Adolescents' Perceptions of Post-Treatment Change: Making Progress Toward a Developmentally-Sensitive Evaluation Process

Background and purpose: Evaluating mental health (MH) services is important for understanding treatment efficacy, and for engaging clients in their treatment. Because adolescents are often more reluctant consumers of MH services relative to adults, progress monitoring and evaluation may be particularly important with these clients. Standardized assessment tools (e.g. symptom inventories) are useful, but these may not capture the most salient feature of post-treatment changes for adolescents. By eliciting how youth define post-treatment change within their developmental context, researchers and clinicians would be better equipped to engage young people in treatment that is accountable to their priorities.

Our current study focuses on two primary questions: (1) How do youth characterize gain or decline in MH 6 months following discharge from psychiatric hospitalization?, and (2) How do youth articulate what has changed in their lives following hospitalization? As part of addressing the first question, we examined the reliability of youths’ reports across qualitative and quantitative measures by comparing open-ended accounts of change to change scores on several established scales.

Methods: This mixed -method study uses data from a project examining youths’ experiences following first-time psychiatric hospitalization. This research uses 6-month follow-up data elicited from face-to-face, in-home interviews with 74 youth. All participants were asked: How are you doing these days in terms of your feelings, thoughts and behavior relative to six months ago when we last spoke?” Additional probes facilitated the articulation of changes in MH (or lack thereof) experienced over the past 6-months. Content analysis proceeded in two steps. First, the authors co-developed post-hoc codes reflecting participants’ perceptions of MH status changes (improved, mixed, same, and worse) and all participants were classified into these categories. To explore the reliability between qualitative classification and quantitative indictors, we used one-way ANOVA to compare means in change scores across the groups on self-esteem (Rosenberg scale), depression (CESD), and personal control Illness Perceptions Questionnaire). The second content analysis sequence aimed to capture youth’s description of what has changed (or not) in their wellbeing over time. This involved conventional content analysis, with open coding conducted independently by the two authors who subsequently generated a consolidated code list used to analyze all transcripts.

Results:  Over half of youth were classified as “improved” (56%), others were classified in the “mixed” (28%, inconsistent improvement), “same” (12%), and “worse” (4%) groups.  This change classification corresponded significantly well to pre-post changes in the quantitative measures of MH and wellbeing. In articulating perceptions of the nature of changes over time, participants discussed:  a) clinical symptoms b) interpersonal relationships (‘harmony/connectedness’, ‘engagement’, and ‘relational flexibility’, c) coping (‘cognitive restructuring’, ‘emotional acceptance/management’, ‘deliberate disengagement’), and  d) sense of purpose (increased focus on school/work’, ‘focus on the future’).

Conclusions and implications: Our findings reveal adolescents’ perspectives on recovery and well-being, and suggest ways that treatment evaluation can be adapted to better meet the developmental needs of young people. The hope is that better evaluation tools can lead to youths’ greater engagement in MH treatment, stronger therapeutic alliances and increased treatment retention.