Background and Purpose: Mental health problems are a significant concern among children and adolescents (Health Canada, 2002; National Institute of Mental Health (NIMH), 2001), and associated with economic burden (Insel, 2008) and detrimental consequences, including criminality, academic failure, teen pregnancy, and suicide (NIMH, 2001). Mental health treatment may provide an opportunity to alleviate mental health problems and mitigate the related consequences. However, the impact of treatment is compromised by dropout rates estimated between 40-60% (Harpez-Rotem et al., 2004). Parental engagement strategies have demonstrated significant improvements in child mental health treatment attendance (see Gopalan et al., 2010). While parent engagement is important, it is also critical to engage the child/adolescent and understand their perceived barriers. To address this gap, a randomized pilot study was conducted examining the effectiveness of an engagement session (ES; Zuckoff et al., 2004) adapted for adolescents on outcomes including initial attendance (i.e., first 3 counseling sessions), self-efficacy, and treatment motivation. The associations between working alliance and treatment barriers on initial attendance were also explored.
Methods: Recruited from four Toronto-based mental health agencies, participants included 51 adolescents (age M=16.2) accepted for non-mandated counseling. Among participants, 47.1% were immigrants and 58.8% lived in low-income neighborhoods. The week before receiving counseling, participants were randomized and received either ES plus self-reports (n=27) or self-reports only (n=24). Baseline self-reports included measures of psychological distress (Brief Symptom Inventory; Derogatis, 1975), self-efficacy (Generalized Self-Efficacy Scale; Schwarzer & Jerusalem, 1995), and intrinsic/extrinsic treatment motivation (Autonomous/Controlled Motivations for Treatment Questionnaire; Zuroff et al., 2005). At 6-week follow-up, agency counselors reported each participant's initial attendance (i.e., attendance of 0-3 sessions) and participants repeated baseline self-reports plus the Working Alliance Inventory (Tracey & Kokotovic, 1989) and an adapted treatment barriers measure (Barriers to Treatment Participation Scale; Kazdin et al., 1997). Group differences in outcomes were examined via one-way ANCOVAs and associations between alliance/barriers on attendance were explored via bivariate regression analyses.
Results: After controlling for baseline extrinsic motivation differences, the ES group demonstrated marginally significantly greater initial attendance (M=2.1, SD=1.0) versus the control group (M=1.5, SD=1.2), (F(1,48)=3.70, p=.06), with a medium effect size (η2=.07). The ES group demonstrated marginally significantly higher intrinsic motivation at follow-up (F(1,47)=3.15., p=.08), with a medium effect size (η2=.06) , indicating that the ES group reported counseling to be more personally valuable than the control group. No significant between-group differences were observed for follow-up extrinsic motivation/self-efficacy. Among participants who attended at least one counseling session, alliance (F(1,40)=8.40, β= .260, p=.006) and barriers (F(1,40)=9.30, β= -.475, p=.004) were significantly associated with subsequent initial attendance, accounting for 14% and 19% of the variance, respectively. Higher self-reported barriers/lower alliance scores were associated with lower initial treatment attendance.
Conclusions and Implications: The ES is a promising intervention for enhancing attendance and intrinsic treatment motivation in “real world” settings with encouraging medium effect sizes which will assist in guiding future ES evaluation efforts. Adolescent-reported working alliance and treatment barriers were significant predictors of subsequent initial attendance. Future research is necessary to explore the potential mediators of adolescent treatment attendance.
