Transitioning to Adult Mental Health Services

Abstract

Longitudinal studies have demonstrated that youth with mental health problems tend to have poor outcomes in adulthood. Moreover, many young adults do not make the transition from child- to adult-focused care even when they acknowledge their need for support. This study is an investigation of the needs and experiences of late adolescents with emotional and/or behavioral problems who accessed mental health services at a local child and adolescent clinic. In general, participants did not appear ready for an institutional transition. Adolescents disclosed their fears, underscoring the importance of supportive relationships, and stated the negative expectations they had concerning adult-focused care. The implementation of clinical supports to increase adolescents’ mental health self-efficacy may promote successful service transitions.

Keywords

adolescents service transition developmental transition mental health mixed methods

In Western societies, the successful transition from adolescence to adulthood is marked by the acquisition of competence in a variety of social and psychological domains, such as separating from one’s parents, developing a healthy self-image, setting and achieving educational and vocational goals, and participating in community life (Eccles, Barber, Stone, & Templeton, 2003). Transitioning through this period of development consists of facing changes in physical, social, and psychological areas of functioning (Davis & Vander Stoep, 1997). This is a period of time during which many individuals explore interpersonal relationships, employment options, and the manner in which they view the world (Rindfuss, 1991). During the transition from adolescence to adulthood, individuals are likely to assume greater decision-making responsibilities in addition to developing an increased sense of accountability for their actions (Arnett, 2001).

Arnett (2000, 2004) coined the term emerging adulthood to characterize this unique developmental period between adolescence and adulthood. Five prominent features that constitute emerging adulthood signal that it is a time when (a) identity exploration occurs, (b) instability is felt, (c) self-focus begins to take shape, (d) emerging adults feel in-between adolescence and adulthood, and (e) they hope for and experience a range of possibilities (Arnett, 2004, 2006). Identity exploration and formation during emerging adulthood has been viewed as an iterative process in which an individual’s changing environmental contexts influence his or her sense of self (Konstam, 2007). Individuals develop different identities or social selves based on their understanding of themselves in the context of their life experiences (Thoits, 1995). In Western cultures, identity formation, which sets the foundation for important life choices regarding relationships, employment, and life goals, appears to be resolved during emerging adulthood (Stark & Traxler, 1974). Arnett (2004) noted that compared with other developmental periods, emerging adulthood is a period during which the greatest possibilities for change typically present themselves. Because the potential for many life changes appears during emerging adulthood, it may be a time when feelings of being “in-between” and a desire for self-exploration are particularly conspicuous. Rather than being characterized as a time of settling into traditional adult roles, emerging adulthood appears to increasingly be a distinctive period of self-discovery and experimentation. Similarly, Tanner (2006) considered emerging adulthood as a critical turning point, or significant transition, in terms of development. The ways in which emerging adults navigate challenges associated with life transitions may provide insight for further understanding the various trajectories of risk and resilience associated with this critical period of development.

Beginning in adolescence, coping with the changes in social roles, expectations, and structures may create a context for increased psychopathology for some young people (Schulenberg & Zarrett, 2006). The prevalence rates of diagnosable mental health problems among adolescents who are approaching emerging adulthood have been striking. According to Offord and colleagues (1996), it was estimated that approximately 24% of young people between the ages of 15 and 24 years had at least one psychiatric disorder the year before the survey was conducted. In a community sample of young people entering adulthood, Reinherz, Giaconia, Lefkowitz, Pakiz, and Frost (1993) found that a relatively large proportion of participants met lifetime prevalence for phobias (22.8%), major depression (9.4%), post-traumatic stress disorder (6.3%), and obsessive-compulsive disorder (2.1%). The highest prevalence rates were for substance use disorders (alcohol abuse/dependence: 32.4%). Individuals who experience mental health difficulties early on in development may be at an increased risk for developing a wide range of difficulties that continue into adulthood (Davis, 2003; Davis & Vander Stoep, 1997). High prevalence of substance use disorders, depression, and anxiety have also been reported elsewhere among adolescents and emerging adults (Costello, Copeland, & Angold, 2011; Wittchen, Nelson, & Lachner, 1998). Compared with typically developing young adults, those with mental health difficulties are less likely to graduate from high school, less likely to find employment, more likely to experience homelessness, and more likely to have multiple pregnancies at a young age and even lose custody of their children (Vander Stoep, Davis, & Collins, 2000). Challenges experienced early on appear to have lasting impacts on the developmental experiences of these emerging adults who face mental health issues.

In addition to concerning prevalence rates of mental health concerns, there is a growing awareness of emerging adults transitioning across an array of service systems. Reiss, Gibson, and Walker (2005) investigated the health care transition experiences of youths with special needs, their family members, and health care providers. Youths and their family members indicated that they were not prepared to participate successfully in the adult health care system, and this was seen as a significant barrier to transitioning through the system. Keller, Cusick, and Courtney (2007) interviewed youth on the verge of transitioning out of the foster care system and preparing to live independently. Data from participant clinical files were analyzed, revealing four distinct sub-groups of youth: “Distressed and Disconnected,” “Competent and Connected,” “Struggling but Staying,” and “Hindered and Homebound.” Three out of four of the emerging adult sub-groups were currently experiencing problems and/or likely to experience problems in their transition to adulthood, while only one sub-group of youth (i.e., “Competent and Connected”) was not currently experiencing problems or likely to experience transition problems in the future. Reid and Dudding (2006) reported similar findings from their exploration of the issues and outcomes of youth aging out of the child welfare system and found that these youth tended to be at risk for not faring well in adulthood. Overall, findings suggest that adolescents with special health care needs are ill-prepared for institutional transitions, and supports from service providers are greatly needed.

Emerging adults with mental health problems appear to face similar transition-related challenges. Longitudinal studies have shown that young people with emotional and/or behavioral problems have difficulties managing and progressing through tasks associated with young adulthood (Armstrong, Dedrick, & Greenbaum, 2003; Vander Stoep et al., 2000). Davis and Vander Stoep (1997) reviewed findings from six large-scale longitudinal studies of American youth who had progressed through the mental health system. Keeping in mind the heterogeneity within these studies, it remained clear that, overall, these adolescents faced serious challenges. Many of them did not receive a high school diploma or the equivalent, they were unlikely to be employed, they tended to have incomes only slightly above the poverty line, and they experienced a particularly high rate of criminal involvement among other negative outcomes. Davis and Vander Stoep (1997) hypothesized that a large proportion of adolescents have “slipped through the service cracks” (p. 407) and remained unidentified. It appears that adolescents with mental health difficulties face particular challenges navigating the road to adulthood.

A major reason for negative institutional transition outcomes is related to the disconnect between child- and adult-focused systems of care. Fragmented and uncoordinated supports between child and adult systems are common, in addition to services in adult mental health clinics that are not appropriate for the developmental needs of young adults (Davis, 2003). This apparent gap between adult and child systems may be exacerbated by the evolving needs of youth who are no longer children but not yet adults. Emerging adults who undergo simultaneous developmental and institutional transitions may face additional challenges, and they may be overwhelmed and limited in their ability to cope with these transitions (Schulenberg & Maggs, 2002). This process of simultaneously transitioning, developmentally as well as institutionally, is likely to be especially difficult for emerging adults with mental health problems. Singh et al. (2010) interviewed a group of youth who had crossed over from the child to the adult mental health system. They found that optimal institutional transition was the result of adequate planning and collaborative care approaches between child and adult teams (Singh et al., 2010). Unfortunately, these optimal transitions were identified in less than 5% of youth who transitioned. There appear to be complex challenges associated with coordinating appropriate transitions and a dearth of research informing the development of appropriate transition procedures and protocols for service providers and users. An understanding of the service needs of these young people as they pass through a period of heightened self-awareness and self-exploration appears warranted.

In response to some of the challenges faced by late adolescents with mental health problems, models of care have been developed. For example, Clark, Deschênes, and Jones (2000) presented their Transition to Independence Process (TIP) framework, which was modeled after longitudinal outcome studies of late adolescents. The TIP model has been developed to support adolescents with emotional and/or behavioral difficulties during their transition to adulthood (http://www.tipstars.org/). Several key aspects of this system designed to prepare adolescents for successful transitions include the implementation of developmentally appropriate services, person-centered planning driven by the youth and self-advocacy, emphasis on utilizing social supports, and functioning across life domains. Adolescents are prepared for tasks associated with adulthood and they are engaged in future planning in areas of education, independent living, and employment. When young people are involved in their own care, this involvement has been related to successful transitions into adulthood, reduced participation in at-risk behaviors, and increased effectiveness of intervention outcomes for youth (American Youth Policy Forum, 2003).

The ways in which adolescents cope as they face the changes associated with developmental and institutional transitions may have important implications for how they might move into adulthood and into adult mental health care. The use of appropriate coping strategies may minimize the negative impact of stressful events on emerging adults. In addition to developing personal coping strategies and resources that may promote successful transitioning experiences, involving family members in mental health service delivery may be equally important. While Arnett’s (2000) theory of emerging adulthood emphasizes the process of moving from dependent to independent status, the significance of relationships with parents is not to be ignored (Tanner, 2006). Parental support and empathy remain important to emerging adults (Powers, Hauser, & Kilner, 1989). Moreover, research has shown that parental attitudes are highly influential on emerging adults’ decisions to access mental health services as adults (Samargia, Saewyc, & Elliott, 2006). Parents continue to have an influence on the service access of their sons and daughters.

The roles that parents play in their sons’ and daughters’ lives change across the latter’s development (Tanner, 2006). Parents are likely the natural support systems of many late adolescents and may be an important source of collaboration and engagement (Clark & Davis, 2000; Jivanjee, Kruzich, & Gordon, 2008). Inviting parents to express their perceived needs in supporting their sons and daughters may be helpful in developing ways to assist parents who themselves prepare for the transition. As adolescents progress through their mental health services, it is hoped that the primary responsibility of the parents or caregivers shifts to the young person himself or herself. Empowering emerging adults to recognize their personal influence on mental health services is likely beneficial.

Research has shown that self-efficacy is positively associated with mental health among young adults (Ogunyemi & Mabekoje, 2007). Specifically, mental health self-efficacy has been defined as youth perceptions of confidence with respect to managing their own mental health condition, services and supports, and using their experiences to help peers and improve service systems (Walker & Powers, 2007). Youth-focused systems have been influenced by a positive youth development approach, a strengths-based perspective where the focus is on actively engaging youth in decision-making processes related to the services they use (Amodeo & Collins, 2007). There is likely a relation between adolescents’ confidence toward managing their own mental health conditions, related services and supports, and supporting improvements in broader mental health service systems and positive transitional outcomes.

Considering the complex challenges faced by adolescents with mental health problems, it is helpful to understand the internal as well as external supports that promote successful outcomes. There may be specific factors associated with resilience (as opposed to risk) that increase the likelihood of positive transition experiences. Among existing transition initiatives, recommendations to support care transitions include engaging and empowering young people to participate in the transition process, focusing on adolescents’ social support networks, and encouraging progress in life domains relevant to adulthood such as career, education, and employment (e.g., Clark & Davis, 2000). Overall, models promoting successful transitions to adulthood and adult-oriented health care appear to focus on capacity building among youth and their caregivers. Resilience during transition may be associated with coping resources. Previous success in coping with stressful situations is likely to increase adolescents’ self-confidence and competence (Seligman, Reivich, Jaycox, & Gillham, 1995). The types of coping skills adolescents use may facilitate positive transition experiences (Leontopoulou, 2006). Perhaps, then, the relations between aspects of youth self-efficacy and empowerment, social support, use of coping strategies, and management of life domains related to becoming an adult are related to successful transitions into adult-focused care.

The Current Study

Because late adolescents with mental health issues face major developmental and institutional transitions, an understanding of their perceived needs and experiences is important. At present, there appears to be few systematic examinations of the perceptions of youth prior to a transition to adult care (Wong et al., 2010) or following a transition to adult care (Singh et al., 2010). Thus, the goal of the current study was to undertake an examination of the perceived needs of a sample of late adolescents with mental health needs at a local mental health clinic.

Research Questions

Three major research questions guided this concurrent mixed methods study:

Research Question 1: What are the current perceived needs of adolescents?

Research Question 2: How do relations between mental health self-efficacy, identity distress, coping strategies, social supports, and severity of mental health problems reflect late adolescents’ readiness for an institutional transition?

Research Question 3: What are the lived experiences of late adolescents who may be transitioning into adult mental health services?

Method

Participants and Recruitment

Participants were recruited from a culturally sensitive outpatient clinic where clinicians provide a variety of mental health services to children and youth. Our sample included late adolescents from a community mental health clinic mandated to provide services free of charge to youth under the requirements of our provincial health care plan based on referral by professionals, parents, or guardians. Of all active clients registered at this local child and adolescent clinic at the time of the study period (N = 531), May 2010 to November 2010, 169 met the study criteria. Forty-eight youths (28.4%) agreed to participate. Participants either had a psychiatric diagnosis or demonstrated significant symptoms indicative of a psychiatric condition, which was assessed at intake into the program by experienced mental health clinicians (clinical social workers, psychologists, and psychiatrists). The mean age of participants was 17.41 years (SD = 0.90), and 32 (66.7%) were female. The majority of participants lived with their parents; only one participant lived alone. The majority of participants were diagnosed with anxiety (87.5%) and/or depressive disorders (56.3%), and had at least two psychiatric diagnoses (64.6%). Total Problems scores (i.e., Externalizing + Internalizing Problems scale total) from the Brief Child and Family Phone Interview (BCFPI-3; Cunningham, Pettingill, & Boyle, 2006) were obtained from clinical files and used to denote severity. Youth were recruited in on-site or over the telephone following initial contact through the circle of care (i.e., clinic staff). Youth participated in the Youth Survey either online, over the telephone, or in person.

Clinicians purposively sampled 10 youth for the in person in-depth interviews. Clinicians purposively referred youth to the researchers who were either undergoing a transition to adult mental health services or youth whom they suspected, based on clinical judgment, might require a transition to adult services at some point in the near future. This targeted selection process was important given that an in-depth exploration of the phenomenon of transition was central to the qualitative component of this study. The relevant ethics review boards (university and hospital) approved this study.

Measures

The Youth Survey included a series of open- and closed-ended questions designed to measure identity distress, coping strategies, perceived social support, and mental health self-efficacy. Participants also reported on their concerns in the following life domains: educational and vocational goals, achieving financial independence, relationships, and independent living.

To understand participant distress associated with any unresolved identity issues, the Identity Distress Survey (IDS; Berman, Montgomery, & Kurtines, 2004) was administered. The IDS is a 10-item youth self-report measure that has been useful in identifying youth experiencing difficulties with identity development (Berman et al., 2004). Items are rated on a 5-point Likert-type scale from 1 (not at all) to 5 (very severely). Items tap into the degree to which participants have been recently upset, distressed, or worried over long-term goals (e.g., being in a romantic relationship), career choice (e.g., deciding on a trade or profession), friendships (e.g., change in friends), sexual orientation and behavior (e.g., feeling confused about sexual preferences), religion (e.g., changed your belief in God/religion), values and beliefs (e.g., feeling confused about what is right or wrong), and group loyalties (e.g., belonging to a club).

The Brief COPE (Carver, 1997) is a multidimensional coping inventory designed to assess the ways in which individuals respond to stressful situations. In this study, participants were asked to indicate the extent to which they anticipated they would engage in each of the strategies if they were to transition into an adult mental health program on a 4-point Likert-type scale (1 = I won’t do this at all to 4 = I will do this a lot). Items reflect 14 dimensions of coping: self-distraction (e.g., “I will do something to think about it less, such as go to movies, watch TV, read, daydream, sleep, or shop.”), active coping (e.g., “I will take action to try to make the situation better.”), denial (e.g., “I will say to myself ‘this isn’t real’”), substance use (e.g., “I will use alcohol or other drugs to help me get through it.”), use of emotional support (e.g., “I will get comfort and understanding from someone.”), use of instrumental support (e.g., “I will try to get advice or help from other people about what to do.”), behavioral disengagement (e.g., “I will give up trying to deal with it.”), venting (e.g., “I will express my negative feelings.”), positive reframing (e.g., “I will look for something good in what is happening.”), planning (e.g., “I will think hard about what steps to take.”), humor (e.g., “I will make fun of the situation.”), acceptance (e.g., “I will learn to live with it.”), religion (e.g., “I will pray or meditate.”), and self-blame (e.g., “I will blame myself for things that happened.”).

The Youth Empowerment Scale–Mental Health (YES-MH; Walker & Powers, 2007) is a measure designed to assess youths’ perceptions of self-efficacy with respect to managing their own mental health condition (e.g., “I know how to take care of my mental or emotional health.”), services and supports (e.g., “I know the steps to take when I think that I am receiving poor services or supports.”), and using their experience and knowledge to help peers and improve service systems (e.g., “I feel that I can use my knowledge and experience to help other young people with emotional or mental health difficulties.”). Twenty-three items are rated on a 5-point Likert-type scale (1 = never or almost never to 5 = always or almost always). Convergent validity has been demonstrated between youth scores on the YES-MH and a measure of the youth participation in their treatment planning process (r = .62). Cronbach’s alphas for the current sample were .82, .71, and .76 for sub-scales reflecting the self, services, and the system, respectively.

The Multidimensional Scale of Perceived Social Support (MSPSS; Zimet, Dahlem, Zimet, & Farley, 1988) was administered to examine perceived support from family (e.g., “My family really tries to help me.”), friends (e.g., “My friends really try to help me.”), and a significant other (e.g., “There is a special person who is around when I am in need.”). Empirical support for the factorial structure of the MSPSS and acceptable support for its construct validity (Zimet et al., 1988) and reliability have been demonstrated (Canty-Mitchell & Zimet, 2000). Cronbach’s alphas among the current sample were high (family: α = .89, friends: α = .89, significant other: α = .92).

A Phenomenological Approach to Understanding Youth Lived Experiences

Interpretive phenomenological analysis (IPA) was the analytic framework for the in-depth interview data (Smith, 1996). The open-ended questions were used flexibly to guide the in-depth interviews and explore the lived experiences of late adolescents who were expected to face or who were confirmed to undergo a mental health institutional transition. The first question posed to participants was broad (i.e., “What are your experiences of being a youth in this program?”). This was done strategically as a means of allowing each participant to start from his or her own place of lived experience. The following interview questions were used as guides to adhere to the research goals: (a) “What are your experiences of being a youth who may eventually switch to an adult program?” (b) “What would this move mean to you?” (c) “What do you imagine a transition to be like?” (d) “What would you need or want in order to have a smooth transition?” and (e) “What are your thoughts and feelings about this?” Additional questions and probes were asked to further encourage conversation.

Data Analysis

Demographic characteristics and standard measures were analyzed with descriptive statistics. All open-ended responses were subjected to content analysis (Krippendorff, 2004). Path analysis, a structural approach to modeling relations between observed variables (Kline, 2011), was used to examine the relations between key variables. Finally, the in-depth interviews were analyzed according to IPA methodology (Smith, 1996) to highlight the themes across participants as well as to capture participants’ idiographic experiences. Interviews were transcribed verbatim and subjected to a detailed case-by-case analysis. In other words, a detailed analysis of a single case was done before moving on to analyze a subsequent case. Each transcript was read in its entirety to obtain an overview of the participant’s experiences. A holistic reading of each transcript was performed in order to ensure that subsequent detailed analyses remained grounded in each participant’s account (Hunt & Smith, 2004). Pseudonyms were used to protect participants’ identity and privacy.

Stages of analysis

IPA consists of three major stages, which were used as a framework for the data analysis (Smith, 1996). In Stage 1, the researcher’s initial thoughts and comments on the content of the interview transcripts were documented. In Stage 2, key themes and superordinate themes were identified and defined. Connections between these themes and superordinate themes were made until a coherent thematic, idiographic account of each participant’s experiences was produced (Smith, 2004). This was followed by a final re-reading of transcripts post-analysis to ensure that interpretations were grounded in the participants’ accounts.

Trustworthiness of the data

As recommended by Smith, Flowers, and Larkin (2009), a set of principles outlined by Yardley (2000, 2008) was used to evaluate the rigor or quality of the in-depth interview data in this study. Yardley (2000) outlined relatively broad criteria that offer researchers different ways to establish quality without adhering to a prescriptive and simplistic method where the subtle differences and nuances of qualitative work may be lost. Furthermore, the breadth of Yardley’s (2000) criteria may be useful to researchers assessing qualitative data from different theoretical orientations. Yardley (2000) presented four general guidelines for assessing the quality of qualitative data: (a) sensitivity to context, (b) commitment and rigor, (c) transparency and coherence, and (d) impact and importance. These criteria were considered and adhered to by the researchers throughout all phases of the study (see Yardley, 2000, for a detailed review of these criteria).

Arguably, the most important criterion for establishing trustworthiness is credibility (Lincoln & Guba, 1985). Credibility refers to the confidence or believability of the findings (Lincoln & Guba, 1985). The commonly used procedures to establish credibility include (a) triangulation (i.e., searching for convergence among differences sources, theories, methods, and so on, to create themes; Denzin, 1978); (b) disconfirming evidence (i.e., searching for data that disconfirm a researcher’s themes; Miles & Huberman, 1994); (c) member checking (i.e., taking the data and the interpretations back to the participants to confirm the credibility of the interpretation; Lincoln & Guba, 1985); (d) the audit trail (i.e., documenting the research decisions and activities throughout the process to ensure that the findings are trustworthy; Lincoln & Guba, 1985); (e) researcher reflexivity (i.e., self-disclosure of personal beliefs, values, and biases that may shape the researcher’s lens of inquiry and interpretation); (f) prolonged engagement in the field (i.e., the researcher situates himself or herself within the research setting); (g) thick, rich description (i.e., describing details of the setting, participants, and themes); (h) collaboration (i.e., involving participants as “co-researchers” in the study); and (i) and peer debriefing (i.e., conducting a review of the research with someone external to the study, yet familiar with the phenomenon of interest; Lincoln & Guba, 1985). In the current study, the use of triangulation was inherent in the mixed methods design, and the audit trail and researcher reflexivity (i.e., the pragmatic approach was the theoretical framework of the study) were used to further establish the credibility and trustworthiness of the qualitative findings.

Mixing Methods

Mixed methods data may be analyzed in a variety of ways. Mixing can occur at different stages in the research process: data collection, analysis, and interpretation of the study findings (Creswell & Plano Clark, 2007; Migiro & Magangi, 2011). In the current study, quantitative and qualitative data were analyzed separately followed by an integrated presentation of the findings and their implications. In other words, data were mixed at the interpretation stages in the discussion.

Results

Participants reported moderate levels of perceived social support and mental health self-efficacy. The mean BCFPI-3 total score was below the clinical cutoff of 70. See Table 1 for participant characteristics. In terms of life domain concerns, mean scores revealed that adolescents were most upset about their career choices (M = 3.31), long-term goals (M = 3.23), and friendships (M = 2.94). There were no significant differences between mean scores for these three items (p > .05). Regarding life domains, majority of adolescents ranked their mental health (57.4%) and education (57.4%) as concerning. Participants reported concerns about locating appropriate adult mental health services (e.g., “Where do I go when I’m an adult?”) and they had questions about adult mental health clinicians (e.g., “What do they do?”; “How can they help me?”).

Table 1.

Sample Characteristics.

Characteristics	Respondents (n = 48)
M age (SD), years	17.41 (0.90)
Gender, No. (%)
Male	16 (33.3)
Female	32 (66.7)
Living arrangements, No. (%)
With family	47 (97.9)
Not with family	1 (2.1)
School attendance, No. (%)
Not currently attending	2 (4.2)
High school	40 (83.3)
College	2 (4.2)
University	3 (6.3)
Other	1 (2.1)
Employment status,^a No. (%)
Not currently working	26 (56.5)
Full-time	1 (2.2)
Part-time	16 (34.8)
Other	3 (6.5)
Measure, M (SD)
YES-MH
Self	2.92 (0.74)
Service/support	3.29 (0.70)
System	2.61 (0.82)
Total	2.94 (0.55)
MSPSS
Family	4.79 (1.47)
Friends	4.68 (1.46)
Significant other	5.34 (1.57)
Total	4.94 (1.30)
BCFPI-3	66.66 (13.65)

Note. YES-MH = Youth Efficacy/Empowerment Scale–Mental Health; MSPSS = Multidimensional Scale of Perceived Social Support; BCFPI-3 = Brief Child and Family Phone Interview.

n = 46 (missing data for two participants).

More than half of the participants expressed specific concerns about their mental health and education, and over 40% of participants had concerns about physical health, family relationships, and friendships. Many mental health concerns reflected participants’ worries about these issues worsening or persisting into the future. Among educational concerns, participants expressed concerns about achieving current educational goals as well as future career-related goals and academic underachievement. Physical health concerns were mainly about participants’ weight and poor eating habits. Majority of family relationship comments reflected negative experiences with family members. Among friendship comments, majority reflected concerns about maintaining friendships and trust, and some comments reflected desires for friendships. Family relationship comments reflected negative experiences with family members. Among these were concerns about not getting along (e.g., “My mom and I don’t get along.”), communication problems (e.g., “I don’t feel like I can tell my parents any of my problems.”), and unfulfilled family relationships (e.g., “No emotional relationship with father.”).

Regarding mental health services and supports, overall, participants were satisfied and reported positive experiences. The majority of participants indicated that individual counseling and psychiatrist appointments were helpful (73% and 69%, respectively). Over 70% of participants thought that stress management and education planning supports would be helpful.

Readiness to Transition Path Model

Although no empirical models have been located to date that captured late adolescents’ readiness to transition to adult-oriented mental health care, elements described in Clark et al.’s (2000) TIP framework were tested in the current study. Person-centered planning driven by the youth and self-advocacy, emphasis on utilizing social supports, and functioning across life domains were incorporated into the model tested in this study.

In preparation for testing the hypothesized Readiness to Transition path model, an exploratory factor analysis was conducted on the Brief COPE items as recommended by Carver and colleagues (1989) to determine the appropriate factor structure for the current sample. Final results revealed an acceptable two-factor model: The items for the first factor represented Proactive Coping strategies (M = 2.63, SD = 0.61) and items on the second factor represented Non-Proactive Coping strategies (M = 2.05, SD = 0.69). Factor loadings are presented in Table 2. The Proactive Strategies factor is composed of items from the Emotional Support, Instrumental Support, Active Coping, and Planning sub-scales of the Brief COPE (Cronbach’s α = .83). The non-proactive factor is composed of Self-Blame, Denial, Substance Use, and Behavioral Disengagement sub-scales (Cronbach’s α = .81). Because the use of proactive coping strategies was of theoretical interest in the current study, these sub-scale scores were included in the path model.

Table 2.

Factor Loadings (>.20) for Items on the Two-Factor Brief COPE.

Items	Proactive strategies	Other strategies
I will get comfort and understanding from someone.	.87	—
I will try to get advice or help from other people about what to do.	.79	—
I will get emotional support from others.	.73	—
I will get help and advice from other people.	.63	—
I will think hard about what steps to take.	.58	—
I will try to come up with a strategy about what to do.	.39	—
I will take action to try to make the situation better.	.36	—
I will concentrate my efforts on doing something about the situation I’m in.	.33	—
I will use alcohol or other drugs to help me get through it.	—	.99
I will use alcohol or other drugs to make myself feel better.	—	.98
I will give up trying to deal with it.	—	.47
I will blame myself for things that happen.	—	.47
I will criticize myself.	—	.39
I will say to myself “this isn’t real.”	—	—
I will give up the attempt to cope.	—	—
I will refuse to believe that it has happened.	—	—

Note. Initial results indicated that the two-factor model yielded a relatively poor fit, Kaiser-Meyer-Olkin measure of sampling adequacy = .53; χ²(323) = 539.33, p < .001. Five items had low (<.60) communalities and were removed in addition to items that did not fit conceptually with the remaining factor items. The final two-factor model was a statistically significant improvement over the initial model, Δχ²(Δdf = 189) = 302.3.6, p < .001.

From the originally hypothesized model, one revision was made and tested based on theoretical relevance to the current study. While it was expected that a global sense of mental health self-efficacy would be predicted by the other variables in the model, it was also anticipated that the concept of readiness to transition would be best reflected in participants’ perceived self-efficacy with respect to managing, negotiating, and monitoring the mental health services they received, particularly because the ways in which late adolescents directly manage their services and supports at the child and adolescent clinic were likely to align with the ways in which they would be able to manage their services at a different clinic. As a result, mental health services self-efficacy was subsequently tested in the model. This final model fit the data well based on the chi-square calculation, χ²(3) = 2.71, p = .438, as well as results from other fit statistics: the Tucker-Lewis index (>1.0), the comparative fit index (>1.0), and the root mean square error of approximation (<.001). Several alternative path models were tested to demonstrate that the final model was appropriate, as it provided the best fit.

Examination of the regression weights revealed significant factor loadings for majority of the variables (p < .05). Significant regression loadings ranged from .24 to .45. There was no significant correlation between perceived social support and identity distress (p > .05). Figure 1 depicts the final Readiness to Transition model with standardized estimates.

Figure 1.

Path model of adolescent Readiness to Transition (standardized estimates).

The model accounted for approximately 38% of the variance in mental health services self-efficacy. Higher identity distress was associated with lower self-reported mental health services self-efficacy. Youth with a higher severity of emotional and behavioral problems had higher mental health services self-efficacy scores. Youth who anticipated utilizing more proactive coping strategies were more likely to have higher mental health services self-efficacy than youth using fewer proactive strategies. Finally, perceived social support predicted high anticipated use of proactive coping strategies. Perceived social support did not predict identity distress nor did social support predict mental health services self-efficacy.

In-Depth Interview Themes

Theme 1: Fears of uncertainty and not knowing

This theme permeated participant accounts, reflecting fear of both the transition to adult-focused care and the transition to adulthood. General ambivalence toward the unknown future was expressed in the majority of participant accounts. For instance, Krista viewed her mental health struggles as a personal failure, and as a result she was anxious about facing adulthood: “I don’t wanna fail, you know? I’ve had already too many failures . . . and I don’t want . . . my adulthood, or whatever you want to call it, to be a failure.” Many participants expected to feel unsettled, stressed, and confused about transitioning. Shannon expressed her confusion concerning why a transition was even necessary: “I’m gonna have to start on a clean slate, with someone who’s never even heard of me before, like, how is that even supposed to work? Like am I starting over?” Shannon was upset, given that the topic of institutional transition had never been discussed. She expected to be “kicked out” once she reached the clinic’s age cutoff. Dennis also questioned the necessity of a transition given that his current therapy was going well: “Like they know everything about me, why now? So changing it to someone else, it would be like starting all over again.”

Participants also expressed some positive as well as mixed feelings about a transition. Krista viewed “starting over” as a welcomed opportunity. The symbolic nature of being “reborn” denoted her view of transition as a fresh start filled with “new responsibilities” with “new doors open.” Sue viewed a program transition as a marker of her adult status: “I’m not being viewed as an adolescent anymore, I’m being viewed as an adult . . . and I look forward to it.” Roberta was torn between the positive aspects of an institutional transition and the ones she feared. This positive attitudinal shift was evident in her statement: “It is change and it’s beneficial. [I]t’s a new perspective, I think there is a lot of positive from like, being able to change?” Shannon stated that a transition would be less abrupt if she decided when it was time to transition. She used the analogy of weaning off of medication as a way to create a smooth transition: “When you stop a medication, you don’t just cut cold . . . why can’t you increment things that are not medication, but work in the same way?” Her description of a graduated transition process was in contrast to her statement:

You’re slowly getting pushed and you’re skidding . . . I’m not ready . . . I haven’t dealt with what I need to here, but deal with it with the next doctor. It’s like someone handing over, calling “Next,” right?

In many ways, participants viewed a program transition as a symbol of transitioning to adulthood. For example, Marisa stated, “At the same time, it’s just kind of like, oh my god, I can’t believe I’m, like, an adult already? You know . . . it’s sort of like 50/50, on the fence, you know?” This view was shared by the majority of participants who felt that they were no longer children but not yet adults.

Theme 2: Trusted relationships and the exposed self

Participants referred to trusting in which the participants felt understood, especially in connecting with mental health professionals. Sue referred to her mental health issues as “extremely out there.” Thus, feeling comfortable disclosing her private thoughts to her current trusted clinician was important to her. Participants described the importance of individualized support, which was about finding the right client-clinician match.

Participants who felt understood as unique clients (i.e., no longer children, although not yet adults) seemed to form positive relationships with professionals. Mila expected that adult clinicians would need to adopt a “different mind-set” to work effectively with late adolescents. Sean expected the professional to somehow make an “adjustment” to his or her “state of mind.” Krista, who had already been in contact with her new adult clinician, expressed her uncertainty about the thought of being placed in a group therapy setting with older adults: “[My new clinician] doesn’t want to put me in with like 34-year-olds . . . ’Cause that’s like, kind of awkward.” Relatedly, the thought of working through emotional issues with older adult clients in group therapy seemed almost unimaginable to Shannon who stated, “Can you imagine, I don’t know, 40-year-olds who [sic] suffering from severe depression and you’re sitting in the same room?”

This awkwardness was underscored by distinctions held by participants in terms of adult- versus child-focused therapies. For example, Marisa stated, “You know, ’cause you’re an adult. I think like . . . the way they’re going to be talking to you is probably going to be different.” Krista characterized differences between child and adult clinicians in terms of verbal tone, “I’m just thinking [at an adult clinic], they’re always dealing with adults and that they’re just more like, ‘Hi how are you . . . okay bye.’ [firm tone].” Dennis expected information to be presented to him, “Like more straight-up. [Adult clinicians] just tell you.” Sean was worried about meeting an adult clinician who acted like a “cold wall,” which was his “biggest worry right now.” Overall, participants expected adult clinicians to be cold, distant, and firm. These descriptions were in contrast to the nurturing relationships that participants described with their current clinicians.

Participants were upset at the thought of leaving their current clinicians. Some participants interpreted the transition as being abandoned by their clinicians. Shannon’s fears of abandonment were articulated in the following analogy:

I don’t feel like I’m moving at a good enough rate to be able to stand out by myself. So it’s like, okay, my legs are still wobbling and yet you’ve abandoned me, it almost feels like? So I’m afraid, I’m terrified actually.

To promote a smooth transition, Dennis and Sean hoped for open communication between current and future clinicians. Sean stated,

Like instead of just handing over a file and being like, yeah, he’s your problem now? . . . I don’t want that, I want it to be like, okay, here’s the guy, he’s coming over, here’s what you need to know about him, here’s the file . . . here’s some additional information . . .

In addition to the significance of having positive relationships with mental health professionals, participants also referred to the importance of their personal relationships. While relationships with friends and romantic partners were consistently positive, there were some negative sentiments toward family relationships. For example, Krista felt disconnected from her parents because they did not believe in mental illness. They discounted the existence of mental illness, which created tension, “[My parents are] very closed-minded about it, they don’t believe that . . . there’s something actually wrong, like with your mental health.”

Theme 3: Mental illness and a vulnerable, isolated self

Youth described their struggles with living with mental health problems. The loneliness of living with a mental health condition was palpable in Shannon’s description of her room being decorated with supportive messages of hope following her hospitalization:

I woke up and there was all these papers on my wall that said, “You’re the best,” “Be the change you want to see.” [These messages] just kind of said . . . I’m out of school, I’m not telling anybody, people think I have cancer or I’m pregnant, I can’t deal with anything or wake up in the morning . . . and the point of [these messages] is not making me feel much better about myself.

Although the messages were meant to be inspirational, they ironically appeared to symbolize the secrecy surrounding her mental health issues. Shannon’s feelings of shame surfaced when she reflected on her peers’ conclusions about her sudden absence from school. Shannon was uncomfortable disclosing any details about her hospitalization to her peers. Mila completely separated her friendships from her mental health issues. She kept her mental health struggles a secret from her friends, “never” wanting to share this information with them.

Theme 4: A person first, patient second

All participants expressed a desire to be involved in their transition process, to feel included. They wanted to be engaged as active participants throughout service provision, rather than as passive recipients of information. Participants’ desires for ways to feel empowered were evident through their statements about being agents of their own mental health care journeys. For example, Mila spoke about ways in which she took control of her own mental health care needs and reflected on how this made her feel, “I kind of feel like I’m taking charge of whatever I need to do in life.” They expressed their attitudes toward being involved in changing their own lives as well as commenting about mental health services for other late adolescents accessing supports. Overall, excerpts reflected participants’ simultaneous desires for empowerment at two levels: at an individual level, in terms of their own personal empowerment and at a broader level, in terms of empowering and advocating for adolescents with mental health needs.

Participants described their experiences of being treated respectfully by mental health professionals versus being treated disrespectfully. When participants did not feel heard, there was a sense of disempowerment. In the past, Shannon felt that she was afforded little dignity by a particular mental health professional who “didn’t seem interested in me . . . she didn’t want to listen to . . . how I felt and stuff.” Before connecting with the services at the current outpatient clinic, Dennis had similar experiences with an unhelpful, unsympathetic mental health professional describing it as “horrible” and feeling like he was “talking to a wall” as he said, “she was nice, personally, but I think she went way too much by the book.” Dennis was frustrated by the robotic nature of the therapy session. This clinician followed protocol too closely (i.e., “by the book”), such that Dennis wanted to feel understood “like a normal person” rather than feeling like the clinician was “studying” him. He said, “We’re both humans, you know what I’m saying? You don’t have to act like a robot.” Dennis’ frustration was evident in his inability to connect and engage with this clinician. Similarly, Sean wanted to be heard by mental health professionals, “I wanted to feel comfortable, at ease with what I’m saying, they’re going to help me, not just treat me as like a patient.” During a transition to adult services, he did not want to be viewed as merely a file number. As he stated, “So yeah, so I’d come in there and they’re like, we’ve heard all about you . . . versus . . . you are patient, you know 0320-whatever, you know that kind of thing?”

Even though some participants felt as though they did not receive much (if any) transition-related feedback from current mental health providers, the majority of youth acknowledged the importance of voicing their concerns. This self-expression seemed to be critical for participants to realize that their opinions and contributions toward their own mental health care were heard and taken seriously. For instance, Marisa described herself as “really, really open-minded” and unafraid to express herself. Shannon considered her therapy work with professionals as an opportune forum for self-expression and collaboration in her statement, “Okay [I’m] here too . . . let’s work towards fixing it, but really listen to me or what I want to do.” She subsequently stated, “And I have so much to say.”

Moreover, many participants felt that an individualized transition process was necessary. Some youth preferred a weaning process whereby they gradually left the child-focused clinic for an adult clinic. Participants did not think that age cutoffs were appropriate indicators of readiness for adult-focused services. Shannon favored individualized transition plans over adhering to strict age cutoffs:

The whole point of still having the flip over, . . . it should be more catered to you, and what you want? . . . Just because [professionals] have put a limit on something, doesn’t mean it’s always right for you.

Discussion

Results from the quantitative and qualitative methods revealed complementary findings in connection with the aim of this study, which was to understand the perceived needs of a sample of late adolescents with mental health and transition-related needs at a local mental health clinic. Data were mixed during the interpretation stages and are presented below topically. There were consistent findings on mental health concerns (current and future), importance of trusted relationships, and complementary findings on mental health self-efficacy and engagement and involvement in current and future mental health supports.

Participants’ relationships with family members were both positive and negative. Positive family relationships were reliable and supportive. Many adolescents appreciated family members who were encouraging and expressed understanding of their mental health issues. Caregiver involvement in their mental health services varied. Some caregivers played more peripheral roles, such as driving them to appointments, whereas others were highly involved and knowledgeable about what was happening in therapy. Among adolescents who experienced negative family relationships, concerns related to their challenges developing or maintaining positive, fulfilling family relationships. In addition, interview results revealed some volatile family relationships, such that participants preferred to keep parents outside of the therapy context.

Participants in this study expressed a variety of current life concerns. They worried about transitioning to adult mental health services as well as transitioning to adulthood. The majority reported concerns about their mental health and education. Furthermore, several expected to have persistent mental health concerns in adulthood; this was the highest ranked anticipated adulthood concern. Overall, they reported moderate levels of self-efficacy with respect to managing their mental health services and supports. Strong perceived social support appeared to be positively linked to the expected use of what may be considered proactive coping strategies during the service transition process, which in turn predicted high mental health services self-efficacy. Late adolescents who reported lower levels of identity distress reported higher mental health services self-efficacy, and youth with more severe mental health problems at intake appeared to have relatively high mental health services self-efficacy. Overall, participants expressed concerns related to their current and future mental health and reported a moderate sense of mental health services self-efficacy.

Participants reported concerns about transitioning and fears concerning change. However, they described positive support from professionals and natural supports. Participants expressed several suggestions for creating a smooth and successful institutional transition. Overall, the youth wanted the transition to be gradual; to be informed of the details of the transition process itself, as well as details about the new adult mental health clinic; to maintain an engaging, open, and person-centered relationship with adult mental health professionals; and to maintain open communication between child and adult clinicians throughout the transition process.

Health care transition is a complex, multifaceted process (Reiss & Gibson, 2002), and for late adolescents, a successful transition likely requires them to possess a degree of self-confidence in order to access and navigate the adult mental health service system. Regarding adolescents who are likely to transition to adult mental health services, having a strong sense of self-efficacy in terms of managing their mental health services and supports is likely to positively influence the transition process. In addition, high mental health self-efficacy may positively impact their motivation to continue accessing services, given adult-focused care’s culture where clients tend to be expected to function like independent, autonomous adults.

High scores on measures of self-efficacy have been associated with lower depression and anxiety among youth (Bandura, Pastorelli, Barbaranelli, & Caprara, 1999), fewer emotional and behavioral problems (Reivich & Shatte, 2002), and lower rates of alcohol use (Taylor, 2000). Contrary to previous findings, greater illness severity at intake seemed to predict higher mental health self-efficacy in the current study. This was counterintuitive; it could be expected that adolescents with less severe mental health problems would be more confident with respect to their abilities to manage their mental health supports. While the results may have been different given a larger sample, it is possible that adolescents with more severe problems at intake may have been provided with more professional support compared with those with less severe mental health issues. Therefore, further exploration of problem severity and its relation to the degree and potential variety of services youth access may prove useful.

Regarding youth empowerment, the emphasis on encouraging youth clients to play an active role is part of a relatively new conceptualization within the system of care. Within the youth empowerment literature, the promotion of a positive youth development approach has been flourishing. Youth are motivated to attain positive developmental outcomes, competence in academic and vocational pursuits, confidence in their abilities, and connections with family, friends, and peers (Lerner, 1995). Participants described their current relationships with clinicians as highly positive; their opinions were valued and respected. Similarly, Woodgate (2006) interviewed youth with depression, and a major theme in the data was that they wanted to feel valued as human beings. Youth in the current sample did not want to feel as though they were not being heard or be left “out of the loop” with respect to an institutional transition.

Late adolescents in this sample reported moderate levels of mental health self-efficacy overall. Particularly among those youth who reported low mental health self-efficacy, it is possible that they did not currently feel prepared to face a future institutional transition. The survey findings were complemented by the in-depth interview findings in which many youth reported feeling fearful and concerned about the potential institutional transition. The interview findings illustrated potential reasons why mental health self-efficacy scores were not high. This limited sense of “transition readiness” was also apparent in the interview findings of Delman and Jones’ (2002) study. For youth in the present sample, it is likely that building their self-efficacy by involving them early on in the transition planning process would be valuable.

Mental health self-efficacy may have been influenced by the participants’ fears and worries concerning transitioning to adult services. Many youths expressed their fears about not being informed of the transition process details. Furthermore, if a transition had already been decided, adolescents had questions about the adult mental health clinic and the new clinician(s). In Wong et al.’s (2010) study, only a small proportion of participants received any kind of information on transitioning or the process from their doctors. It appears that a critical component of easing the fears and worries of youth who face an institutional transition is to provide them with details about the transition and promote their involvement in the process.

A major theme that was developed from the in-depth interviews was that participants were not only fearful at the thought of an ensuing institutional transition, but that they felt similarly fearful about transitioning to adulthood. These results were consistent with the reported distress over achieving long-term goals and making career choices, which have been markers of adulthood. This finding was consistent with Leavey’s (2005) analysis of interviews with adolescents. Those with mental health issues may have age-appropriate skills in certain areas of development, but they may be lagging or facing greater challenges in other areas compared with those without mental health issues, making them “developmentally different” (Leavey, 2005, p. 123). Therefore, the developmental difficulties experienced by these youths may make the transition from child- to adult-focused care especially daunting.

Participants expressed a desire to be heard and actively involved in therapy as well as during a possible service transition. These findings converged with results from Kruzich and Jivanjee’s (2011) study where youth participants had concerns about not being heard by their mental health service providers. Mental health professionals who genuinely value the insights that adolescents offer with respect to their mental health supports are likely promoting youths’ positive engagement in therapy. Davis and Butler (2002) suggested that in adult-focused systems of care, supports are typically not tailored to meet the needs of those who are no longer children but not yet adults. Child-focused systems are generally designed to support children and youth at these developmental levels, while similarly adult-focused systems are designed to help adults (Davis & Butler, 2002). It is therefore important for clinicians who work with young adults to view them as a unique group of clients with needs that may be different from typical, middle-aged adult clients seeking mental health supports in an adult mental health program.

In order to engage youth, it may be important to acknowledge them as people first and patients second. In the few studies to date involving youth in the decision-making process, young people reported feeling in charge of their own lives in a positive way as a result of their involvement (Matarese, Carpenter, Huffine, Lane, & Paulson, 2008; Walker & Child, 2008). Whether or not youth feel in charge of their mental health services may depend on what Lofquist (1989) referred to as a Spectrum of Attitudes, in which the attitudes of a particular group of individuals may impact their behaviors toward another group of individuals. The spectrum of adult attitudes toward youth may be such that (a) youth are viewed as objects, (b) youth are viewed as recipients, and/or (c) youth are viewed as partners. Different attitudes held by adults concerning youth may leave the latter feeling either isolated or engaged. In steering away from previous conceptualizations of youth as passive recipients of mental health services, encouraging perceptions of youth as active partners throughout service provision in child mental health care and in preparing for transitions into adult mental health services may create a positive foundation for youth empowerment and self-efficacy that will be utilized across their life spans.

A major limitation of the current study was the small sample size, which may influence the interpretability of the findings. The results may therefore reflect a unique subset of late adolescents. Therefore, the generalizability of these findings must be interpreted with caution. Also, if there was a larger sample and data collected at multiple time points, the dynamic nature of readiness to transition may have been more accurately captured. Longitudinal research on youth who undergo successful versus unsuccessful mental health service transitions is sorely needed. Understanding the reasons for continuity (or discontinuity) of care is central to ensuring that optimal intervention for youth with ongoing mental health problems is provided. A potential limitation to the generalizability of these results is that late adolescents in this sample were currently accessing mental health services. Adolescents with mental health problems who have not accessed professional supports may have different concerns, needs, and perceptions regarding developmental transitions than those who are seeking mental health services and supports.

Despite these limitations, practical implications are worth noting. First, participants’ fears concerning institutional transition were often related to their assumptions that adult clinicians are not equipped to work with young adult clients. This assumption may be partially supported by Clark et al. (2000) who stated that service providers who are actually qualified to work with late adolescents have not been available even when funding has been available to develop transitional supports for youth. This disconcerting finding suggests the need to develop and broaden the expertise of professionals working with late adolescents. Second, the results from the current study underscore the need for mental health professionals to promote youth participation and engagement over the course of service provision. Formal programs for late adolescents that are guided by both child and adult clinicians would be helpful in assisting families and their sons and daughters in preparing for the transition to adulthood and, if necessary, adult mental health services.

Overall, understanding the needs of adolescents with mental health challenges is important given the developmental changes associated with emerging adulthood in areas such as relationships, work, and worldviews. Decisions around romantic relationships, career pursuits, leaving the family home, and becoming financially independent are tasks associated with successful transition in Western societies. For adolescents with mental health needs, navigating through the developmental tasks of adolescence and emerging adulthood in addition to managing the institutional service transitions in the mental health system may make successful transitions particularly difficult. Identifying how to best support these young people along positive developmental trajectories toward developing meaningful and fulfilling lives as independent, thriving, and contributing members of the communities in which they live is critical. An exploration of ways to effectively engage mental health system supports (youth and adult clinicians) and other supports within adolescents’ interrelated environments (family, friends, community supports) is important in creating optimal transition experiences.

Conclusion

Late adolescents’ readiness to transition is a complex phenomenon that is influenced by a host of interrelated factors. The findings from the current study revealed that youth reported moderate levels of self-efficacy with respect to managing their current mental health services and supports in the child and adolescent clinic. Furthermore, youth were concerned about both transitioning into adulthood and into adult mental health care. Trusting relationships with service providers and family, friends, and significant others were important to adolescents. Participating youth expressed strong desires to be actively involved and heard throughout their service experiences, particularly during a transition to adult services. Clinical supports aimed at enhancing current mental health self-efficacy of late adolescents may promote successful developmental and institutional transitions into adulthood and beyond.

Footnotes

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Mary Lynn Porto (third author) was employed as a social worker at the mental health organization where the research took place.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Priscilla Burnham Riosa, PhD, BCBA-D, is a post-doctoral fellow at York University, and a behavior consultant supporting children and youth with Autism Spectrum Disorder (ASD). She is a doctoral-level board certified behavior analyst and has worked with individuals with ASD and their families for many years. Her research interests are in understanding the impact of ASD on the individual, the family, and broader social contexts. She is particularly interested in positive mental health, psychosocial intervention, and relatedly, the social, emotional, and behavioral functioning of individuals with ASD and their families across the life span.

Michèle Preyde, PhD, is associate professor in the College of Social and Applied Human Sciences at the University of Guelph. With a collaborative model of community-engaged scholarship, she and community representatives have developed, conducted, and mobilized research with vulnerable populations. With this approach, her research includes the perceptions of service recipients, issues affecting practice and program delivery, and outcomes research. She has also conducted a number of systematic reviews and meta-analyses. She has focused her research on the social development of youth at risk for sub-optimal achievement of life domains and the psychosocial impact of illness.

Mary Lynn Porto, MSW, MHSc, CHE, has held a number of leadership positions in both hospital and community mental health programs and is currently a manager with the Centre of Addiction and Mental Health (CAMH) in the Early Psychosis Intervention Out-Patient Programs, Complex Mental Illness. She has been a strong advocate for system improvement in both child and adult mental health care.

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