attached, which contributes to their loneliness [34]. As loneliness is also correlated with less family support and less activity involvement [35] lonely young people often do not seek help for their loneliness from their families either.
Formal help-seeking refers to seeking help from professional sources such as teachers, psychologists or counselors [29]. Young people do seek help in a formal way from school psychologists or counselors and their medical practitioner [36] and also through telephone help-lines [2].

Age and Gender
Help-seeking varies based on age and gender. Help-seeking as a form of coping appears to decline with age. The most frequent strategy that 7-12-year-old children reported they had used in the past to stop feeling lonely was seeking helpfrom others, usually from parents, siblings, grandparents and peers [37]. However, as children become older they develop more capacity for self-regulation, have more autonomy, experience and knowledge and are able to use more coping strategies but surprisingly tend to use withdrawal as a coping mechanism for their loneliness [38].
There is also a gender imbalance in young people's help-seeking behaviors, with adolescent boys more reluctant than girls to seek help through face-to-face counselling. This may be due to their belief that they should adhere to gender norms such as competitiveness, emotional stoicism, anti-femininity and homophobia [39].
Males also need to be capable of reciprocation and discussing a problem such as loneliness, could feel that they could not return the favor.

Help-lines
Telephone crisis hotlines are a method of enhanced accessibility for mental health services while minimizing stigma. Telephone counseling has demonstrated cost benefits, as well as having high counseling client acceptance rates [40]. It is also convenient, confidential and anonymous [41]. Rickwood et al. [29] reported that young people experiencing suicidal thoughts would not seek help except for anonymous telephone help-lines. Help-lines for children are well utilized with an estimated 9 million calls made worldwide annually [42]. In Australia Kids Help Line cannot cope with the volume of calls and therefore, some young people are not answered or have long waiting periods [6]. Telephone counseling has been reported to have a positive effect for young people resulting in significantly less psychological distress at the end of the call when compared to the beginning [43].
Telephone lines provide two types of support, emotional and instrumental.
Emotional support is provided by having a caring adult listen to the young person's needs and feelings of loneliness. Instrumental support is giving general problemsolving and guidance to overcome the problem [44]. These kinds of support have gender implications with some authors arguing that males reluctance to seek help might not be "inescapably located in masculinity" [44, p. 78] but could be the response of agencies to young males. In their study of three help-lines in the USA these authors drew a distinction between instrumental help, that is, practical assistance and counseling-orientated help-lines, arguing that young males generally preferred instrumental assistance.

Persistent reluctance
However, it is known that young people are hesitant to seek formal help from counselors when they most need it [29]. In Australia the mismatch between needing help and seeking it is greatest for those aged 16-24 years, similar to age patterns internationally [45]. When boys do seek professional assistance they do not want their peers to know as they do not wish to appear weak or troubled [46].
Several studies have also shown that some young people are reluctant to use help-lines. Sixty percent of young Australians with a mental health illness reported they were more comfortable accessing help from friends and the internet than from professional services such as telephone hotlines or community agencies [31]. The reasons that adolescents aged 13 to 19 years gave for not accessing help-lines in particular were mostly related to feelings of self-reliance and shame [47]. These young people often either thought their problem was not serious enough or they wanted to solve the problem by themselves. Although these New York students were aware of the help-lines they reported more negative attitudes to using this pathway to help, preferring to go to school counselors and mental health professionals or seek help on the internet..
Lonely young people might also be reluctant to use help-lines as it has been shown that they find it difficult to talk to others, and are anxious about how they would be accepted by a counselor [48]. The heightened levels of distress which therefore accompany the action of asking for help often need to be addressed before the presenting issue can be talked through by the counselor [49].

Web counseling
In an effort to address young people's reluctance to use telephone help-lines, organizations have increasingly offered online counseling. This medium is extensively utilized by young people [50], especially lonely young people. Liu, Shen, Xu, & Gao [51] found that, for 8-12 year-olds with low self-esteem loneliness was reduced when using the Internet to seek information. It has also been reported that lonely children and adolescents communicate more often with strangers online about personal and intimate topics than those who did not self-report being lonely [52].
Similarly, it has been shown that lonely children with a learning disability were more involved with people they had only met online again reflecting their unfulfilled social needs [53]. Additionally, 21% of 12-17-year-olds say they have specifically searched the internet for information to help themselves [54]. It is conceivable therefore online help services could be utilized to reduce loneliness in young people.  [55].

Reasons for requesting help on help-lines
There are limited studies which examine the reasons that children call helplines. The data comes mainly from the help-lines themselves when the counselor categorizes the call. The main reasons are family problems, sexuality, school problems, suicide, abuse, substance abuse, peer relationships and mental illness [56]. There are three possible reasons for the lack of documented calls for help with feelings of loneliness from young people.
One is the coding categories that help-lines use. Help-lines code calls for the purpose of reporting to their funding agencies and also to assist in training counselors, but not specifically for research purposes. Some help-lines require the counselor to code the call first into crisis or non-crisis and then into topic categories. Usually, the counselor can only categorize the call into one main reason. For example, KHL calls are logged into one of 36 problem categories [6], one of which is peer relationships including peer pressure, jealousy, friendship breakdowns and feeling shy or lonely.
This category accounted for 16% of all calls in 2004, rising to 19.9% in 2013 [55].
Kidshelpphone in Canada categorizes the calls into 13 categories with issues with peers being the second highest rate at 19% after mental health issues. The main concerns for an American Teenline from 1993-1994 were peer relationships [56].
This limited categorization of only one main reason for the call could be one of the reasons why loneliness is not a major category in these help-line call records.
The second reason for the apparent low number of calls from young people about loneliness could be that loneliness is considered by the help-line counselors to be only a symptom of a mental health problem and not a problem in its own right. In recent years loneliness in young people has not been extensively studied as a unique and separate psychological construct. The focus of the behavioral health research related to loneliness has concentrated more on depression, anxiety and bullying in young people, including loneliness as ancillary to these conditions. This is despite research showing that loneliness is a unique phenomenon which is distinguishable from other mental health problems, such as anxiety and depression [25,57,58].
However, in clinical practice counselors have not focused on loneliness as a separate clinical problem [59].
Thirdly, it is probable that a lonely young person calling a help-line for a mental health condition would admit to feeling depressed rather than saying they are feeling lonely [60]. Those young people with a mental illness are known to have twice the prevalence of loneliness than typically developing young people and conversely lonely children have twice the prevalence of mental illness [61,62]. Therefore, these young people may be likely to use telephone help-lines. Young people seeking help could fear the stigma of loneliness, even to the extent of not talking about it with their counselors [63].
We could speculate therefore, that many young people who access help-lines for psychological problems could also be lonely. Lonely young people's use of telephone help-lines could therefore be seriously underestimated with the current system of recording only the dominant reason for young people's call in the opinion of the counselor. It is also interesting to note that both clients and counselors may not necessarily recognize loneliness as a problem and therefore might not discuss it.

Conclusion
When young people are chronically lonely they not only feel distressed but have adverse life outcomes. Loneliness in children and adolescents is difficult to recognize by others and thus self-help options such as telephone help-lines (especially those which provide an online service) could be one avenue of assistance. However, there needs to be public awareness campaigns such as for depression and anxiety [64] which de-stigmatizes loneliness for young people as well as training for counselors to enquire about possible feelings of loneliness when young people present with other problems.